Aktuelle Therapieoptionen bei Vorhofflimmern J. Auer

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Norbert Krause
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1 Aktuelle Therapieoptionen bei Vorhofflimmern J. Auer Abteilung für Innere Medizin 1 mit Kardiologie und Intensivmedizin KH St. Josef Braunau Akademische Lehrabteilung der Medizinischen Universitäten Wien, Graz, Innsbruck und Salzburg

Aktuelle Behandlungsstrategien für VHF Prävention von Thromboembolien Frequenzkontrolle Rhythmuskontrolle Allgemeine Ziele: Reduzierung

2 Aktuelle Behandlungsstrategien für VHF Prävention von Thromboembolien Frequenzkontrolle Rhythmuskontrolle Allgemeine Ziele: Reduzierung der Symptome und Verbesserung der Lebensqualität Verminderung der Auswirkungen von VHF auf die Herzfunktion Senkung des Schlaganfallrisikos

3 Behandlungsoptionen bei VHF Kardioversion Medikamentös Elektrisch Medikamente zur VHF-Prävention Antiarrhythmika Nicht-antiarrhythmische Medikamente Medikamentöse Kontrolle der ventrikulären Frequenz Medikamente zur Reduzierung des Thromboembolischen- Risikos Nichtmedikamentöse Optionen AV-Knoten-Ablation und Schrittmacherimplantation Katheterablation Chir. OP (Maze, Mini-Maze)

4 Vorhofflimmern Therapie symptomatisch asymptomatisch Auer J, Brugada J. Eur Heart J 2011 Ablation/Device Rhythmuskontrolle(Antiarrhythmika) Frequenzkontrolle ANTIKOAGULATION! paroxysmal permanent

5 CASTLE AF, CABANA Rolle der pharmakolog. rhythmuserhaltende Therapie ESC 2018

6 Chron. HI und VH-Fli Prävalenz Prevalence of AF (%) I II-III III-IV IV 49,8 25,8 28,9 14,4 15,4 10,1 4,2 SOLVD-P SOLVD-T V-HeFT CHF-STAT DIAMOND CHF GESICA CONSENSUS Maisel WH, et al. Am J Cardiol 2003

8 Lungenvenenisolation bei HI Pat.

9 Chron. HI und VH-Fli Kausaler Zusammenhang?? Anter, E. et al. Circulation 2009;119:2516

10 LVI vs. AV-Ablation PABA-CHF n= 41 NYHA II / III EF < 40% Khan M et al. N Engl J Med 2008;359:

11 CASTLEAF Rationale and Objective Study the effectiveness of catheter ablation of atrial fibrillation in patients with heart failure in improving hard primary endpoints of mortality and heart failure progression when compared to conventional standard treatment

take AAD LVEF 35% NYHA class II ICD/CRTD with Home Monitoring

12 CASTLEAF Inclusion Criteria Symptomatic paroxysmal or persistent AF Failure or intolerance to 1 or unwillingness to take AAD LVEF 35% NYHA class II ICD/CRTD with Home Monitoring capabilities already implanted due to primary or secondary prevention

Study Design CASTLEAF Investigator initiated, Prospective, Multicenter ( 31 sites, 9 countries), Randomized, Controlled 3013 pts Eligibility Assessment 179 pts 153 pts (26 crossovers) Enrolled/

13 Study Design CASTLEAF Investigator initiated, Prospective, Multicenter ( 31 sites, 9 countries), Randomized, Controlled 3013 pts Eligibility Assessment 179 pts 153 pts (26 crossovers) Enrolled/ Randomized 397 pts 21 pts excluded 200 pts Runin 5 weeks 197 pts Ablation Followup: 3, 6, 12, 24, 36, 48, 60 months 13 pts excluded Conventional ICD/CRTD check Adverse event documentation Echocardiography 6minute walk test Optimization of medication for HF Home Monitoring programming NYHA, weight, BP, QoL Patients diary 165 pts (18 crossovers) 184 pts

14 Baseline Characteristics- CASTLE AF Ablation group (179 patients) Conventional group (184 patients) Age years 64 (5671) 64 (5673.5) New York Heart Association class I (%) II (%) III (%) IV (%) 2 1 Left ventricular ejection fraction % 32.5 ( ) 31.5 ( ) Current type of atrial fibrillation Paroxysmal (%) Persistent (%) CRTD implanted (%) ICD implanted (%) 73 72

Baseline Characteristics- CASTLE AF Ablation group (179 patients) Conventional group (184 patients) ACEinhibitor or ARB no. (%) 94 91 Betablocker no.

15 Baseline Characteristics- CASTLE AF Ablation group (179 patients) Conventional group (184 patients) ACEinhibitor or ARB no. (%) Betablocker no. (%) Diuretic no. (%) Digitalis no. (%) Oral anticoagulant no. (%) Antiarrhythmic drug no. (%) Amiodarone no. (%) 97 85

16 ResultsCASTLE AF Rate Versus Rhythm Control in Conventional Arm Percent of Patients (%) Rate control: Beta-blocker Digitalis Calcium antagonist Atrioventricular node ablation (in 5 patients) Rhythm control: Antiarrhythmic drug Atrial fibrillation ablation (18 crossover cases) Follow Up Time (Months)

17 ResultsCASTLE AF AF Burden Derived from Memory of Implanted Devices Percent (%) in Time Baseline 3M 6M 12M 24 M 36M 48M 60M AF Burden Ablation Conventional

18 ResultsCASTLE AF Absolute change in LVEF from baseline 20 p*=0.001 p=0.055 p*=0.005 LVEF Change from Baseline mo 36mo 60mo Ablation Conventional

19 ResultsCASTLE AF Serious Adverse Events Event Ablation Group (n=179) no. patients with event (%) Conventional Group (n=184) no. patients with event (%) Pericardial effusion (acute) 3 (1.7) 0 Severe bleeding (acute) 3 (1.7) 0 Stroke or TIA 7 (3.9) 12 (6.7) Pulmonary vein stenosis 1 (0.6) 0 Pneumonia 3 (1.7) 1 (0.5) Groin infection 1 (0.6) 0 Worsening heart failure 1(0.6) 0

ResultsCASTLE AF Primary Composite Endpoint (Death, wors. HF Hosp.) Freedom 1 0.8 0.6 0.4 0.2 HR, 0.62 (95% CI, 0.43 0.

20 ResultsCASTLE AF Primary Composite Endpoint (Death, wors. HF Hosp.) Freedom HR, 0.62 (95% CI, ); 0 Patients at Risk P=0.007 Risk Reduction: 38% Ablation Conventional Ablation Conventional

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