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AF in Patients with Heart Failure Role of AVN Ablation and CRT

AF in Patients with Heart Failure Role of AVN Ablation and CRT. Win K. Shen, MD Professor of Medicine Mayo Clinic College of Medicine Chair, Cardiovascular Diseases Mayo Clinic Arizona ACC Florida, 2014. DISCLOSURE. Relevant Financial Relationship(s) None Off Label Usage None.

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AF in Patients with Heart Failure Role of AVN Ablation and CRT

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  1. AF in Patients with Heart Failure Role of AVN Ablation and CRT Win K. Shen, MD Professor of Medicine Mayo Clinic College of Medicine Chair, Cardiovascular Diseases Mayo Clinic Arizona ACC Florida, 2014

  2. DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None

  3. ObjectivesAtrial Fibrillation and Heart Failure • Cyclical Relationship: Mechanisms • AF promotes HF • HF promotes AF • A Case Study • Indications for CRT • What should be the minimum % of pacing? • When to ablate the AVN? • A review of guidelines and consensus

  4. Development of CHF in Pt with AFib Cumulative incidence of CHF Years Impact of incident CHF on mortality (RR+CI) Impact of incident AFib on mortality Development of AFib in Pt with CHF Men Men Women Women 2.7(1.9-3.7) 1.6(1.2-2.1) 3.1(2.2-4.2) 2.7(2.0-3.6) Cumulative incidence of AF Years AFib and CHF – Temporal Relations and MortalityFramingham Study Benjamin: Circ, 2003 CP1119361-1

  5. Atrial Fibrillation and CHF AFCHF • Loss of atrial contraction • Impaired ventricular filling • High heart rates A vicious cycle Atrial fibrillation Neurohormonal activation Sympathetic stimulation Use of negative inotropic drugs ¯ EF ¯ perfusion CHF AF • Atrial dilatation • Stretch receptor activation • Neuro-humoral modulation • Signal transduction/bioenergetics • Electropysiologic remodeling • Fibrosis CHF Triggered activity Refactoriness Conduction Automaticity CP1110819-1

  6. 71 year-old man has mixed CM for 2-3 years. He has permanent AF. Despite medical therapy, he has SOB walking 2-3 blocks and worse at higher altitude. Most recent EF was 28%, LVEDD 59 mm. He has been treated with carvedilol, losartan, lasix, simvastatin, ASA, warfarin. EKG is shown, QRSD 150 msec. Case Study

  7. Case Study What would you recommend? CRT is indicated (I) CRT can be useful (IIa) CRT may be reasonable (IIb) CRT is not recommended (III)

  8. Case Study If you did implant a CRT, would you recommend AVN ablation? Yes No

  9. Case Study If you did not recommend AVN ablation, what would be the desired % of pacing? > 50% > 70% > 90% ~ 100%

  10. CP1313975-1

  11. Recommendations for CRT in Patients With Systolic Heart Failure AHA/ACC/HRS 2012

  12. Cardiac Resynchronization Therapy Permanent AFib Brignole et al: EHJ 34:2281, 2013

  13. Case Study What would you recommend? CRT is indicated (I) CRT can be useful (IIa) CRT may be reasonable (IIb) CRT is not recommended (III)

  14. Variable BV Pacing in AF Conducted AF Response (BV) VSR/VTR Pseudo Fusion

  15. Six Studies Reporting Outcome Datafor AF Patients Undergoing CRT for HF *Represents mean age of CRT-AF patients as a group; †24% lost to follow-up Ganesan et al: J Am Coll Cardiol 2012;59:719–26

  16. Mean Difference in NYHA Functional Class for CRT-AF Patients Undergoing AVNA vs Medical Therapy with Rate-Controlling Drugs Difference Difference in meansStudy name in means P and 95% CI Molhoek 2004 -0.100 0.572 Ferreira 2008 -0.500 0.000 Dong 2010 -0.300 0.009 -0.339 0.002 -20 -10 0 10 20 Favors AVNA+ Favors AVNA- Ganesan et al: J Am Coll Cardiol 2012;59:719–26

  17. Case Study If you did not recommend AVN ablation, what would be the desired % of pacing? > 50% > 70% > 90% ~ 100%

  18. Case Study CRT-D Implanted (05/22/12)

  19. Case Study Post Implantation EKG (5/22/12)QRSD 138 msec

  20. Case Study Follow Up (10/22/13) 98% BV pacing QRSD 138 msec, LVEDD 55 mm EF 42%, symptoms improved from II to 1-II

  21. Indication for AVJ Ablation in Patients With Symptomatic Permanent AFib and OptimalPharmacological Therapy Heart Failure, NYHA class III–IV and EF <35% Reduced EF and uncontrollable HR, any QRS QRS ≥120 ms QRS <120 ms CRT Adequate rate control Inadequate rate control Incomplete BiV pacing Complete BiV pacing No AVJ ablation No CRT AVJ ablation and No CRT AVJ ablation and no CRT AVJ ablation No AVJ ablation Brignole et al: EHJ 34:2281, 2013

  22. AF and HF ACC Florida, 2014

  23. Functional class I SOLVD, 1992 SOLVD, 1991 II-III V-HeFT, 1991 CHF-STAT, 1991 III-IV Stevenson, 1996 GESICA, 1994 IV CONSENSUS, 1987 Patients (%) European Survey of Primary Care Physicians • 15 countries • 1,363 physicians • 11,062 pt • 1999-2000 Atrial fib 22% Symptoms Moderate  severe 41% Cleland J: Lancet, 2002 Atrial Fibrillation in Heart Failure Stevenson W CP1090494-1

  24. Heart Failure, Left Atrial Size and Tissue Fibrosis A * B * Avg atrial %fibrosis LA area (cm2) Control CHF Control CHF C D Cha, AJP 2003 CP1068448-51

  25. 60 60 60 40 40 EF(%) 30 20 0 AF 120 AF 70 AF 76 AF 70 Heart rate (bpm) Serial Changes in EF 80-Year-Old Female *Heart rate 140 one week earlier Grogan M: AJC 69:1573, 1992 CP1000536-4

  26. Cardiac Output Wedge Pressure 8 25 AF–Adverse Effect of Irregular Rate P<0.002 20 P<0.01 6 15 mmHg L/min 4 10 2 5 0 0 VVI VVT VVI VVT VVI = regular rate at mean AF rate VVT = irregular rate tracking AF Clark et al: JACC, 1997 CP942080-15

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