Individualisierte, stadiengerechte Therapie des Vorhofflimmerns Grenzen und Möglichkeiten

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1 Individualisierte, stadiengerechte Therapie des Vorhofflimmerns Grenzen und Möglichkeiten Thomas Zerm, Dpt. Kardiale Elektrophysiologie Albertinen Herz- und Gefässzentrum, Hamburg Atrial Fibrillation: 1.5-2% of the general population Prevalence of Diagnosed Atrial Fibrillation in Adults: National Implications for Rhythm Management and Stroke Prevention: the Anticoagulation and Risk Factors In Atrial Fibrillation JAMA. 2001;285(18): doi: /jama

2 EHRAS Klassifikation EHRAS I-IV (a-d) 2

Persistierend (>7 d) langanhaltend Persistierend (>1 Jahr)

3 Verschiedene klinische Stadien des Vorhofflimmerns Erste diagnostizierte VHF-Episode Paroxysmal (meist <48h) Persistierend (>7 d) langanhaltend Persistierend (>1 Jahr) permanent (akzeptziert) Klinische Manifestationen des Vorhofflimmerns 3

Pathophysiologische Aspekte bei der Entstehung des Vorhofflimmerns COUMEL SCHE TRIAS Stadien der Veränderung des Vorhofmyokards LGE-MRI: Möglichkeit zur

4 Pathophysiologische Aspekte bei der Entstehung des Vorhofflimmerns COUMEL SCHE TRIAS Stadien der Veränderung des Vorhofmyokards LGE-MRI: Möglichkeit zur Darstellung und Quantifizierung von fibrose-assoziierten Veränderungen des links-atrialen Myokards Akoum et al. MRI for AF Patient Selection and Ablation Approach,

MRI for AF Patient Selection and Ablation Approach Relevante

5 Assoziation des Fibrosegrades (Utah Score) zur kliunischen Verlaufsform des Vorhofflimmerns Akoum et al. MRI for AF Patient Selection and Ablation Approach Relevante pathogenetische Ursachen für die Entstehung von Vorhofflimmern Shenasa et al. Europace

6 ESC/ EHRA Guidelines (2016) zur Rhythmuskontrolle bei Vorhofflimmern 6

Eskalierende rhythmuskontrollierende Therapie bei Vorhofflimmern, Modell: Albertinen

Dronedaron Katheterablation PVI Re-PVI Substratmodifikation Chirurgische Ablation

Grunderkrankung Orale Antikoagulation entsprechend des individuellen Risikoprofils Guided

7 Eskalierende rhythmuskontrollierende Therapie bei Vorhofflimmern, Modell: Albertinen Vorhofflimmerkompetenznetzwerk Medikamentöse Therapie Flecainid Propafenon Sotalol Dronedaron Katheterablation PVI Re-PVI Substratmodifikation Chirurgische Ablation Concomitant Maze Stand Alone Hybrid Konsequente Behandlung der identifizierten Grunderkrankung Orale Antikoagulation entsprechend des individuellen Risikoprofils Guided Lifestyle Changements Psychokardiologische Mitbehandlung Frequenzkontrolle Betablocker, Ca-Antag. ±Digitalis AVJ-Modulation 7

Recurrence of Atrial Arrhythmias in the Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial Atrial Fibrillation/Flutter/Tachycardia

8 Recurrence of Atrial Arrhythmias in the Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial Atrial Fibrillation/Flutter/Tachycardia 1) CABANA, NEJM 2018 Fast Trial: Vergleich Katheterablation und thorakoskopische Ablation Fast Study Prior failed CA 65% Years since Dg 7 Boersma et al: Circulation

9 Fast Trial: Vergleich Katheterablation und thorakoskopische Ablation Unpublished Data Courtesy Dr. M. Castella Effekt der AV-Knoten-Ablation und CRT bei Patienten mit permanentem Vorhofflimmern MILOS-Studie Hazard Ratio AVN-Ablation + CRT vs. medikamentöser Frequenzkontrolle Cause of Death Gasparini et al, Eur Heart J,

Effizienz derzeitig eingesetzter Therapieverfahren bei

therapy 120 100 80 60 40 20 0 Drugs Catheter Ablation Surgical

ys Quellen: Albertinen Registry 1000 pat. CA for AF, S.

10 Effizienz derzeitig eingesetzter Therapieverfahren bei Vorhofflimmern Acute and long term response to AF (any type) therapy Drugs Catheter Ablation Surgical Ablation HR control drugs HR control AVJ ablation acute 1 y 4 ys Quellen: Albertinen Registry 1000 pat. CA for AF, S. Salzberg für chirurgische Ablationsverfahren S. Salzberg - VERTRAULICH 10

11 11

12 Mindestanforderungen an ein diagnostisches Work-Up für Patienten mit Vorhofflimmern Quelle: Albertinen Registry 1000 pat. CA for AF 12

13 Major gaps in evidence 1. Phenotypes of AF Atrial fibrillation has different causes in different patients. More research is needed to identify and treat distinct types of AF. 2. How much AF constitutes a mandate for therapy? Adequately powered studies are required to evaluate the diagnostic accuracy of new technologies for screening AF, the diagnostic yield in different populations, and the implications on anticoagulant and other therapy. 3. Stroke risk in specifi c populations Sp ecific AF groups should be studied to better characterize their risk for AF, stroke, and other complications, including patients with one stroke risk factor, women and non-caucasian patients. 4. Anticoagulation a. After successful rhythm control: Currently, anticoagulation should be continued in AF patients at risk of stroke, even after successful ESSENTIAL restoration MESSAGES of sinus rhythm. FROM Controlled THE 2016 trials ESC are GUIDELINES required to FOR evaluate THE the safety and timing of termination MANAGEMENT of anticoagulation OF ATRIAL FIBRILLATION in these patients. 4. Anticoagulation a. After successful rhythm control: Currently, anticoagulation should be continued in AF patients at risk of stroke, even after successful restoration of sinus rhythm. Controlled trials are required to evaluate the safety and timing of termination of anticoagulation in these patients. b. For cardioversion: Oral anticoagulation is recommended for cardioversion of new-onset AF over 48 hours, but safety may be further improved by initiating pre-cardioversion anticoagulation at <24 hours. c. In patients w ith chronic kidney disease: There is very little evidence on the effects of anticoagulation in patients with GFR <30 ml/min, or on renal replacement therapy, groups at high risk of both stroke and bleeding. d. After a bleed or stroke: Even after major or intracranial bleeding, reinitiating anticoagulation may still have a net clinical benefit. Patients with a prior ischaemic stroke are at the highest risk of recurrent events. 5. Left atrial appendage (LAA) occlusion for stroke prevention LAA occluders have yet to be tested against NOACs, or for the most common clinical indication, patients with absolute contraindication for oral anticoagulation. 6. Comparison of rate control agents ESSENTIAL MESSAGES FROM THE 2016 ESC GUIDELINES FOR THE Rate control is almost universally used but there is very limited evidence comparing the effects MANAGEMENT OF ATRIAL FIBRILLATION of different agents. 13

14 5. Left atrial appendage (LAA) occlusion for stroke prevention LAA occluders have yet to be tested against NOACs, or for the most common clinical indication, patients with absolute contraindication for oral anticoagulation. 6. Comparison of rate control agents Rate control is almost universally used but there is very limited evidence comparing the effects of different agents. 7. Key questions on catheter ablation Can rhythm control therapy convey a prognostic benefit in AF? How effective is ablation in persistent and long-standing persistent AF? What is the optimal technique for repeat catheter ablation? 8. Key questions on surgical AF ablation What are the benefits and risks of thoracoscopic AF ablation? Does surgical LAA exclusion prevent strokes in AF? What lesion sets and energy sources should be used in concomitant AF surgery? ESSENTIAL MESSAGES FROM THE 2016 ESC GUIDELINES FOR THE MANAGEMENT OF ATRIAL FIBRILLATION ESSENTIAL MESSAGES FROM THE 2016 ESC GUIDELINES FOR THE MANAGEMENT OF ATRIAL FIBRILLATION 14

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