6 курс / Кардиология / И_А_Овсыщер_Ведение_больных_после_РЧИ_УЛВ
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―Conclusions. Patients who discontinued OAT 3 to 6 mo after successful AF ablation had a similar incidence of thromboembolic events (TE) to pts who remained on OAT. Moreover, the rate of major hemorrhages was significantly lower. On the basis of these results, it seems that the risk– benefit ratio favors the discontinuation of OAT after successful AF ablation even in pts at moderate-high risk of TE based on CHADS2 score alone.‖
If a physician believes that AF ablation was effective/curative, he/she does not need to restore OAT to the patient and the patient does not need continuous rhythm monitoring.
Questionnaire of 43 European/US EP Cardiologists Having Experience with AF Ablation
Courtesy of A. Raviele in: Atrial Fibrillation Ablation. A Natale, A Raviele eds, Blackwell 2007
There is no need in OAT after successful AF ablation
Themistoklakis S, et al. 2692 pts JACC 2010;55:735.
Nademanee K, et al. 635 pts JACC 2007;51. J Cardiol. 2010 ;55:1.
Oral H, et al. 755 pts Circulation. 2006;114:759.
Hayes CR, et al. 49 pts J Interv Card Electrophysiol. 2010; 27:117
Tao H, et al. 520 pts J Interv Card Electrophysiol. 2010;27(1):33.
Dagres N, et al. 844 pts Thromb Haemost. 2009;102(4):754.
5495 pts after successful AF ablation without OAT
―Our conclusion: do not stop the warfarin until we have prospective, randomized clinical trials that can help guide us in providing anticoagulation therapy for our patients.‖
If a physician believes that currently AF ablation is most
effective, but only palliative approach |
(like AAD) for AF |
treatment, he/she should maintain OAT, |
and the patient does |
not need continuous rhythm monitoring. |
|
FU 831 pts after PVI performed in 2005 (643 pts with a single and 188 pts with 2 ablations). All pts had Holter recordings done at 3, 6, and every 6 months after ablation. In the 1st year after ablation, 23.8% had early recurrence. Over FU for (4.6 yrs), only 8.9% had late arrhythmia recurrence. At last FU, clinical improvement was in 89.9%: 79.4% arrhythmia free off AADs and 10.5% with AF controlled with AADs. Only 4.6% continued to have drug resistant AF. It was possible to safely discontinue AOT in a substantial proportion of pts with no recurrence in the year after ablation. The procedure-related complication rate was very low-2.4%.
Of 587 pts with no arrhythmia recurrence in the year after ablation, warfarin was stopped in 449 pts (76.5%) with CHADS score of 2 or lower. Of those, 207 pts (46.1%) had a CHADS score of 0; 191 (42.5%) had a CHADS score of 1 and 51 (11.4%) had a CHADS score of 2. Of all 587 pts, 164 had a CHADS score of 2 but only 51 of those were considered for discontinuation of warfarin (31.1%). Stroke incidence of 0.06%/year.
Conclusions - PVI is safe and efficacious for long term maintenance of sinus rhythm and control of symptoms in pts with drug resistant AF. It obviates the need for antiarrhythmics, negative dromotropic agents and anticoagulants in a substantial proportion of pts.
Cat listening to Stevie Wonder
Is There Need for Continuous Noninvasive Rhythm Monitoring in AF Patients?
Probably yes
Continuous monitoring better than intermittent, and external monitoring more attractive than implantable (a priory)
However, there is no data how long monitoring should be after AF ablation
There is no data how long monitoring should be after ischemic stroke/TIA.
There is no data concerning cost-effectiveness.
Hindricks G, et al. Circ Arrhythm EP. 2010;3:141 Brignole M, et al. Europace 2009;11:671
Kirchhof P, et al. Eur Heart J 2009;30:2969.
