af ablation is a waste of time and money dr dhiraj gupta mrcp md dm liverpool heart and chest...
TRANSCRIPT
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AF ablation is a waste of time and money
Dr Dhiraj Gupta MRCP MD DMLiverpool Heart and Chest Hospital
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AF ablation is a waste of time and money:
(you must be joking!)
Dr Dhiraj Gupta MRCP MD DMLiverpool Heart and Chest Hospital
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A recap of what we’ve learnt this morning….
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AF kills you (slowly)….
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AF makes you miserable….
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AF costs megabucks….
2.4% of the total NHS budget
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Conventional treatments limited efficacy
Drugs only work in 1 in 3 patients
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Not only are drugs potentially ineffective but…..
• They often cause unacceptable side effects
• Discontinuation rates due to Adverse Effects:
• CTAF: 18% Amio, 11% Sotalol
• AFFIRM: 12% Amio, 11% Sotalol, 28% Flecainide
• They may increase mortality
• SPAF: esp. in heart failure
• AFFIRM: AAD associated with mortality (p=0.0005)
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Dronedarone isn’t the answer….
• Mild antiarrhythmic action
• AF recurrence at 1 year: 64% vs 75% for Placebo
• << Amiodarone (free from AF at 6 mo: 37% vs 58%)
• Increased mortality in Heart Failure (ANDROMEDA)
• Only approved by the NICE with reservations
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….and neither is cardioversion
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Finally, a cure is in sight!......
Culprit: triggers in pulmonary veins
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Treatment: Pulmonary Vein Isolation
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The procedure works…..
Current success rates 80%
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in long standing persistent AF too..
N Redo AAD therapy Results Complications
HaissaguerreJCE 2005
60 1/2 Stopped at ablation
95% at 11 months
2 Tamponades
OralNEJM 2006
77 1/3 Amio 6/52 pre & 3/12 post
77% at 1 year
0
PostchCirc 2008
88 1/2 Stopped at ablation
81% at 20 months
2 Tamponades1 TIA
LoJCE 2009
87 1/4 AAD for 2/12 post
79% at 21 months
1 Tamponade
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It’s clearly better than drug therapy
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AF ablation has evolved rapidly…
• Success rates have doubled
• Paroxysmal AF: 40-50% to 80-90%
• Persistent AF: 30-40% to 70-80%
• Procedure times have halved
• From 4-6 hours to 2-3 hours
• Complication rates have halved: 4% to 2%
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Current technology has improved accuracy
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The last thing we now need is a party pooper!
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Ablation80% chance of
cureOne-stop solution
Drugs30% efficacy
Life long suffering
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If you always do what you always did…you’ll always get what you’ve always
got
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Yes, AF ablation costs money…
• 100,000 AF cases a year Median 1.5 procedures
• £4000 per ablation
• Total cost: half a billion pounds
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But where would you rather spend this money?
• ? Iraq War: £ 4.5 billion (Mar 2006)
• ? Olympics: £9.8 billion
• ? NHS IT project: £15 billion
• ? Bank Bailout £850 billion
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Upfront costs outweighed by subsequent savings…
• Costs of recurrent hospital admissions
• Electrical cardioversions
• Absences from work
• Costs of lifelong drug therapy
• Regular INR tests
• Decreased risk of the serious AF sequalae
• Stroke
• Heart Failure
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Measures to make ablation more cost effective
1. Careful patient selection: ablation not offered
• Very long standing Persistent AF (>3 years)
• Very large LA (>5.5 cm)
• Morbid Obesity (BMI >40)
• Age >80 years
• Significant co-morbidity
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Measures to make ablation more cost effective
2. Individualised ablation strategy:
Improve single procedure success rates
Accepted for oral presentation at Cardiostim, Nice June 16-18, 2010
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Finally...
What would you want?!