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José Ramón González Juanatey Cardiology and Intensive Cardiac Care Department

Quality of Life in Patients with Typical Atrial Flutter Following Cavotricuspid Isthmus Ablation . The Santiago Cohort. José Ramón González Juanatey Cardiology and Intensive Cardiac Care Department University Hospital. Santiago de Compostela. Spain. Atrial Tachycardias. Focal.

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José Ramón González Juanatey Cardiology and Intensive Cardiac Care Department

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  1. Quality of Life in PatientswithTypical Atrial FlutterFollowingCavotricuspidIsthmusAblation. The Santiago Cohort José Ramón González Juanatey Cardiology and IntensiveCardiacCareDepartment University Hospital. Santiago de Compostela. Spain

  2. Atrial Tachycardias Focal Macroreentry ● Flúter auricular derecho Flúter auricular dependiente del istmo cavotricuspídeo - Típico o antihorario - Típico reverso u horario - Reentrada de doble onda - Reentrada inferior (lower loop reentry) - Reentrada intraístmica Flúter auricular no dependiente del istmo cavotricuspídeo - Reentrada de la pared libre derecha - Incisional - Reentrada superior (upper loop reentry) ● Flúter auricular izquierdo - Perimitral - En relación con venas pulmonares - Septal ●Automatismo ●Actividad desencadenada ●Microreentrada Atrial Flutter. Clasification Saoudi et al. Eur Heart J 2001;22:1162-82

  3. Reverse Typical Atrial Flutter. ECG Flutter Wave: ♦ Componente negativo que precede al positivo en derivaciones inferiores. A veces este componente lo hace indistinguible del Fl típico. ♦ Melladura en derivaciones inferiores y V1 ♦V1 negativa y mellada ♦DI positiva ♦aVL negativa

  4. Improve Survival Increase functional capacity Improve Atrial dysfunction Atrial Flutter Ablation Clinical Objectives Reduce Morbidity Symptoms improvement Electrical stability Increase Quality of Life BP=blood pressure; COPD=chronic obstructive pulmonary disease

  5. Quality of Life and Atrial Flutterablation • Differentstudieshaveprovedanimprovement in QoLafter CTI AFlablation1-5 butmost of them: • Notstandardizednornormalized (americanpopulation). • Standardized and normalized to americanbutnot to ownpopulation. • Notadjustedbyage and sex (theoldesthavepoorQoL and malehavebetterQoLthanfemale). • Subgroups has notbeenanalized (especially atrial fibrillation). • Results has neverbeenexpressed as importantclinicalminimaldifferences (MID). This concept allows to knowif a treatment produces a relevantclinicalbenefit to thepatient and notonlystatisticallysignificantchanges. • Notevaluation in a short and long-term. • NotEvaluation of structural and functionalcardiacchanges. 1. Calkins et al. Am J Cardiol 2004; 94:437-42; 2. O´Callaghan et al Heart 2001;86:167-71; 3. Feld et al. Am CollCardiol2004;43:1466-72; 4. Lee et al. Am J Cardiol1999;84:278-83.5. Meissner et al. Clin Res Cardiol 2007;96:1-9.

  6. GarciaSeara et al. RevEspCardiol 2011;64:401-408

  7. Atrial Flutter Santiago Cohort. ClinicalCharacteristics

  8. Atrial Flutter Santiago Cohort. ClinicalCharacteristics

  9. Short Form (SF-36) Quality of LifeQuestionnaire

  10. FlutterAblation. ProcedureComplications and Follow-up

  11. 80 60 40 20 0 -20 CSM CSF FF RF DC SG VT AS RE SM BaselineQuality of Life. Standarized and NormalizedfortheSpanishPopulation. Age and gender-adjusted CSF: componentsummaryPhysical CSM: componentsummaryMental SD: Estándardeviation FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental Population Mean and SD: 50 ± 10 Light Deviations: > 4 puntos Moderate Deviations: > 6 puntos Severe Deviations: > 8 puntos GarciaSeara et al. Cuad. Estimulación cardíaca 2010:31-41

  12. 1-year Quality of Life. Standarized and NormalizedfortheSpanishPopulation. Age and gender-adjusted SG:salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental CSF: componentsummaryPhysical CSM: componentsummaryMental FF: función física RF: rol físico DC: dolor corporal GarciaSeara et al. Cuad. Estimulación cardíaca 2010:31-41

  13. Quality of Life at Baseline and 1-Year Follow-up, Standarized and NormalizedfortheSpanishPopulation. AdjustedforAge and Gender GarciaSearaJ, …, González-Juanatey JR et al. RevEspCardiol 2011;64:401-408

  14. AbsoluteDifferences in Quality of Life at Baseline and 1-Year Follow-up, Standarized and NormalizedfortheSpanishPopulation. AdjustedforAge and Gender FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental *p<0,05;CSF: componentsummaryPhysical ;CSM: componentsummaryMental; SD: standarddeviation Population Mean and SD: 50 ± 10 Light Deviations: > 4 puntos Moderate Deviations: > 6 puntos Severe Deviations: > 8 puntos GarciaSeara et al. RevEspCardiol.2011

  15. Differences in Quality of Life at Baseline and 1-Year Follow-up Standarized and NormalizedfortheSpanishPopulation. AdjustedforAge and Gender ES: Effectsize SRM: Standarized Response Mean MCID: Minimumclinicallyimportantdifference CSF: ComponentsummaryPhysical; CSM: ComponentsummaryMental ● ≥0,80: ImportantVariations ●0,50-0,79: ModerateVariations ●0,20-0,49: Light Variations ●0,01-0,19: VerymodestVariations GarciaSeara et al. RevEspCardiol.2011;64;401-08

  16. Differences in Quality of Life at Baseline and 1-Year Follow-up Atrial FibrillationduringtheFollow-up FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental *p<0,05; Los datos se expresan en mean ± SD SD: standarddeviation GarciaSeara et al. HealthQualLifeOutcomes 2012

  17. Quality of LifeDimensions at 1-Year Atrial FibrillationduringFollow-up VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental FF: función física RF: rol físico DC: dolor corporal SG: salud general *p<0,05; Data are expressed as mean ± SD CSF: componentsummaryPhysical CSM: componentsummaryMental SD: standarddeviation GarciaSeara et al. HealthQualLifeOutcomes 2012

  18. Differences in Quality of Life at Baseline and 1-Year Follow-up Type of Atrial Flutter FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental *p<0,05; Data are expressed as mean ± D DE: Standard deviation

  19. Quality of LifeDimensions at 1-Year Type of of Atrial Flutter FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental. *p<0,05; Data are expressed as mean ± SD and [median].

  20. Differences in Quality of Life at Baseline and 1-Year Follow-up Gender FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental *p<0,05; Los datos se expresan en media ± DE SD: standarddeviation

  21. Differences in Quality of Life at Baseline and 1-Year Follow-up StructuralCardiacDisease FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental *p<0,05; Los datos se expresan en media ± DE SD: standarddeviation

  22. Differences in Quality of Life at Baseline and 1-Year Follow-up Number of Episodes FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental *p<0,05; Los datos se expresan en media ± DE SD: standarddeviation

  23. Differences in Quality of Life at Baseline and 1-Year Follow-up PersistentFlutter and Ventricular Cycle FF: función física RF: rol físico DC: dolor corporal SG: salud general VT: vitalidad AS: actividad social RE: rol emocional SM: salud mental *p<0,05; Los datos se expresan en media ± DE SD: standarddeviation GarciaSeara et al. HealthQualLifeOutcomes 2012

  24. Differences in Quality of Life at Baseline and 1-Year Follow-up FlutterType / Ventricular Cycle / StructuralHeartDisease *p<0,05. Los datos se expresan en media ± DE. FF: función física; RF: rol físico; DC: dolor corporal; SG: salud general; VT: vitalidad; AS: actividad social; RE: rol emocional; SM: salud mental, CSF: componente sumario físico, CSM: componente sumario mental; TES: transición del estado de salud; FlApers.: flúter persistente, FlAparox.: flúter paroxístico; Cp: cardiopatía GarciaSeara et al. HealthQualLifeOutcomes 2012

  25. Structural and FunctionalCardiacRemodeling. Differencesamongcardiacstructural and funcional parameters *p<0,05 Cuantitative data are expressed as mean ± SD ● AD: Aurícula derecha ● cf: fracción de acortamiento ● AI: aurícula izquierda ● dAI: dimensión de aurícula izquierda ● FEVI: fracción de eyección de ventrículo izquierdo ● VD: ventrículo derecho ● FC: frecuencia cardíaca ● E: velocidad máxima de onda E ● A: velocidad máxima de onda A ● E/A:cociente entre E y A ● TdecE: tiempo de deceleración de la onda E ● TRIV:tiempo de relajaciónisovolumétrica ● TIV: tabique interventricular ● DTD:diámetrotelediastólico de VI ● DTS:diámetrotelesistólico de VI ● PP: pared posterior de VI GarciaSeara et al. RevEspCardiol 2012

  26. Structural and FunctionalCardiacRemodeling. Differencesamongcardiacstructural and funcional parameters DiastolicLeft Ventricular Function P=0,22 P=0,000 GarciaSeara et al. RevEspCardiol 2012

  27. Quality of Life at Long-termafter CTI Ablation p*: baseline- 1 y p**: baseline- 6 y

  28. Quality of Life at Long-termafter CTI Ablation Cabanas-Grandío et al. HealthQualLifeOutcomes 2014

  29. Quality of Life at Long-termafter CTI Ablation Cabanas-Grandío et al. HealthQualLifeOutcomes 2014

  30. Quality of Life at Long-termafter CTI Ablation. Atrial Fib

  31. Quality of Life at Long-termafter CTI Ablation Chronic Oral Anticoagulation

  32. Quality of Life at Long-termafter CTI Ablation. Diabetes

  33. FactorsRelatedto Long-termQuality of Lifeafter CTI Ablation PhysicalComponentSummary Mental ComponentSummary Cabanas-Grandio P et al. Health and QofLOutcomes. 2014; 12: 47

  34. Atrial Fibrillation-free Survival. Atrial FlAblation Santiago Cohort Seara JG et al. Clin Res in Cardiol. 2014

  35. Atrial FibIncidenceafter CTI Ablation. The Santiago Cohort

  36. Atrial Fib, Stroke and DeathRiskafter Atrial FlutterAblation

  37. Atrial Fibrillation, Stroke and DeathDeterminants in Patientswith CTI Ablation. MultivariateAnalysis

  38. Stroke and DeathDeterminants in Patientswith Atrial FibrillationduringFollow-up. MultivariateAnalysis

  39. Atrial FibRecurrenceafter CTI Ablation. The Santiago Cohort Group 3: isolated AFL Group 2: Afib + AFL Group 1: IC AFL García Seara et al. Int J Cardiol. June 2014

  40. Conclusions • A clinicallysignificativeimprovement in HRQoLmeasuresafter 1-year wasfound in patientswithtypical trial flutterwhounderwentcavotricuspidisthmuscatheterablation and can be offered as a validtherapeutic alternativa tomost of thepatients • In ourpopulationwefoundinversestructural and functionalcardiacremodelling at 1-year follow-up withmuchimprovedleft ventricular ejectionfraction, rightatriumcontractionfraction, and diastolicdysfunctionpattern. • CTI ablationprovides a sugnificantimprovement in long-termQoLforthedimensions of Physical Role, Vitality and Mental Health. Previous diabetes mellitus, Atrial Fib, oral anticoagulation, basal QoL and Atrial Flutterrecurrenceweredeterminants of a worselong-termQoL. • Patientswith Atrial Fibduringfollow-up show a significantloweHRQoL at 1-year post-ablation.

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