Pulmonary Vein Isolation: Who Should Be Considered?
Paul A. Rogers, MD, PhD Clinical Cardiac Electrophysiology John Ochsner Heart and Vascular Institute
Disclosure of Relationships • None
Atrial Fibrillation Triggers
Freedom from AF in 28/38 pts. (62%) at 8±6 months
Haïssaguerre M et al. N Engl J Med 1998;339:659-666.
ThermoCool AF Freedom from Symptomatic Atrial Arrhythmias 70% RFA
Improvement in Quality of Life 10
N=106
19% AAD N=61 36 (65%) crossover
% change
13 (12.6%) redo
5
0
RFA AAD
-5
-10
-15
SF-36 SF-36 Symptom Symptom mental physical frequency severity
Wilbur D et al. JAMA. 2010;303(4):333-340.
Case 1 • AB, 79 year-old woman – Symptomatic persistent atrial fibrillation x 4 months – DCCV x 4 – Failed sotalol, currently taking amiodarone
• PMHx: HTN, hypothyroidism, mild cardiomyopathy, COPD • ECHO: LVEF 45%, no LVH, normal LA size
Case 1
A. Increase Metoprolol B. PPM/AV node RFA
C. Offer PVI D. DCCV
Patients without Atrial Tachyarrhythmias in the Absence of Antiarrhythmic-Drug Therapy.
70%
4%
IIa Symptomatic persistent AF, failed prior AAD Oral H et al. N Engl J Med 2006;354:934-941.
Case 2 • RM, 54 year-old man – Symptomatic, paroxysmal atrial fibrillation x 2yrs – Flecainide 100mg twice daily + metoprolol x 8 months, still with recurrences – Recent admission, converted while being rate controlled with diltiazem gtt
• PMHx: HTN, CAD prior MI/PCI, obesity, SSS s/p PPM • ECHO: LVEF 65%, no LVH
Case 2
A. Change to Class III AAD B. AVN RFA
C. Offer PVI D. Continue Flecainide
Freedom from recurrent AF without AAD (RFA group) after the 90-day treatment adjustment period 89%
N=52
23%
N=55
Mean AADs used: 2.5 ± 1
I
Symptomatic paroxysmal AF, failed prior AAD
Pierre Jaïs et al. Circulation. 2008;118:2498-2505
Case 3 • JL, 45 year-old man – Symptomatic, paroxysmal atrial fibrillation x 5 months – Episodes typically last 4-5 hours, has 1-2 episodes weekly. Diagnosed with outpatient monitoring – Exercised regularly before, now afraid to due to induction of atrial fibrillation. – Has read about PVI and strongly prefers to avoid medications.
• PMHx: none • ECHO: LVEF 65%, no LVH, normal LA size
Case 3
A. Initiate AAD/Class 1 agent B. Restrict exercise
C. Monitor for progression D. Offer PVI
Time to First Recurrence of any Atrial Tachyarrhythmias (A) and Symptomatic Atrial Tachyarrhythmias (B)
IIa Recurrent symptomatic paroxysmal AF, no prior AAD Morillo CA et al. JAMA. 2014;331:692-700.
Case 4 • DS, 76 year-old man – Persistent atrial fibrillation x 2 years – Currently without observable symptoms – Tried DCCV x 3 with anti-arrhythmic therapy • Flecainide, sotalol, amiodarone
• PMHx: hypertension, diabetes mellitus II • ECHO: LVEF 65%, severe left atrial enlargement
Case 4
A. AVN RFA/PPM B. Try Multaq/DCCV
C. Continue current management D. Offer PVI
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD
No Prior Class I/III AAD
January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD A
Symptomatic Pa AF
No Prior Class I/III AAD
January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD A
Symptomatic Pa AF B
Symptomatic Pe AF
No Prior Class I/III AAD
January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD A
Symptomatic Pa AF
Symptomatic Pe AF
B B
Symptomatic LS Pe AF
No Prior Class I/III AAD
January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD A
Symptomatic Pa AF
Symptomatic Pe AF
B B
Symptomatic LS Pe AF
No Prior Class I/III AAD B
January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
Symptomatic Pa AF
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD A
Symptomatic Pa AF
Symptomatic Pe AF
B B
Symptomatic LS Pe AF
No Prior Class I/III AAD B
Symptomatic Pa AF C
January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
Symptomatic Pe AF
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD A
Symptomatic Pa AF
Symptomatic Pe AF
B B
Symptomatic LS Pe AF
No Prior Class I/III AAD B
Symptomatic Pa AF C
Symptomatic Pe AF
C
Symptomatic LS Pe AF
January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
2014 AHA/ACC/HRS AF Guidelines
After failing Class I/III AAD A
Symptomatic Pa AF
Symptomatic Pe AF
B B
Symptomatic LS Pe AF
No Prior Class I/III AAD B
Symptomatic Pa AF C
Symptomatic Pe AF
C
Symptomatic LS Pe AF
C January CT et al. J Am Coll Cardiol. 2014;64:2246-2280.
Stand alone surgical ablation