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TRANSCRIPT
The Convergent Approach for the
Treatment of Persistent Atrial Fibrillation
Bryan Piedad, MD, FACC
Wellstar Medical Group
Atrial Fibrillation
• Most common arrhythmia worldwide
• Prevalence of atrial fibrillation
– 1-2 % estimated prevalence
– Increasing incidence with age
– Only 12 to 15% of all patients with afib are paroxysmal
– Overwhelming majority of patients are persistent
• Significant morbidity and mortality
• Significant health care costs
Percutaneous Ablation for Atrial Fibrillation
• Primary strategy in paroxysmal afib is
electrical isolation of the pulmonary veins
• Good success rate for paroxysmal atrial
fibrillation (70 to 80%)
• Low complication rate (2-4%)
• Minimally invasive
Wellstar Electrophysiology
• Calendar year 2012
– 130 percutaneous ablations
• Calendar year 2013
– 200 percutaneous ablations
– Highest volume cryo-ablation center in the Southeast
– Top 10 in the country for cryo-ablation volume
– Training center for cryo-ablation
– Research site for cryo-ablation
Limitations of Percutaneous Ablation
• Lower success rates for persistent atrial fibrillation (50%
to 60%), especially with enlarged and fibrotic atria
• Need for repeat ablation in up to 50% of patients
– Average number of procedures is 2.3 per patient
• Difficulty in delivering and confirming contiguous lesions
• Extensive endocardial lesions and the risk for embolus
• Potential esophageal damage and risk for esophageal-
atrial fistula formation
Convergent Approach• Multi-disciplinary approach
– Cardiac Anesthesiology
– Cardiothoracic Surgery
• Linear lesions via an epicardial approach
• Closed chest, trans-diaphragmatic endoscopic approach
– Cardiac Electrophysiology
• Percutaneous EP testing and ablation (PVI and CTI
ablation)
Percutaneous Endocardial Ablation After Epicardial Ablation
Percutaneous AccessBreakthrough Locations @
Pericardial Reflections
Study% Persistent /
Longstanding AFMonitoring Level Procedure Efficacy Redos
Serious Adverse Event Rate4
Allegheny CV StudyB
AER 2013N=43
86%Med
2wk Monitors 89% @ 6 mo1 NR 0%
2-Site US CV StudyAHeart Rhythm
N=101
83%(Avg CHADS = 2.1)
MedReveal & Holter
79.7% @ 12 mo170.5% @ 12 mo1(Survival Analysis)
6% 6%
4-Site US CV StudyB
Boston AF 2012N=115
83.5%Med
72h Holter
84% @ 11.4 mo1
77% @ 11.4 mo2
64% @ 11.4 mo3
4% 6.1%
Slovenia CV StudyA,B
Boston AF 2012, JCEN=50
94%High
All Reveals91% @ 1 yr1
78% @ 1 yr3 2% 10.0%
OLOL CV StudyB
HRS 2012N=104
73%Med
72h Holter92% @ 8 mo1
68% @ 8 mo3 4%0%
(5.8% > 30d)
CPW CV StudyB
HRS 2012N=39
79%Med
72h Holter94% @ 12.6 mo1
68% @ 12.6 mo3 6% 2.6%
STV CV StudyB
HRS 2012N=61
88%Med
72h Holter79% @ 11 mo1
66% @ 11 mo3 8% 3.3%
4-Site EU CV StudyD
EU JournalN=73
100%High
Reveals or 7d Holters79% @ 1 yr1 4% 11.0%
2-Site CV StudyA
Innovations 2011N=65
92%Med/High
Reveal or 24h Holter88% @ 1 yr1
83% @ 1 yr3 NR 7.7%
1Efficacy = Sinus Rhythm; 2Efficacy = Sinus Rhythm & No AAD Tx; 3Efficacy = Sinus Rhythm & Off AADs, 4Safety = 30-Day Adverse EventsAPublished Article; BPublished/Presented Abstract; CAccepted Abstract; DSubmitted Article; EAccepted Article
Published/Presented Outcomes
Summary
• 1. Highly effective therapy for patients with persistent
atrial fibrillation that still maintains a minimally
invasive approach
• 2. Reduction in repeat procedures
• 3. Providing a new treatment option for a significant
proportion of the afib population which has been
somewhat “forgotten”
• 4. Marketing opportunity for the health care system,
cardiology, cardiac electrophysiology and CT surgery