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Brett D. Atwater, M.DAssistant Professor of MedicineDuke University Medical Center

Durham VA Medical Center

NOT Everyone Benefits from Atrial Fibrillation Ablation!

Dr. Kevin Jackson

• Universally loved by patients

• Respected by all of his colleagues

• Right about most things…

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Dr. Kevin Jackson

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Let’s Ablate Them All!Yeeeee

Hawwwww!!!

Page 42011 ACCF/AHA/HRS Focused Update on the Management of Patients With

Atrial Fibrillation

My Job is Easy, Just Find a Single Situation Where AF Ablation DOES NOT Benefit a Patient!

Rate vs. Pharmacologic Rhythm Control Trials (6615 Mostly Older Patients with No/Minimal AF Symptoms)

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N Primary Endpoint

HR (Rate vs. Rhythm Control)

P

PIAF 252 Improvement in AF Symptoms

1.10 0.31

AFFIRM 4060 Mortality 0.87 0.08

RACE 522 Composite 0.73 0.11

STAF 200 Composite 1.09 0.99

HOT CAF 205 Composite 1.98 >0.71

AF-CHF 1376 Cardiovascular Mortality

0.94 0.59

AFFIRM Trial Results

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Trials of Rate Control vs. Catheter Ablation

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Symptoms According to Type of AF

Page 8Michiel Rienstra et al. Circulation. 2012;125:2933-2943

10-20% of patients

Frequency of Rate vs. Rhythm Control Strategies in the Real World, ORBIT-AF

• 68% of patients in US clinics are managed with rate control strategy, 32% with a rhythm control strategy

• Patients followed by EP and more symptomatic patients are more likely to be treated with a rhythm control approach

• If 90% of AF patients have symptoms but only 32% are receiving a rhythm control strategy, likely underusing this strategy

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Am Heart J. 2013 Apr;165(4):622-9

Summary of AF Ablation in Patients with No/Minimal Symptoms (10-20% of AF patients)

• Data support non-inferiority of rate control compared to pharmacological rhythm control approach in older patients with minimally symptomatic AF

• No data supporting use of AF ablation vs. rate control in minimally symptomatic AF

• Guidelines favor use of rate control approach in patients with No/ minimally symptomatic AF

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SO I WIN!!!, Patients with no AF related symptoms probably don’t benefit from ablation…

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What About SYMPTOMATIC Patients?

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Pharmacologic Rhythm Control in Symptomatic Patients Trial N F/U

(mos)SR Quality of Life

RACE1 512 27 +29% Improved among patients with AF at enrollment

HOT-CAFÉ2

205 20 NR Improved LVEF and exercise capacity

SAFE-T3 404 12 +10% Improved SF-36

CAFÉ-II4 61 12 +66% Improved SF-36, LVF, NT-BNP

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1. N Engl J Med. 347(23):1834-402. Chest 2004 Aug;126:476-863. N Engl J Med; 352:1861-724. Heart;95:924–930

DIAMOND STUDY 2001

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N Engl J Med 1999; 341:857-865

Ablation for Rhythm Control

n F/U QOL

Milan1 211 12 ImprovedSTOP-AF2 245 12 ImprovedMayo3 502 24 ImprovedBordeaux4 63 12 ImprovedCleveland/ Austin5

1420 15 Improved

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1. J Am Coll Cardiol 2003;42:185–972. Presented at 30th Sessions of HRS, 20103. J Am Coll Cardiol, 2010; 55:2308-23164. Heart Rhythm. 2005 Jun;2(6):619-235. J Am Coll Cardiol, 2012; 59:606

Milan 2003- Ablation vs. AAD

•Mortality Medical•Mortality Ablation•P-

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Mortality Stroke/HF02468

101214161820

AblationMedical Therapy

P< .001 P< .001

Symptomatic AF Management by the Guidelines

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Catheter Ablation is only recommended as first line for symptomatic patients

with paroxysmal AF

Special Circumstances

• No data for use of catheter ablation for management of symptomatic AF in any of the following:– Acute coronary syndrome– Acute HF episode– Acute hyperthyroidism– Postoperative cardiac or thoracic surgery– AF complicating acute pulmonary conditions, including

COPD flare, pneumonia, or PE

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Summary

• AF ablation has not been prospectively tested against a rate control strategy in older patients and those with No/ minimal symptoms

• Rhythm control strategies including AF ablation are probably underused in symptomatic AF patients but not all symptomatic AF patients are good ablation candidates

• AF ablation is recommended as first or second line treatment of young symptomatic patients with paroxysmal AF

• AF ablation is currently second line treatment in older symptomatic patients and in patients with persistent AF

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Dr. Kevin Jackson

CABANA Trial- Answers are Coming!

• 2200 patients (2062 enrolled)• Designed to test the hypothesis that ablation of AF

will be superior to current state of the art rate control or pharmacological rhythm control for decreasing the combined incidence of – death– disabling stroke– serious bleeding– cardiac arrest

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