ESC Congress 2017 In Review – Focus on Arrhythmias - 5

ESC Congress 2017

In Review

Arrhythmias

New Oral Anticoagulants
Reza Wakili, MD, West-German Heart and Vascular
Center Essen, University Duisburg-Essen, Germany,
believes there is strong cumulative evidence in the
general population supporting the use of non-vitamin
K antagonist (VKA) oral anticoagulants (NOAC) to treat
AF that is comparable to the results from large randomised controlled trials (RCT).
Between 20% and 30% of all strokes are due to AF
[Kirchhof P et al. Eur Heart J. 2016]. Between 1992 and

2010, ischaemic stroke rates among Medicare patients
with AF decreased significantly in all demographic subpopulations in all age categories, coincident with increasing use of anticoagulation [Shroff GR et al. J Am Heart
Assoc. 2014]. However, VKAs, such as warfarin, carry a
high risk of bleeding, require routine monitoring of the
INR, and present many food and drug interactions. More
recently, NOACs targeting a single factor of the coagulation cascade (IIa: dabigatran, Xa: rivaroxaban, apixaban
and edoxaban) have been developed, showing an overall
favourable risk-benefit profile, with significant reductions in stroke, intracranial haemorrhage, and mortality
with a similar risk of major bleeding as with warfarin, but
with an increased risk of gastrointestinal (GI) bleeding
[Ruff CT et al. Lancet. 2014; Ntaios G et al. Stroke. 2017].
If the benefits of NOACs are so evident, why do we
need general population data? In clinical practice the
patient populations and settings vary and those differences may affect observed benefits and risks. In the
GARFIELD-AF observational study of general population data in 17,162 individuals, the use of rivaroxaban,
dabigatran, and apixaban were associated with similar
outcomes to those reported in RCTs [Bassand JP et al.
Eur Heart J. 2016]. Most importantly, intracranial haemorrhage is significantly decreased with NOACs compared with VKAs in both RCTs and registry data. As a
consequence of generally more favourable results with
NOACs compared with VKAs, the pattern of OAC use is
changed since the introduction of NOACs. Data from the
registry showed that the use of VKAs and antiplatelet
monotherapy declined and the use of factor Xa inhibitors and direct thrombin inhibitors for AF treatment
increased (absolute increase ~15%) between 2010 and
2015 (Figure 2) [Camm AJ et al. Heart. 2017]. This was
observed across all the CHA2DS2-VASc score subgroups.
Figure 2. Evolution of Antithrombotic Treatment in AF
100
90
80

Proportion of Patients, %

Hybrid Approaches to Ablation of AF
The ideal AF ablation procedure should be minimally
invasive, result in transmural lesions, involve the permanent isolation of the PVs, and offer the possibility of
customising the treatment strategy. Laurent Pison, MD,
PhD, FESC, Heart and Vascular Center, Maastricht UMC,
Maastricht, The Netherlands, feels the hybrid strategy
offers the best advantages for successful ablation. This
approach combines the strengths and minimises the limitations of either surgical or catheter ablation alone by
combining them. Prof Pison reviewed a few of the early
procedures that led to the hybrid approach [Vroomen M
and Pison L. J Interv Card Electrophysiol. 2016].
The improved Cox-Maze-procedure (Cox-Maze IV) has
achieved good success rates in both paroxysmal and persistent AF over the long-term while being less invasive
[Weimar T et al. Circ Arrhythm Electrophysiol. 2012]. A
surgical approach involving a complete thoracoscopic
PVI with ganglionic plexus ablation and LAA amputation is safe and effective for the treatment of lone AF.
Freedom from AF was obtained in 77% of patients during
a mean follow-up of 11.6 months [Yilmaz A et al. Eur J
Cardiothorac Surg. 2010]. Interpretation of most surgical
studies, however, is limited by inconsistent methodologies, incomplete follow-up and insufficient methods used
for rhythm assessment (eg, telephone interviews).
Hybrid AF ablation is minimally invasive and results
in durable lesions and high rates of chronic PVI even
after long-term follow-up [Velagic V et al. J Cardiovasc
Electrophysiol. 2016]. Only recently, practical guides to
perform this procedure have been developed. Surgical
and catheter ablation may be performed at the same
time or as a 2-stage procedure, (electrophysiology
study after surgery either during the same or a later
hospital admission). Surgery involves a thoracoscopic
approach (monolateral or bilateral thoracic, subxiphoidal, transabdominal transdiaphragmatic). Surgical epicardial ablation can be performed with cryoenergy or
unipolar / bipolar radiofrequency energy. Compared
with standard minimally invasive surgical approaches,
the hybrid approach yields better results in long-standing persistent AF [La Meir M et al. Int J Cardiol. 2013].
Indeed, the hybrid procedure appears to offer the best of
2 techniques but more randomised trials will be needed
like the HARTCAP-AF study, an ongoing prospective trial
comparing hybrid ablation to catheter ablation alone.

70
60
50
40
30
20
10
0

Cohort 1
2010-11
(n = 5311)

VKA

VKA+AP

Cohort 2
2011-13
(n = 11,562)

FXaI

FXaI+AP

Cohort 3
2013-14
(n = 11,343)

DTI

DTI+AP

Cohort 4
2014-15
(n = 10,923)

None

Anticoagulated Patients

AF, atrial fibrillation; AP, antiplatelet; DTI, direct thrombin inhibitors;
FXaI, factor Xa inhibitors; VKA, vitamin K antagonists.
Republished with permission of the BMJ Publishing Group, from Evolving
antithrombotic treatment patterns for patients with newly diagnosed atrial
fibrillation, Camm AJ. Heart. 2016;103:307-314. Copyright 2017. Permission
conveyed through Copyright Clearance Center, Inc.

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