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Possess the following knowledge/experience:
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Location:Hyderabad / Secunderabad
Contact:Novartis Healthcare Pvt Ltd
Thursday, April 9, 2009
Assessing Patient Management and Outcomes in Atrial Fibrillation: Does your health insurance plan know more than your doctor?
Assessing the landscape of any major public health challenge and the effectiveness of existing health care practices is a difficult proposition in any circumstance for health care planners and providers. To do so with relatively current health care data has not been a feasible reality. Too often health care planners have been relegated to use of venerable but dated clinical information. Equally often, clinical trial data collected for a purpose other than outcomes research have been extrapolated well beyond their original intent. The field of atrial fibrillation is no exception. The durable and well-reported Framingham study data have provided modern day framework for a natural history base of the disease over many decades . More recent analyses have shown worldwide similarity in patterns and increasing prevalence . The cascade of anticoagulant trials in the nineties with their metanalyses and methodology also provided outcome endpoints that have been widely used as a benchmark . More recently, NIH clinical trials such as the AFFIRM trial have provided some outcomes analyses . Yet these tools provide information that may have been captured some time ago and significantly lag current medical experiences and practice.
Scenes from a CFAE: Complex Fractionated Atrial Electrogram Map in a Woman with Longstanding Persistent Atrial Fibrillation Following Mechanical Mitra
Case: A 62-year-old woman was referred for atrial fibrillation (AF) ablation. She had longstanding persistent AF for 8 years since mechanical mitral valve replacement for rheumatic heart disease.
EPS: A strategy of substrate-based ablation targeting areas of complex fractionated atrial electrograms (CFAE) was pursued. These sites were identified by inspection of electrograms and verified with software-based electrogram analysis, with the left atrial roof demonstrating the highest density of CFAE sites. Successful catheter ablation was performed. The patient has remained free of recurrence over 4 months of follow-up.
Discussion: This case presents a successful ablation procedure using the emerging strategy of CFAE-targeted ablative lesions. Given the patient’s longstanding persistent AF and mechanical mitral valve, the high density of CFAE sites on the left atrial roof was an unexpected finding. Analysis for CFAE sites guided the procedure in a direction that might otherwise not have been undertaken, leading to a successful ablation.
Superior vena cava (SVC) triggers constitute 6-8% of non-pulmonary vein (PV) foci that initiate atrial fibrillation (AF). Since SVC cardiomyocytes originate from the right sinus horn they possess enhanced automacity and after-depolarization leading to arrhythmogenicity. In a recent study by Arruda et al. 12% of patients had SVC triggers and empiric adjunctive isolation of SVC-right atrium (RA) along with PV isolation resulted in higher long term success rate than the group that underwent PVI alone. They demonstrated that adjunctive isolation of SVC along with PVI is a safe and feasible strategy for ablation of AF.
On this anniversary issue, I wanted to congratulate you and thank you for making the Journal of Atrial Fibrillation (JAFIB) a great success. With specific focus on atrial fibrillation we were able to surpass our targets for the past year with your active participation and support. With continued progress made in the diagnostic and therapeutic tools in treating AF, this past year has witnessed a period of consolidation and introspection of what we have been doing. We have come to agree that pulmonary veins are a major source arrhythmia initiation and maintenance and should be the primary target for isolation.
Atrial fibrillation (AF), the most common arrhythmia in clinical practice, accounts for nearly one third of all hospitalizations for cardiac rhythm disturbances. Consequently, this has stimulated intense investigative interest in the development of effective therapeutic options. However, the electrophysiologic (EP) mechanisms of this arrhythmia have been long debated and remain unclear. This has limited the development of effective management strategies. Previous studies have shown the progressive remodeling associated with AF, initially believed to be functional and electrical in nature, now has structural and contractile impact . It is increasingly clear that the latter two processes play an increasingly important role in the recurrence and persistence of AF [2-4]. In an effort to clarify AF mechanisms, numerous experimental models have been developed. Their relationship to human mechanisms remains poorly defined. Direct mapping of human AF has been attempted but is still in its evolution. It is the purpose of this commentary to review existing mapping techniques and propose a new approach for mapping of human AF.
This review describes a new technique for mapping of human atrial fibrillation in the electrophysiologic laboratory on a beat to beat basis. It permits biatrial mapping and high resolution mapping in the atrium of interest. It has been used routinely in clinical practice and clinical observations and experience are presented.
The prevalence of atrial fibrillation (AF) increases with age. As the population ages, the burden of AF increases.AF is associated with an increased incidence of mortality, stroke, and coronary events compared to sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to reduce immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in elderly patients , ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily.
Sinus node dysfunction (SND) is commonly encountered in the clinic. The clinical phenotype ranges from asymptomatic sinus bradycardia to complete atrail standstill. In some cases, sinus bradycardia is associated with other myocardial conditions such as congential abnormalities, myocarditis, dystrophies, cardiomyopathies as well as fibrosis or other structural remodeling of the SA Node. Although there are many etiologies for symptomatic slow heart rates, the only effective treatment available today is the implementation of a pacemaker. The predominant ion channel currents contributing to the pacemaker activity in the sinoatrail node (SAN) include currents flowing through hyperpolarization-activated, cyclic nucleotide-gated (HCN) channels, L- type Ca, T- type Ca, delayed rectifier K, and acetylcholine (ACh)-activated channels.
Atrial fibrillation (AF) is by far the most common tachyarrhythmia in humans. Prevalence of this rhythm disorder is 0.3-0.4% of adult population and increases with age from 2-4% in people over the age of 60 to 11.6 % in those over the age of 75 . In recent years, increasing number of patients are subjected to catheter ablation in an effort to cure AF. It has been shown that a successful AF ablation results in improved quality of life as well as left ventricular function when compared to other treatment modalities including pharmacologic treatment and pacemaker devices . Most ablation strategies today target electrical isolation of the pulmonary veins (PVs), which are believed to be the site of major foci triggering AF .
Predictors of Success After a First Circumferential Pulmonary Vein Isolation for Atrial Fibrillation
Background: To identify and characterise pre-procedural and procedural parameters which predict maintenance of sinus rhythm after a first circumferential pulmonary vein isolation (CPVI) for recurrent atrial fibrillation (AF).
Methods: 100 patients (54±10 yrs) undergoing CARTO-guided CPVI for symptomatic drug refractory, paroxysmal or shortstanding persistent AF were studied. The endpoint was complete electrical isolation within the encircled regions. 3D left atrial (LA) volume was measured by CARTO geometry. Follow-up examinations (symptoms, ECG, 24-hour ECG recording) were performed at 1 and 3 months and every 3 months thereafter.
Results: After the first CPVI, 71 patients (71%) were free of AF without antiarrhythmic drug therapy (follow up:28±11 months). The only independent and significant predictors for freedom of AF after the first CPVI were duration of AF history and 3D LA volume (p<0.05). However, a significant overlap in durations of AF history and 3D LA volumes between failures and successes was observed.
Conclusions: (1) Using the “circumferential pulmonary vein isolation” approach, the first catheter ablation leads to resolution of arrhythmia in »70% of symptomatic AF patients. (2) Independent predictors for freedom of AF after initial CPVI are duration of AF history and 3D LA volume. (3) Due to considerable overlap between failures and successes, these parameters can not be used to identify patients who should not undergo CPVI or in whom an additional ablation beyond CPVI is required. On the other hand, our results do suggest that an ablation strategy early in the course of AF disease can influence successful outcome.