Transcript AF ablation
AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital AF ablation is a waste of time and money: (you must be joking!) Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital A recap of what we’ve learnt this morning…. AF kills you (slowly)…. AF makes you miserable…. AF costs megabucks…. 2.4% of the total NHS budget Conventional treatments limited efficacy Drugs only work in 1 in 3 patients 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) 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 ….and neither is cardioversion Finally, a cure is in sight!...... Culprit: triggers in pulmonary veins Treatment: Pulmonary Vein Isolation The procedure works….. Current success rates 80% in long standing persistent AF too.. N Redo AAD therapy Results Complications Haissaguerre JCE 2005 60 1/2 Stopped at ablation 95% at 11 months 2 Tamponades Oral NEJM 2006 77 1/3 Amio 6/52 pre & 77% at 1 3/12 post year 0 Postch Circ 2008 88 1/2 Stopped at ablation 81% at 20 months 2 Tamponades 1 TIA Lo JCE 2009 87 1/4 AAD for 2/12 post 79% at 21 months 1 Tamponade It’s clearly better than drug therapy 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% Current technology has improved accuracy The last thing we now need is a party pooper! Ablation Drugs 80% chance of cure One-stop solution 30% efficacy Life long suffering If you always do what you always did…you’ll always get what you’ve always got Yes, AF ablation costs money… • 100,000 AF cases a year Median 1.5 procedures • £4000 per ablation • Total cost: half a billion pounds 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 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 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 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 Finally... What would you want?!