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La gestione della fibrillazione atriale nel
paziente con insufficienza cardiaca quando
conservativi, quando aggressivi
Andrea Mortara
Dipartimento di Cardiologia e Unita
Scompenso POLICLINICO DI MONZA, Monza
Incontro con gli Esperti, Milano Settembre 2007
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Atrial fibrillation is increasing
FA sta aumentando negli anni FA e relata
alleta anche nello SC
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20 of patients with heart failure develop AF
within 4 years
Unadjusted cumulative incidence of first AF after
Heart Failure - Framingham Study
CHF FA 54 per mille/persone/anno
FA CHF 33 per mille/persone/anno
Development of AF was associated with increased
mortality hazard ratio of 1.6 (95 CI, 1.2 to
2.1) in men and 2.7 (95 CI, 2.0 to 3.6) in
women.
Wang, T. J. et al. Circulation 20031072920-2925
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Development of AF is associated with Clinical
deterioration in Heart Failure(Pozzoli et al
JACC 1999)

• Prospective follow-up of 344 patients with CHF
  and sinus rhythm for 19 12 months.
• 28 patients developed AF which became permanent
  in 18 pts
• When AF occurred
• NYHA class worsened (from 2.4 0.5 to 2.9 0.6,
  p 0.0001),
• peak exercise O2 consumption declined (from 16
  5 to 11 5 ml/kg per min, p 0.002),
• cardiac index decreased (from 2.2 0.4 to 1.8
  0.4, p 0.0008),
• mitral and tricuspid regurgitation increased
• thromboembolism occurred in 3 of the 18 patients
  with AF.
• 9 of 18 patients died after AF
• occurrence of AF was a predictor of major cardiac
  events.

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Pozzoli et al. 199831(1)197-204.
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Atrial Fibrillation is Associated with increased
Mortality in Heart FailureDries et al SOLVD
JACC 1998
Atrial Fib
Sinus
p
n
419
6098
Mortality
34
23

Heart Failure Death
17
9

Arrhythmic Death
7
6
NS
RR 1.34 (1.11 - 1.61) adjusted for severity,
medication
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The DIG Investigators. Chest. 2000118914-922.
From Shivkumar, Weiss, Fonarow, and Narula
eds. Braunwalds Atlas of EP in HF.
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Atrial Fibrillation and risk of events in the
CHARM Trial (JACC 2006)
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Pedersen OD Diamond Study Group, Circulation 2001
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Atrial Fibrillation and Stroke
Meta-AnalysisHart et al, Ann Intern Med 1999
131492

• Risk of stroke 6 per yr (5 - 6 fold increase)
• Warfarin (INR 2.0 - 2.6)
• 62 reduction (CI 48 - 72)
• N needed to treat to prevent 1 stroke 37
• intracranial hemorrhage 0.3 / yr
• major hemorrhage 0.6 / yr
• 20 of patients discontinue anticoagulation
• Aspirin (25 mg - 1300 mg/day)
• 22 reduction (2 - 38)

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The elderly are particularly vulnerable to stroke
when atrial fibrillation is present.
Stroke and cardiovascular condition Framingham
study (Wolf, 1991)
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Atrial fibrillation In Dogs with Rapid
Ventricular Pacing-Induced HF(Stambler et al JCE
200314499)

• CHF induced by 3 wks of rapid ventricular pacing
• Inducible focal atrial tachycardias consistent
  with triggerred automaticity associated with Ca2
  overload
• Atrial fibrosis
• Prolongation of atrial action potential duration

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Dynamic Nature of Atrial Fibrillation Substrate
During Development and Reversal of Heart Failure
in Dogs Shinagawa, K. et al. Circulation
20021052672-2678
Baseline Heart failure induced by rapid
ventricular pacing Recovery from heart failure
(5 weeks)
Masson trichrome-stained transverse LA sections
from 1 representative dog per group (original
magnification x400)
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Rapid heart rates depress contractility
abnormal force - frequency in relationship in
heart failure
200
Nonfailing
Failing
100
change in Force
0
20
60
120
180
Heart Rate (beats / min)
Pieske Circ Res 1999 Gwathmey JCI 1990 Mulieri
Circulation 1992 Heerdt PM, Circulation.
20001022713-9.
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Adverse Hemodynamic Effects of AF Irregular RR
Intervals Impair Cardiac Performance
p N16
Cardiac Output (L/Min)
Cardiac Output (L/Min)
NSR AF VVI VVI VVT
60 AVG
VVI -AVG VVT
Clark DM. JACC 1997 301039-45
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Changes of CI in patients who did and did not
develop AF (Pozzoli et al, JACC 1998)
Cardiac index (l/min/m2)
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The effects of rate and irregularity on
sympathetic nerve activity in human subjects.
(Segerson NM et al Heart Rhythm 2007420-6)

• It has been shown that atrial fibrillation is
  associated with an increase in sympathetic nerve
  activity (SNA) compared with sinus rhythm
• Greater degrees of irregularity cause greater
  sympathoexcitation and that the effects of
  irregular pacing on SNA are independent of the
  hemodynamic changes.

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Affermazioni dalla letteratura
- Lo SCC e un fattore di rischio per sviluppare
FA - Linsorgenza di FA in pazienti con SCC e
associato a deterioramento clinico ed emodinamico
e ad una peggiore prognosi - I dati danno
percio una forte motivazione a prevenire e a
trattare la FA nello SCC
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.. You will realize that blood gets into the
ventricle not through any pull exerted by the
distended heart but through the driving force
exerted by the beats of auricles .. W.
Harvey 1628
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Ablazione della Fibrillazione Atriale nello
Scompenso Cardiaco
LEFT ATRIUM Posterior basal view
R. pulmonary artery
L. pulmonary artery
R. superior pulmonary vein
L. auricle
L. superior pulmonary vein
L. atrium
R. inferior pulmonary vein
L. inferior pulmonary vein
Coronary sinus
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Left Atrium, Posterior Wall Variable Anatomy
(Common)
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Asirvatham and Friedman. From Shivkumar, Weiss,
Fonarow, and Narula eds. Braunwalds Atlas of EP
in HF. 2005.
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Relativa importanza del trigger verso substrato
Modificata da D Parker circulation 2000
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Left Atrium, Posterior Wall Pulmonary Vein
Isolation
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Ablazione della FA Approccio Circonferenziale
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Ablazione della Fibrillazione Atriale - Tecniche -

• Combined Modality Imaging
• Fluoroscopy (biplane, for rapid 3-D estimates)
• High resolution gated CT or MRI
• 3-D electroanatomic mapping
• Intracardiac echo
• In the future
• Multi-modality image co-registration combining
• real-time anatomy and function

Current
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Left Atrium (LA) andPulmonary Vein Anatomy
3-D CT Reconstruction (Extreme PA Cranial View)
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Catheter Ablation for Atrial Fibrillation in
Heart Failure (Hsu LF et al New England J Med
2004)

• 58 consecutive patients with heart failure and
  LVEF
• 58 control patients without CHF undergoing AF
  ablation matched for age, sex
• After 127 months, 78 of CHF pts vs 84 of
  controls remained in sinus rhythm (P0.34) (69
  and 71 without antiarrhythmic drugs
• CHF pts had improvement in
• LV ejection fraction 2113
• LV diastolic diameter 66 mm
• LV systolic diameter 87 mm
• exercise capacity, symptoms, and and QoL
• LV EF improved even if rate control before
  ablation was judged adequate

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Quando il controllo del Ritmo nello Scompenso
Cardiaco?

• Fattori favorevoli al controllo del Ritmo
• Primo o infrequenti episodi di FA persistente
• FA asintomatica anche permanente, se mai eseguito
  un tentativo di ripristino RS
• FA sintomatica
• Difficolta di controllo della frequenza
• Controindicazioni a TAO
• Fattori favorevoli al controllo della Frequenza
• Eta biologica avanzata
• Controindicazione allamiodarone
• Inefficace/i CVE

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Cumulative Costs of Atrial Fibrillation Procedure
in Ontario
Costs equalized at 3.2-8.4 yrs of follow-up
Registro Canadese Y. Khaykin, J Cardiovasc
Electrophysiol 2006
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Effetti Collaterali della Ablazione della FA (6
delle procedure)

• Stenosi della vena polmonare
• (Non e piu importante dopo il cambiamento della
  tecnica)
• Tromboembolismi e Stroke
• (0-5. TAO adeguata a ridotto il problema)
• Fistola Atrio-Esofagea
• (rara, ma molto grave, dipende da estensione
  ablazione)
• Flutter Atriale
• Complicanze legate al cateterismo

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Ablazione del Nodo AV e Impianto di PM Biv.ICD

• Vantaggi
• Adeguato controllo del ritmo senza farmaci
• Regolarizzata la frequenza cardiaca
• Svantaggi
• Richiede impianto del PM (ma e ICD)
• FA continua necessaria TAO
• Rischio di Torsioni di Punta dopo ablazione AV
• Rischio di deterioramento se stimolato da Vdx
  (Biv.)

GN Kay et al Ablate and Pace J Intervent Card
Electrophy 1998 Brignole et al Circulation
1998 Geelen P, et al. VF and sudden death after
AVJ ablation. PACE 1997203438. Jordaens L, et
al. Sudden death and long term survival . Eur J
Card EP 1993211029. Gasparini M, et al.
Long-term follow-up after AV ablationPACE
20002319259. Ozcan C, et al. Long-term
survival . . NEJM 2001344 104351.
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HFFA
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HFFA
??
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HFFA
Insufficiente controllo
X
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STUDI IN CORSO
AF-CHF Controllo del Ritmo vs
Frequenza AVERT-HF Ablazione nodo AV e BIV
Pacing CABANA Ablazione AF superiore a
terapia convenzionale