ESC Congress FA eBook 2016 - 20

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Table 1. Classification Based on Type of Valvular AF
Type 1 Valvular AF
(Treat with VKA)

Type 2 Valvular AF
(May treat with VKA or NOAC)

* Mitral stenosis

* Aortic stenosis

* Mechanical prosthetic valve
replacement

* Aortic regurgitation
* Mitral regurgitation
* Tricuspid regurgitation
* Tricuspid stenosis
* Pulmonic regurgitation
* Pulmonic stenosis
* Bioprosthetic valve
replacement
* Trans-aortic valve replacement
* Mitral clip

AF, atrial fibrillation; NOAC, non-vitamin K antagonist anticoagulant; VKA, vitamin K antagonist.

Survival Free From
Cardiovascular Hospitalization / All-Cause Mortality

Figure 1. Cardiovascular Events Based on the Timing of HF
and AF
100
90
80
70
AF first

60
50
40

Heart failure first

30
20
Log rank P < .001

10
0
0

No. at risk
AF first
137
HF first
45

9
Time, m

99
23

85
18

72
17

66
14

60
13

51
6

AF, atrial fibrillation.
Reprinted from Smit MD et al. The importance of whether atrial fibrillation or heart failure
develops first. Eur J Heart Fail. 2012;14(9)1030-1040. 10.1093/eurjhf/hfs097. By permission of
John Wiley and Sons on behalf of the European Society of Cardiology.

Noting that preventing embolic stroke with NOACs
may increase the risk of hemorrhagic stroke Jose L.
Merino, MD Hospital Universitario La Paz, Madrid,
Spain, reviewed some of the studies that evaluated the
alternatives to NOACs with respect to bleeding risk to
assess whether this might affect the choice of therapy for
patients already at high bleeding risk.

October 2016

In the ACTIVE W trial warfarin was significantly superior to clopidogrel plus aspirin for prevention of vascular
events in patients with AF at high risk of stroke [ACTIVE
Investigators. Lancet. 2006]. In the AVERROES trial, apixaban reduced the risk of stroke or systemic embolism
without significantly increasing the risk of major bleeding or intracranial hemorrhage in patients for whom
vitamin K therapy was unsuitable. [Connolly SJ et al. N
Engl J Med. 2011].
Another alternative to NOACs is left atrial appendage
(LAA) occlusion. Although the PROTECT AF trial found
LAA occlusion to be noninferior to warfarin for embolic
stroke prevention, a periprocedural bleeding hazard was
identified [Holmes DR et al. Lancet. 2009].
After reviewing these studies, Prof Merino, said that
he is in agreement with the ESC recommendations that
no treatment or treatment with an antiplatelet are not
alternatives for NOACs and that most high risk bleeding patients, including the elderly and frail, should still
receive NOAC therapy.
In answer to the question, Who may not benefit from
catheter ablation? Hans Kottkamp, MD, Hirslanden
Hospital, Zurich, Switzerland, suggested that most AF
patients would benefit from catheter ablation, though
symptomatic patients with paroxysmal AF are the most
favorable category. He does not see the presence of HF
as precluding ablation, noting that in a recent trial, ablation was superior to the antiarrhythmic medication, amiodarone, in achieving long-term freedom from AF and
reducing unplanned hospitalization and mortality in HF
patients with AF [Di Biase L et al. Circulation. 2016]. He
does suggest, however, that patients with persistent AF
and those with long-standing AF be treated in the context
of a clinical trial.
Prof Kottkamp added that, within limits, age is also
not a factor, noting that in his department the mean age
of AF ablation patients has increased from 58 to 69 years
within the last 10 years and that aggressive risk factor
management (eg, obesity and metabolic syndrome) can
improve the long-term success of AF ablation [Pathak RK
et al. J Am Coll Cardiol. 2014].
The presence of atrial fibrosis has been suggested as
the reason for multiple ablation procedures [Kottkamp
H. Eur Heart J. 2013]. Prof Kottkamp noted that a new
substrate modification concept in redo procedures
employing circumferential isolation, so-called box isolation of fibrotic areas (BIFA), has been shown to achieve
freedom from AF/atrial tachycardia (72.2% of patients
with paroxysmal and non-paroxysmal AF in a single
procedure and in 83.3% with 1.17 procedures/patient;
Figure 2) [Kottkamp H et al. J Cardiovasc Electropohysiol.
2016].

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