EP Lab Digest - October 2007 - (Page 22)

EP GUIDELINES OCTOBER Adopting and Implementing the AF Ablation Consensus Statement Contributed from the Heart Rhythm Society The AFib Summit, held during the Heart Rhythm 2007 Annual Scientific Sessions, May 9-10, in Denver, Colorado, featured world-renowned experts who presented the latest in the diagnosis, management, drug therapy, outcomes, and ablation techniques for atrial fibrillation (AF). Sessions during the AFib Summit covered the following topics: AF mechanisms; clinical outcomes of AF ablation; new generation imaging for ablative interventions; facilitating good outcomes and avoiding bad ones; anti-thrombotic, anti-arrhythmic, and antiinflammatory drug therapy for AF; how to perform ablative intervention; special considerations for non-pharmacologic therapies; and the means by which to pull it all together. A highlight of the AFib Summit was the release of a revised consensus statement on atrial fibrillation. In this article, the central components of the HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation are described as well as how the incorporation of the statement’s guidelines will impact treatment of atrial fibrillation in the future. The AFib Summit featured a special presentation that summarized the newly released consensus statement on ablation of AF, which was followed by an interactive panel discussion with the experts in AF.In this article, we will summarize both the consensus statement and the panel discussion. partnership with the European Heart Rhythm Association (EHRA) and European Cardiac Arrhythmia Society (ECAS) and endorsed by the American Heart Association, American College of Cardiology, and Society of Thoracic Surgeons. The statement was released electronically just prior to Heart Rhythm 2007, and was published in the HRS and EHRA journals in June 2007.1 The consensus statement summarizes the opinions of 27 task force members, who have been recognized as the world’s most prominent leaders in the field of electrophysiology (EP). Task force members received a survey and responded based on their own experiences in treating patients. Aspects of AF ablation that represented a true “consensus” were identified and described in the document, which also includes a review of the literature. Dr. Calkins stated that the statement has been well received by the community of electrophysiologists who care for patients with atrial fibrillation and/or perform catheter ablation procedures. From a clinical perspective this document has been well received for several reasons. First, the document has provided clear indications and contraindications for performing AF ablation procedures. This has been very useful in discussing the complexities of the procedure with patients. Second, the consensus document has clarified that electrical isolation of the pulmonary veins is the primary objective of an AF ablation procedure, particularly when performed for patients with paroxysmal atrial fibrillation. Third, the document has provided fairly specific advice concerning anti-coagulation strategies prior to, during, and following AF ablation procedures.And finally, the consensus document has clarified the length of the blanking period following AF ablation, which helps determine when repeat ablation procedures should be considered. An additional component of the statement, which has been well received by the EP community, is the detailed description of the potential complications associated with AF ablation.This has been particularly useful to clinicians who are faced with deciding Consensus Statement Recap: AF Definitions: The task force members agreed to use the definitions in the AHA/ACC/AF consensus document published in August 2006, with a few important exceptions: The term “permanent AF” is not appropriate in the context of patients undergoing ablation of AF, as it refers to a group of patients where a decision has been made not to pursue restoration of sinus rhythm by any means.2 Thus, the group agreed that the terms “permanent AF” and “chronic AF” should no longer appear in AF literature. Instead, the term “persistent AF” should be used. “Persistent AF” is defined as AF sustained beyond 7 days, or lasting less than 7 days but necessitating pharmacologic or electrical conversion. The term “longstanding persistent AF” should be used when referring to continuous AF lasting longer than one year. Indications for Catheter Ablation: Task force members agreed that the main indication for catheter ablation is symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication. They added that in rare clinical situations, performing AF ablation as first-line therapy may be appropriate. Another reasonable indication is selected symptomatic patients with heart failure and/or reduced ejection fraction. Task force members also agreed that the presence of a left atrial thrombus is a contraindication to catheter ablation of AF. Indications for Surgical Ablation: The group agreed that candidates for surgical ablation include: • Symptomatic AF patients undergoing other cardiac surgery. • Selected asymptomatic AF patients undergoing cardiac surgery in which the ablation can be performed with minimal risk. • Patients who prefer a surgical approach, who have failed one or more attempts at catheter ablation, or who are not candidates for catheter ablation. AF Ablation Techniques: Task force members agreed on the following: Ablation strategies that target the pulmonary veins (PVs) and/or PV antrum are the cornerstone for most AF ablation procedures. If the PVs are targeted, complete electrical isolation should be the goal. For surgical PV isolation, entrance and/or exit block should be demonstrated. Finally, careful identification of the PV ostia is mandatory to avoid ablation within the PVs. They also concluded that ablation of the cavotricuspid isthmus is recommended only in patients with a history of typical atrial flutter or indicible cavotricuspid isthmus dependent atrial flutter. In addition, for patients with longstanding persistent AF, ostial PV isolation alone may not be sufficient. “It is clear that we don’t know which of the many techniques discussed at this Summit is the right adjunctive technique, but this speaks to the point that you may need to do more than simply isolate the veins. Whether that’s a first or second procedure is a matter of the operator’s preference,” said Dr. Calkins. “The document does not state which technique or technology may be better because there are no good comparative studies.” Pre-Procedure Management and Intraprocedure Anticoagulation: The consensus was that anticoagulation guidelines, published in the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With AF,2 should be followed for long-term management of AF ablation patients as well as for patients undergoing cardioversion procedures. The task force members also agreed that patients with persistent AF who are in AF at the time of ablation should have a transesophageal echocardiogram performed to screen for thrombus. Lastly, heparin should be administered during AF ablation procedures to achieve and maintain an activated clotting time of 300 to 400 seconds. Post-Procedure Management: The consensus was that low molecular weight heparin or intravenous heparin should be used as a bridge to the resumption of systemic anticoagulation following AF ablation. Also, Coumadin is recommended for all patients for at least 2 months following an AF ablation procedure. Decisions regarding the use of Coumadin more than 2 months following an ablation procedure should be based on the patient’s risk factors for stroke and not on the presence or type of AF. Lastly, the discontinuation of warfarin therapy post-ablation is generally not recommended in patients who have a CHADS score of 2 or greater. Training Requirements and Competencies: “The document gives a detailed description of training that is needed to perform this procedure safely and with high quality,” explained Dr. Calkins. The ACC/AHA 2006 update of the clinical competence statement on catheter ablation proposed a minimum of 30–50 AF ablation procedures for those who undergo fellowships in clinical cardiac EP.3 “We felt that this number underestimates the experience required for a high degree of proficiency, and that exact numerical values are difficult to specify because technical skills develop at different rates.” Comparisons at high- and low-volume centers show that outcomes are better at centers that have performed more than 100 procedures. Also, trainees who intend to independently perform AF ablation should consider additional training after the standard fellowship is completed. Electrophysiologists who have already completed a fellowship and undergone training for AF ablation should observe experienced colleagues and be supervised when they begin to routinely perform these procedures. In the absence of definitive data, numerical requirements are arbitrary. The exact number may depend on prior experience with transseptal punctures and cannulation of the left atrium. EPs should perform several ablation procedures for AF per month if they intend to remain active in this area. Finally, they should track the outcomes of their procedures and verify that appropriate follow-up has been arranged. Follow-up and Clinical Trial Considerations: Task force members agreed on the following definitions of success: • A three-month blanking period should be employed after ablation when reporting outcomes. • Freedom from AF/flutter/tachycardia off antiarrhythmic therapy is the primary endpoint of AF ablation. • For research purposes, time to recurrence of AF following ablation is an acceptable endpoint after AF ablation, but may underrepresent true benefit. • Freedom from AF at various points following ablation may be a better marker of true benefit and should be considered as a secondary endpoint of ablation. • Epis

Table of Contents Feed for the Digital Edition of EP Lab Digest - October 2007

Finally! The New Registered Cardiac Electrophysiology Specialist (RCES) Credential: Interview with Christopher M. Nelson, RN, RCIS, FSICP ECG 101: Closing the Gap Phenomenon Contents Letter from the Editor ICD Patient Support Group: St. Peter’s Hospital Spotlight Interview: Community Healthcare System Use of Magnetic Catheter Navigation for Ablation of Focal Tachycardias Echocardiography: The Preeminent Front Line Screening and Diagnostic Tool for Cardiovascular Imaging and Physiological Assessment First Annual EP Lab Digest Salary Survey: Last Chance! Clinical Trial Update: 2007 Email Discussion Group Adopting and Implementing the AF Ablation Consensus Statement Electrophysiology in the West Summit Events Calendar The Sustained Treatment of Paroxysmal Atrial Fibrillation (STOP AF) Clinical Trial: Interview with Kevin Wheelan, MD Industry News and Products

EP Lab Digest - October 2007

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