Heart Failure and AF: Where Does Ablation Fit in?

[EngMac]

This is an interesting Medscape article. medscape.com/viewarticle/88...

A couple of statements made are:

"Look at which type of procedure is performed by your electrophysiologist. Pulmonary vein isolation alone is not enough."

"I think that today you have heard some very interesting clinical data. We all see AF. My biggest fear around AF is an emergency department that gives intravenous (IV) diltiazem, not knowing what is underneath that rhythm. The low-EF patients can really get hurt with IV diltiazem because it significantly drops cardiac output. I usually recommend that if you are in a hurry, give some IV metoprolol. Give it slowly right there at the bedside and stand there. You do not leave when you are giving IV anything. Try to cut down the rate that way, rather than with IV diltiazem."

"I think there is room for updating the guidelines. Right now [catheter ablation] for AF is recommended after failure of the drugs. My message to clinicians is to think about catheter ablation earlier rather than later. From our experience in the AATAC trial, we had a success rate range from 29% to 61%, according to the procedure performed and the operator performing the procedure."

Studies of course are studies and whether the conclusions apply to all patients is the big challenge.

[BobD Volunteer]

Interesting re PVI alone as that is all cryoablation can do. Hence the frequent need for later RF ablation to deal with other areas.

Here in UK I do not think they IV anything during A and E except maybe amiodarone.

Many EPs in UK have been saying for years early intervention is best.

[UScore in reply to BobD]

Yeah, my EP is keen on early intervention.

I had Flecainide on IV when I went to A&E with AF.

[ILowe in reply to UScore]

I seem to remember reading somewhere:

1. Flecainide is as good as amiodarone, for IV, but you have to monitor many things and know what you are doing, especially when it is the first time for a patient taking flecainide

2. Since flecainide is absorbed quickly, especially on an empty stomach, then taking a bolus orally, then monitoring, is safer and often succeeds

3. Oral amiodarone, when given as one single large dose, with or without fasting, creates a bolus that can shock the heart into good behaviour. It is much safer than IV. The big danger is low blood pressure and low heart rate, so best done in hospital the first time. This is well known in other countries such as France. Followup can be Amiodarone or Flecainide.

Thanks for the warning about diltiazem. We patients need to know enough to question things.

[irene75359]

On reading the adverse reports on Amiodarone, on my medical record on my iphone (which my husband assures me would be checked in an emergency) I have stated no Amiodarone. I carry and use Flecainide as a PIP.

[rosyG]

are you interested in AF and Heart failure? will PM you if so

[EngMac]

Rosy, do you wish to speak to me or someone else on this post? You can PM me if you wish.