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AF ablation is a waste of time and money

AF ablation is a waste of time and money. Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital. AF ablation is a waste of time and money: (you must be joking!). Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital. A recap of what we’ve learnt this morning….

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AF ablation is a waste of time and money

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  1. AF ablation is a waste of time and money • Dr Dhiraj Gupta MRCP MD DM • Liverpool Heart and Chest Hospital

  2. AF ablation is a waste of time and money:(you must be joking!) • Dr Dhiraj Gupta MRCP MD DM • Liverpool Heart and Chest Hospital

  3. A recap of what we’ve learnt this morning….

  4. AF kills you (slowly)….

  5. AF makes you miserable….

  6. AF costs megabucks…. 2.4% of the total NHS budget

  7. Conventional treatments limited efficacy Drugs only work in 1 in 3 patients

  8. Not only are drugs potentially ineffective but….. • They often cause unacceptable side effects • Discontinuation rates due to Adverse Effects: • CTAF: 18% Amio, 11% Sotalol • AFFIRM: 12% Amio, 11% Sotalol, 28% Flecainide • They may increase mortality • SPAF: esp. in heart failure • AFFIRM: AAD associated with  mortality (p=0.0005)

  9. Dronedarone isn’t the answer…. • Mild antiarrhythmic action • AF recurrence at 1 year: 64% vs 75% for Placebo • << Amiodarone (free from AF at 6 mo: 37% vs 58%) • Increased mortality in Heart Failure (ANDROMEDA) • Only approved by the NICE with reservations

  10. ….and neither is cardioversion

  11. Finally, a cure is in sight!...... Culprit: triggers in pulmonary veins

  12. Treatment: Pulmonary Vein Isolation

  13. The procedure works….. Current success rates 80%

  14. in long standing persistent AF too..

  15. It’s clearly better than drug therapy

  16. AF ablation has evolved rapidly… • Success rates have doubled • Paroxysmal AF: 40-50% to 80-90% • Persistent AF: 30-40% to 70-80% • Procedure times have halved • From 4-6 hours to 2-3 hours • Complication rates have halved: 4% to 2%

  17. Current technology has improved accuracy

  18. The last thing we now need is a party pooper!

  19. Drugs 30% efficacy Life long suffering Ablation 80% chance of cure One-stop solution

  20. If you always do what you always did…you’ll always get what you’ve always got

  21. Yes, AF ablation costs money… • 100,000 AF cases a year Median 1.5 procedures • £4000 per ablation • Total cost: half a billion pounds

  22. But where would you rather spend this money? • ? Iraq War: £ 4.5 billion (Mar 2006) • ? Olympics: £9.8 billion • ? NHS IT project: £15 billion • ? Bank Bailout £850 billion

  23. Upfront costs outweighed by subsequent savings… • Costs of recurrent hospital admissions • Electrical cardioversions • Absences from work • Costs of lifelong drug therapy • Regular INR tests • Decreased risk of the serious AF sequalae • Stroke • Heart Failure

  24. Measures to make ablation more cost effective 1. Careful patient selection: ablation not offered • Very long standing Persistent AF (>3 years) • Very large LA (>5.5 cm) • Morbid Obesity (BMI >40) • Age >80 years • Significant co-morbidity

  25. Measures to make ablation more cost effective 2. Individualised ablation strategy: Improve single procedure success rates Accepted for oral presentation at Cardiostim, Nice June 16-18, 2010

  26. Finally... What would you want?!

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