In this short video interview filmed at EHRA 2022, Dr Dhiraj Gupta (Liverpool Heart and Chest NHS Foundation Trust, UK) discusses research surrounding atrial fibrillation in heart failure, and the considerations that must be taken when approaching AF ablation.
Discussion points: - Research surrounding atrial fibrillation in heart failure - Conflicts in this research - Further research required - Considerations when approaching AF ablation - Take-home messages for clinicians
Recorded on-site in Copenhagen, EHRA Conference 2022. Interviewer: Jonathan McKenna Editor: Jordan Rance
This content is intended for healthcare professionals only.
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2 -> So atrial fibrillation and heart failure
3.93 -> are the two global pandemics
in the cardiovascular arena.
7.83 -> They both tend to worsen
the outcomes of each other.
11.33 -> And so there's been lots
of interest in improving
13.8 -> those outcomes over the
last 20 years or so.
16.6 -> Historically, the rhythm control strategy
19.5 -> used to involve cardioverting these people
21.71 -> and giving them anti-arrhythmic drugs,
23.78 -> and the historical
trials show no difference
26.23 -> with that strategy and no improvement.
28.6 -> More recently, with catheter ablation,
31.25 -> the chances of maintaining
sinus rhythm are much higher.
34.672 -> And hence, there've been
lots of head to head,
36.68 -> randomised control trials,
38.25 -> which have addressed this very issue.
40.19 -> So it's very difficult to
know in an individual patient
44.21 -> what best to do because it's such
45.77 -> a wide spectrum of patients.
47.87 -> There are some people in
whom atrial fibrillation
50.49 -> is the fundamental reason
for the heart failure
53.14 -> or at least it's contributing
to the heart failure.
56.12 -> And it's those patients
who you really want
58.17 -> to address with ablation.
59.9 -> Equally, there are some patients
in whom atrial fibrillation
62.37 -> happens as a byproduct of
longstanding heart failure,
66.3 -> almost as a end-stage disease.
68.94 -> In them,
69.773 -> there's little to gained
by doing catheter ablation.
72.52 -> So far, on the trials I have done
74.66 -> have not made a distinction
between these two subtypes.
77.45 -> So essentially, all-comers
with heart failure
80.4 -> and atrial fibrillation have
been included in these trials.
83.76 -> The most important thing we need
85.97 -> is to identify those patients
87.94 -> with atrial fibrillation and
heart failure who are likely
90.59 -> to benefit from rhythm control
with catheter ablation.
93.61 -> So you are enriching that
population and making the risks
97.4 -> and the expense of catheter ablation
99.26 -> worthwhile in these patients.
101.41 -> So, the most important thing
to consider is that patients
104.674 -> with congestive heart
failure are very different
107.45 -> from your usual AF ablation population.
109.45 -> These patients are often sicker.
110.53 -> They're often older, they
have lots of co-morbidities.
113.78 -> So the risk of complications
is much higher.
117.09 -> So you need to be aware that
you're bringing your A game
119.5 -> to the table when you're doing
AF ablation in these people.
122.37 -> So you need to do,
123.203 -> you need to use your best technology.
125.22 -> You need to be minimalistic in terms
127.54 -> of what you can achieve
because these patients
129.4 -> often cannot tolerate long procedures
131.405 -> and you need to be realistic
in your expectations.
134.12 -> Well, first of all, be
aware that now there are
136.4 -> good quality data showing
that rhythm control
139.485 -> with catheter ablation improves
outcomes in these patients.
142.98 -> So often, these patients feel better.
145.5 -> They have better objective
criteria for performance,
149.05 -> such as six-minute walk distance,
151.291 -> levels of NT-proBNP levels.
153.241 -> And often, they live longer as well.
155.12 -> If you follow up these
patients long enough.
156.83 -> So the awareness is key
and that education needs
159.9 -> to be disseminated all through the,
161.795 -> to the primary providers
and secondary providers.
