AFIB Cases For Students

Current Treatment Of Atrial Fibrillation-
From Antiarrhythmic To Ablation
Eyal Nof M.D

Director of Invasive EP Service
Davidai Arrhythmia Center, Leviev Heart Center, Sheba Medical
Center, Tel-Hashomer,
and Sackler School of Medicine, Tel-Aviv University, Tel-
Aviv, Israel
Sheba Medical Center

Tel Hashomer The Leviev Heart Center
Case No 1 :
• 52 yo, no PMH.
• Incidental finding of hrs of AF on Rec Holters:
What to do?
1. Ignore; 2. BB; 3. AAD; 4. Ablation (PVI)- RF? Cryo?

But ….. Sinus is Better !!!
SINUS RHYTHM is
related with
surveillance
AAD increases
mortality

SR>> rate control

2020 ESC Guidelines for the diagnosis
and management of atrial fibrillation
developed in collaboration with the
European Association for
Cardio-Thoracic Surgery (EACTS)

Types of AF Triggers
ectopic foci
Paroxysmal AF
Persistent AF
Electrophysiologic
Remodeling
Chronic Substrate
Permanent AF fibrosis
Sheba Medical Center Stambler et al JCE 2003;14:499

Tel Hashomer Li, Nattel et al. Circulation. 1999;100:87-95 The Leviev Heart Center
AF ablation – evolving approaches
Triggers Substrate
Drivers

AF Disease Progression
Paroxysmal AF develops into persistent AF with an overall rate of 5.5%
per year1
At-risk 1
Asymptomatic Paroxysmal Persistent Long-Standing Persistent Permanent
for AF
Atrial remodeling, AF progression, consequences and co-morbidities2,3
Ablation success rates4,5
Blomstrom Lundqvist, ESC 2019
1. Kato T, et al. Circ J (2004) 68: 568 2. Kirchhof et al. 2016 Guidelines for the management of AF developed in collaboration with EACTS. Eur Heart J. 2016;37:2893-2962 3. Nattel et al. Early management
of atrial fibrillation
to prevent cardiovascular complications. Eur Heart J. 2014; 35(22):1448-56 4. Schotten et al. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev. 2011; 91:265-325 5.
Zhao et al. Observation
of the efficacy of radiofrequency catheter ablation on patients with different forms of atrial fibrillation. Euro Rev Med Pharmacol Sci. 2016; 20:4141-47 6. Quan et al. Predictors of late atrial fibrillation recurrence
after cryoballoon-based pulmonary vein isolation: a meta-analysis. Kardiologia Polska. 2017; 75(4):376-85

Figure 19 Long-term rhythm control therapy
©ESC
©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)

Antiarrhythmic therapy
EFFICACY
• After 5 years only half pts are in sinus

AFFIRM sub-study (JACC, 2003)

Pulmonary vein triggers are important for paroxysmal atrial fibrillation
Haissaguerre M, et al. N Engl J Med 1998; 339:659-666
Myocardial sleeve around PV
Perez-Lugones, et al. JCE 2003;14: 803
Initiation of AF by rapid
firing in a PV

Pulmonary Vein Isolation is the Cornerstone of
AF Ablation
2020 ESC AF Guidelines
PVI is the best documented target for catheter ablation and
the cornerstone of all AF ablation procedures2
▪ “The cornerstone of AF catheter ablation is the complete
isolation of pulmonary veins by linear lesions around their
antrum…” 2
▪ “AF catheter ablation is a well-established treatment for the
prevention of AF recurrences. When performed by
appropriately trained operators, AF catheter ablation is a
safe and superior alternative to AADs for maintenance of
sinus rhythm and symptom improvement” 2
2017 HRS/EHRA Consensus Statement

> 90% “Electrical isolation of the PVs is recommended during all
AF ablation procedures (Class I, LoE A)”3
Of AF triggers found near PVs1
Growing Body of Published Literature

5 RCTs demonstrated no benefit in ablation beyond PVI for
AF (n > 1,100) 4-8
1. Haïssaguerre M, et al. N Engl J Med 1998; 339:659-666 2. Hindricks, G., et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European
Association of Cardio-Thoracic Surgery (EACTS). European Heart Journal, 1–126. 2020 3. Calkins H, et al. Heart Rhythm. 2017 Oct;14(10):e275-e444. 4.Verma A, et al. N Engl J Med. 2015;372:1812–1822
5. Wong KC, et al. Circ Arrhythm Electrophysiol. 2015; 8:1316–1324 6. Verma A, et al. J Cardiovasc Electrophysiol. 2011 May;22(5):541-547 7. Dixit S, et al. Circ Arrhythm Electrophysiol. 2012;5:287-294 8.
Tel Hashomer
Vogler J, et al. J Am Coll Cardiol. 2015 Dec 22;66(24):2743-2752 The Leviev Heart Center
LEFT ATRIAL
CIRCUMFERENTIAL
ABLATION (LACA)
NAVEX

Contact Force:

Arctic Front Advance Cryoballoon

Event-free Survival for the Primary Efficacy and Safety
End Points in the Modified Intention-to-Treat Cohort.
Kuck K et al. N Engl J Med 2016;374:2235-2245.

The new kid in town?
PULSED FIELD ABLATION -
PFA
Maor et al. Heart Rhythm, Vol 16, No 7, July 2019

Are we in a perfect world? …

PFA CRYO
Reddy et Al. JACC EP 2021 Kuniss et Al. Europace 2021

Collateral damage:
In 5/5 pts! All alleviated with NTG

Is compromising good or bad?

One size fits all???
PFA protocols are not disclosed by

industry
Maor et al. Heart Rhythm, 2019

How to maintain SR?
CA
AAD

Preventing Progression Of AF: How To Treat?
Ablation reduces the percentage of AF progression vs. medical therapy alone
• Systematic review in general

population (primarily medical
therapy only) vs. catheter ablation
studies
• Weighted progression from
paroxysmal to persistent or
permanent AF by follow-up
duration
• The percentage of AF progression
increases over time (i.e., with
longer follow up duration) in
general population studies (n = 21),
but remains flat in AF-ablation
studies (n = 8)
Proietti et al. A systematic review on the progression of paroxysmal to persistent atrial fibrillation: shedding new light on the effects of
27
catheter ablation. JACC: Clinical Electrophysiology. 2015; 1(3):105-115.
Cryo-FIRST
Primary Endpoint (ITT analysis)
Cryoballoon catheter
ablation was associated
with a >50% risk
reduction in atrial
arrhythmia recurrence
compared to AAD therapy
over 12 months in the
Cryo-FIRST study
Kuniss et al. Catheter Cryoablation Versus Antiarrhythmic Drug as First-Line Therapy of Paroxysmal Atrial Fibrillation (Cryo-FIRST). Presented at the German Cardiac Society conference DGK
2020. Sheba Medical Center
STOP AF First
Primary Efficacy Endpoint
FREEDOM FROM PRIMARY EFFICACY FAILURE
Freedom from primary

efficacy failure at 12
months:
• Cryoballoon: 75% (95% CI:
65-82%)
• AAD: 45% (95% CI: 35-55%)
Wazni, O., et al. Safety and Efficacy of cryoballoon catheter ablation as a first line treatment for patients with paroxysmal atrial fibrillation: primary results of the randomized STOP AF First
Sheba
study. Presented Medical
at ESC Center
2020 – The Digital Experience.
Recommendations for rhythm control/catheter ablation
of AF (2)
Recommendations Class Level
AF catheter ablation after failure of drug therapy
AF catheter ablation for PVI is recommended for rhythm control after one
failed or intolerant class I or III AAD, to improve symptoms of AF recurrences
in patients with
• Paroxysmal AF, or I A
• Persistent AF without major risk factors for AF recurrence, or A
• Persistent AF with major risk factors for AF recurrence B
AF catheter ablation for PVI should be considered for rhythm control after
one failed or intolerant to beta-blocker treatment to improve symptoms of IIa B
AF recurrences in patients with paroxysmal and persistent AF.
©ESC

of AF (3)
First-line therapy
AF catheter ablation for PVI should/may be considered as first-line rhythm
control therapy to improve symptoms in selected patients with symptomatic:
• Paroxysmal AF episodes, or IIa B
• Persistent AF without major risk factors for AF recurrence. IIb C
as an alternative to AAD class I or III, considering patient choice, benefit,
and risk.
©ESC

Kirchhof et. al. EAST trial – NEJM 2020

Kirchhof et. al. EAST trial
– NEJM 2020

Kirchhof et. al. EAST trial – NEJM 2020

What if ablation fails?
• 1. AAD
• 2. Redo procedure
• 3. Pacemaker and AVN

Multipoint and Scar Mapping:

Back to our pt:
• 1. Offered PVI with CRYO
• 2. After PVI – need for 2 months with

DOAC and AAD.

Case No. 2
• 76 yo
• ISCMP
• LVEF 35%
• AFIB on incidental ECG
• Age Unknown
• LA: 45mm LAVI: 55

CABANA
D. Packer at HRS
D Packer HRS 2018 2018

CABANA
D Packer HRS 2018

of AF (4)
First-line therapy (continued)
AF catheter ablation:
• Is recommended to reverse LV dysfunction in AF patients when
tachycardia-induced cardiomyopathy is highly probable, independent of I B
their symptom status.
• Should be considered in selected AF patients with HF with reduced LVEF to
IIa B
improve survival and reduce HF hospitalization.
AF catheter ablation for PVI should be considered as a strategy to avoid
pacemaker implantation in patients with AF-related bradycardia or
IIa C
symptomatic pre-automaticity pause after AF conversion considering the
©ESC
clinical situation.

Case No 3
• 65 yo F
• Hx of PAF , failed multiple CV on 1C AAD.
• Echo: NL LVEF, LA 42/ LAVI 35
• Now in persis. AFIB

Three Strategies of Ablation for Persistent Atrial Fibrillation.
Verma A et al. N Engl J Med

STAR AF II
2015;372:1812-1822

Persistent AFIB:

• The target AI was 500 for anterior, 450 for roof, and 400
for inferior and posterior segments.
• If AF did not terminate to SR after CPVI, SR was

restored by electrical cardioversion.
• A high-density voltage mapping of the LA (minimum

number of collected surface points of at least 300) was
created.

Results:
• In the STABLE-SR group, 77
• of 134 (57.5%) patients underwent CPVI only, 55 of 134
(41.0%) patients underwent additional fibrotic substrate
modification beyond CPVI.

What is new in the 2020 Guidelines? New recommendations (7)
Recommendations Class
Recommendations for rhythm control/catheter ablation of AF (continued)
First-line therapy
AF catheter ablation for PVI should/may be considered as first-line rhythm control
therapy to improve symptoms in selected patients with symptomatic: IIa
• Paroxysmal AF episodes, or
• Persistent AF without major risk factors for AF recurrence as an alternative to AAD
IIb
class I or III, considering patient choice, benefit, and risk.
Techniques and technologies
Use of additional ablation lesions beyond PVI (low voltage areas, lines, fragmented
IIb
activity, ectopic foci, rotors, and others) may be considered but is not well established.
©ESC

Central Illustration Management of AF (2)
©ESC
©ESC

Complications of AF Ablation
Table 16 Procedure-related complications in catheter ablation and

thoracoscopic ablation of AF (1)
Complication severity Complication type Complication rate
Catheter ablation Thoracoscopic ablation
Life-threatening Periprocedural death <0.1% <0.1%
complications Oesophageal perforation/fistula <0.5% N/A
Periprocedural thromboembolic <1.0% <1.5%
event
Cardiac tamponade ≈1% <1.0%
Severe complications Pulmonary vein stenosis <1.0% N/A
Persistent phrenic nerve palsy <1.0% N/A
Vascular complications 2-4% N/A
Conversion to sternotomy N/A <1.7%
©ESC
Pneumothorax N/A <6.5%
NA = not available.

Sheba Algorithm
PAF
Young, no SHD >60, Co morbidities SHD
But no SHD
RFA w/ Cryo RFA w/ Cryo vs. 1C Mutaq/ Amio

(Sotalol out)
Persistent AFIB or Redo
LA< 5.5, AFIB< 6 LA> 5.5+ AFIB> 12

months months
DCCV+ AMIO>> RFA Hybrid Procedure:

w/ PWI + SVC+ scar Maze+ EPS and CTI

Key Messages
• Sinus Rhythm >>> Atrial Fibrillation
– Mortality
– Stroke
– HF
– Hospitalization
• Catheter ablation >>> Anti Arrhythmic

Drugs
• Early Intervention >>> Late Intervention


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Current Treatment Of Atrial Fibrillation-

From Antiarrhythmic To Ablation

Eyal Nof M.D

Sheba Medical Center

1. Ignore; 2. BB; 3. AAD; 4. Ablation (PVI)- RF? Cryo?

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center Stambler et al JCE 2003;14:499

Sheba Medical Center

Atrial remodeling, AF progression, consequences and co-morbidities2,3

Ablation success rates4,5

Blomstrom Lundqvist, ESC 2019

Tel Hashomer The Leviev Heart Center

Sheba Medical Center

• After 5 years only half pts are in sinus

Sheba Medical Center

Haissaguerre M, et al. N Engl J Med 1998; 339:659-666

Myocardial sleeve around PV

Perez-Lugones, et al. JCE 2003;14: 803

Sheba Medical Center

2017 HRS/EHRA Consensus Statement

Growing Body of Published Literature

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

Kuck K et al. N Engl J Med 2016;374:2235-2245.

Sheba Medical Center

Maor et al. Heart Rhythm, Vol 16, No 7, July 2019

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

In 5/5 pts! All alleviated with NTG

Sheba Medical Center

Sheba Medical Center

PFA protocols are not disclosed by

Maor et al. Heart Rhythm, 2019

Sheba Medical Center

Sheba Medical Center

• Systematic review in general

FREEDOM FROM PRIMARY EFFICACY FAILURE

Freedom from primary

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

• 3. Pacemaker and AVN

Sheba Medical Center

Sheba Medical Center

• 2. After PVI – need for 2 months with

Sheba Medical Center

Sheba Medical Center

Sheba Medical Center

D Packer HRS 2018

Sheba Medical Center