af ablation is a waste of time and money dr dhiraj gupta mrcp md dm liverpool heart and chest...

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AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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Page 1: 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

Dr Dhiraj Gupta MRCP MD DMLiverpool Heart and Chest Hospital

Page 2: 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 DMLiverpool Heart and Chest Hospital

Page 3: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

A recap of what we’ve learnt this morning….

Page 4: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

AF kills you (slowly)….

Page 5: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

AF makes you miserable….

Page 6: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

AF costs megabucks….

2.4% of the total NHS budget

Page 7: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

Conventional treatments limited efficacy

Drugs only work in 1 in 3 patients

Page 8: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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)

Page 9: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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

Page 10: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

….and neither is cardioversion

Page 11: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

Finally, a cure is in sight!......

Culprit: triggers in pulmonary veins

Page 12: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

Treatment: Pulmonary Vein Isolation

Page 13: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

The procedure works…..

Current success rates 80%

Page 14: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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

Page 15: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

It’s clearly better than drug therapy

Page 16: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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%

Page 17: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

Current technology has improved accuracy

Page 18: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

The last thing we now need is a party pooper!

Page 19: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

Ablation80% chance of

cureOne-stop solution

Drugs30% efficacy

Life long suffering

Page 20: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

If you always do what you always did…you’ll always get what you’ve always

got

Page 21: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

Yes, AF ablation costs money…

• 100,000 AF cases a year Median 1.5 procedures

• £4000 per ablation

• Total cost: half a billion pounds

Page 22: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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

Page 23: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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

Page 24: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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

Page 25: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

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

Page 26: AF ablation is a waste of time and money Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital

Finally...

What would you want?!