SEMINOR ON

MANAGEMENT OF ATRIAL
FIBRILILLATION
BY:
Dr. DILIP KUMAR JAIN
Under the guidence of

Dr. RAJMANI
Asst. Prof. Medicine Deptt.
J.L.N. Medical College & Hospital
Ajmer-305001
 REFRENCES
 HARRISON’S principles of Internal
Medicine 17th edition
 BRAUNWALD’S Heart disease 8th
edition
 LEOSCHAMROTH’S An
introduction to Electro Cardiography 7th edition
 Various internet sites
 ATRIAL FIBRILLATION
 AF: It is an arrhythmias characterized by seemingly disorganized
atrial depolarization without effective atrial contraction.
 AF is most common sustained arrhythmias.
 Incidence- very common
1% > 60 years
75%> 69 years
From framingham data lifetime risk after age 40 years
26% Men
23% Women
Men> Women
 AF is common in adult population .It is extremely unusual in
children unless structural heart ds in present or there is another
arrhythmia that precipitate the AF such as PSVT with WPW
syndrome.
 Independently associated with : H/O CHF, Valvular heart disorder,
stroke , Left atrial enlargement, abnormal aortic or mitral valve
function , treated systematic HTN, advanced age, obesity.
 Occasionally AF occur in
:--Acute hyperthyroidism
:--Acute Vagotonic episode
:--Acute alcohol intoxication
:--Common during the acute or early Recovery
phase of major vascular ,abdominal or thoracic surgery .
Also be triggered by after supraventricular tachycardia such
as AVNRT.
 ECG
 Small irregular baseline undulation of variable amplitude and
morphology call f-wave at rate of 350-600 beat/min.
ventricular response is grossly irregular (Irregularly- irregular)
and untreated pt normal AV conduction is usually b/w 100-160
beat/min ,in patient with WPW syndrom VR during AF can
exceed 300 beats/min and lead to VF. AF should
be suspected when ECG show supraventricular complex at an
irregular rhythm and no obvious P wave. In long standing
cases of AF, the deflexsion is low amplitude and the baseline
almost straight with minimal smooth low amplitude undulations.
Physical Findings:
 Slight variation in intensity of 1st heart sound.
 Absent of a-wave in JVP
 Irregularly irregular ventricular rhythm
 often fast ventricular rate, a significant pulse deficit.
 If VR become regular in AF conversion into sinus rhythms atrial
tachycardia, AFL constant ratio of conduction beat or development of
junctional tachycardia or VT should be suspected.
Symptom :
1. Asymptomatic
2. Only minor palpitation or sense irregularity of their pulse
3. Severe palpitation
4. Anginal symptom
5. Exercise intolerance & easy fatigability are hallmark of poor rate control
with exertion .
6. Occasionally the only manifestation severe dizziness or syncope a/w pause
that occur upon termination of AF before sinus rhythm resume.
 MECHANISM
 AF initiation & maintenance appear to represent a complex interaction
b/w driver responsible for initiation and complex anatomical atrial
substance that promote the maintenance of multiple wavelets of (micro)
re-entry. The drivers appear that enter pulmonary vein also documented
around the orifice of pulmonary vein and non-pulmonary vein.
 Four Important aspects :
1. Treatable contributory factor
2. Control of ventricular rate
3. Prevention of recurrence
4. Prevention of thromboembolic episode.
 CLINICAL IMPORTANCE RELATED TO
1. Loss of atrial contractility .
2. Inappropriate fast ventricular response
3. Loss of atrial appendage contractility & emptying lead to risk of clot
formation and subsequent thromboembolic event.
 EMBOLISATION & ANTICOAGULATION
 Risk of systemic emboli probably arising in left atrial cavity or
appendage.
 Non-valvular AF is the most common cardiac disease a/w
cerebral embolism.
 Half of cardiogenic emboli occur in patient with non-valvular
AF.
 Risk of stroke in patient with non-valvular AF 5-7 time greater
than control without AF.
 Overall 20-25 ischemic stroke caused by cardiogenic
embolism.
 Risk factor that predict stroke in non-valvular AF
include:
---H/o previous stroke or TIA (RR 2.5)
---H/o DM (RR1.7)
---H/o HTN (RR1.6)
---Increasing age (RR 1.4 for each decade)
---Annual stroke risk at least 4% if untreated
 Only stroke risk factor -- CHF
-- CAD
LVDF & LA size > 2.5/m2 on echocardiographic examination are
a/w with thromboembolism.
 Patient younger than 60-65 yrs who have echocardiogram & no
risk factor have extremely low risk for stroke.
 Risk of stroke with lone AF is relatively low
 Anticoagulation therapy is 50% more effective than aspirin
therapy for prevention of ischemic stroke in AF patience.
 Risk factor anticoagulation associated brain hemmorhage:-
1.Exessive anticoagulation
2. Partially controlled HTN
 Individuals younger than 60 yrs. Of age without any clinical risk
factor or structural heart ds (lone AF) not require anti-thrombotic
therapy for stroke prevention (b/c low risk factor )
 Stroke rate is also low in age of 60 and 75 years with lone atrial
fibrillation. These Patience adequately protected from stroke by
ASPIRIN therapy.
 In very elderly patience >75 yrs with AF anticoagulation should
be with caution & carefully monitored because of the potentially
increased risk of intra cranial hemmorhage.
 RECOMMENDATION FOR
ANTITHROMBOTIC THERAPY
 Any patience with AF who has risk factor for stroke should be
treated with warfarin to achieve INR 2-3 for stroke prevention.
 Prior stroke
 TIA
 Significant valvular heart ds
 HTN
 DM
 >65 years
 LA enlargement
 CAD
 CHF
 Contradiction to anticoagulation & unreliable individual should
be considered for Aspirin therapy.
 Patience with AF who do not have any preceding risk factor
have a low stroke risk & can be protected from stroke with
Aspirin.
 In patience > 75 years anticoagulation should be used with
caution & monitored carefully to keep INR less than 3.0
(because risk of intra-cranial hemmorhage)
 Risk of Embolisation following cardioversion to sinus
rhythm in AF varies from 0 to 7% :----
:-depending on under lying risk factor
:-independent of mode of cardio-version
:-High Risk  Prior embolism
 Mechanical valve-prosthesis
 Mitral Stenosis
:-Low Risk Patience < 60 yrs without underlying heart ds
 High risk group should receive chronic anticoagulation
regardless of whether they will undergo cardio version.
 Patience not in low risk group who have AF longer than 2
days should receive warferin for 3 week before elective
cardio-version (Keep INR 2-3), for 3-4 weeks after
reversion to sinus rhythm.
 Alternative strategy TEE (Tran-esophageal
echocardiogram) to exclude the presence of atrial thrombus.
 It predict group at risk for Development of
thromboembolism follower cardiogram that the patient are
immediately treated with Heparin followed by therapeutic
dose of warferin.
 Anticoagulation with Heparin has been recommended
foremergency cardio version when 3 weeks of anticogulation or
Tran esophageal echocardiogram can't be obtained.
 No matter which strategy is used anticoagulation should be
continued for at least 4 weeks following cardio-version
 Newer strategies for stroke prevention in AF
ORAL THROMBIN INHIBITOR
Eg Ximelagatran
Melagatran
Wide therapeutic window not requiring monitoring.
 OBLITERATION OF LEFT ATRIAL
APPENDAGE
 Non rheumatic AF more than 90% thrombi from LA appendage.
 Surgical closure is recommended only as adjuvant procedure in
patient undergoing mitral valve surgery.
 PLAATO PROCEDURE:-
 Percutaneous LAA trascatheter occlusion via the
transeptal approach.
 Expanding nitinol cage is placed under transoesophageal
echocardiography guidance and allowed to expand in LAA thus
filling it and effectively excluding it from the circulation.
 It is not appropriate for anticoagulation.
 EVALUTION

 Search for reversible cause

 2D-Echo
 ECG
 T3, T4, TSH
 Persistent or labile HTN. Should be identify.
 Heart Failure treatment should be optimized.
MANAGEMENT:
 Goal – 1. Reduce risk of thrombo-embolism( described earlier). 2.
To control symptom
 2. TO CONTROLL SYMPTOM:-By controlling the
ventricular rate during AF and /or restoring and maintaining sinus
rhythm.
Overall treatment strategy should be individualized for
each patience & based on whether patient are symptomatic from
uncontrolled ventricular rates or from atrial fibrillation itself and
risk for side effect from drug.
 As general rule asymptomatic patient found to have AF or routine
ECG are not likely to require rhythm control and rate control is
usually sufficient.
 Ambulatory monitoring co-relating the patience ventricular
response and rhythm to symptom and exercise testing can be
useful to this end.
 A trial of aggressive rate control or conversely cardio-version and
maintenance of sinus rhythm are some time necessary to make
this determination.
ACUTE MANAGEMENT:
 AF discovered 1st time should be evaluated for precipitating
cause.
 Clinical status determine initial therapy.
 Objectives being to slow the ventricular and/or restore atrial
systole.
 If sudden onset of AF with a rapid ventricular rate result in acute
cardiovascular de-compensation.
 Electric cardio-version is initial treatment of choice.
 ELECTRO CARDIO VERSION
 BIPHASIC EXTERNAL DEFIBRILLATION :Direct current
thoracic cardio version during short acting anesthesia using
200 J biphasic shock synchronously.
 In-Refractory case
 Dual defibrillators (720 J,two defibrillation at tendem)
 INTERNAL CARDIOVERSION:via intracavitary catheter can
be effective when tranthorasic shock fail, particular in
obese patience or in those with significant pulmonary ds.
 Alternatively anti arrhythmic drug that lower
defibrillation threshold such as ibutilide can be use to
protect the patient and increase success of DC cardio
version.
 CHEMICAL CARDIOVERSION WITH ANTI
ARRHYTHMIC
1. IV/oral Procainamide
2. IV Flecainide
3. IV/oral Amiodaron- Less effective
4. IV Ibutilide
In absence de-compensation can be treated with
 Digitalis
 Beta blockers
 Calcium antagonists
:-Combined used of digitalis & a beta blocker or calcium
antagonist can be helpful in slowing the ventricular rate.
:-Digitalis more effective if associated with LVDF.
:-Without such dysfunction, a beta blocker may be
preferable to control the ventricular rate.
 LONG TERM
For Rate control strategy
 DRUGS  Digitalis alone or
 CCB (Diltiazem & Verapamil) combination
 Beta Blocker
Ambulatory monitoring and/or exercise testing can be useful
adequate rate control during activity. a testing to
maintain a resting optical rate of 60-80 beat/min. that does not
exceeds 100 beats/min. after slight exercise.

Surgically:- In some patience with frequent recurrence and rapid

ventricular rate not controlled by drug or intolerant to drug, or
worsening of LV function.
RADIO FREQUENCY CATHETER ABLATCON

 1st line approach for treating patient with symptomatic AF

 Foci predominantly clustered in pulmonary vein.
 Ablation lesion around the PV should be deployed within atrium
probably at least 1cm from PV ostia.
 Complication:- 1. PV stenores 2.
Pericardial effusion 3. Cardiac tamponade
4. Atries ophageal fistula
5. Systematic embolic event
 SURGICAL ABLATION
 Typical performed at the time of other cardiac valve or coronary
artery surgery and less commonly alone.
1. COX surgical maze procedure
:- Interept all macroreentrant circuit in atria
:- Multiple incision procedure
2. Liner line ablation-- more preffered
3. Pulmonary vein isolation
Anti arrhythymic therapy can be discontinued after
catheter or surgical ablation.
 NEWER surgical technique
:-RF clamp
:-Cryoablation
:-RF pen
:-High intensity ultrasound

 Implantation of rate adaptive VVI pacemaker—Acceptable

 Atrial or dual chamber pacing– Preferable
(because incidence of AF & stroke less)
 TO MAINTAIN SINUS RHYTHUM
 Class IA,IC,III(amiodaron,sotalol) azimilide and dofetilide.
 Sotalol is less effective than amiodaron or IC agent
 Class IA agent poorly tolerated and rarely used.
 General rule for patient without structural heart ds. (HTN-heart
disease), IC agent( propafenon, flecainide) are well tolerated and
first line agent.
 For patient with structural heart ds Amiodaron, Dofetilide or
Sotalol reasonable first line agent.
 A single episode of AF may not warrant any intervention or only
short course of beta blocker therapy.
 In patient with occasionally episode of persistent AF (require
cardio version) “a pill in pocket” approach either flecainide or
propafenone usually high doses is administered only after the
onset of AF to convert AF.
THANK YOU
 IMPLANTABLE ATRIAL DEFIBRILLATOR

 It involves transvenous lead in RA and coronary sinus

 Conversion rate 90% in drug refractory AF.
 Effective shock need at 3 but energy as little as .1 J
may give discomfort so associated with poor patient
tolerance.
 Newer model combine ATP ( Anti tachycardiopacing)
IAD,ICD, allowing termination & both atria &
ventricular arrhythmias.
 PACING OF AF
 AF occurs in sick sinus syndrom
 Atrial or dual chamber pacing preferred to ventricular
pacing.
 Lower Incedence of AF & reversal of atrial
remodelling
 Vagal mediated & related to bradycardia.
 Significantly lower incidence & thromboembolism
stroke and mortality.
 TO PREVENT RECURRENT AF

Catheter Ablative Surgical Ablative

Therapy Therapy
 Most ablation strategies incorporate technical that solate atrial
muscle sleeves entering pulmonary vein .
 Identified as sense .9 majority of trigger responsible for the
intiation of AF.
 Alternatively to pharmocology therapy with recurrent
symptomatic AF.
RF CATHETER ABLATION THERAPY
 Inmore persistent form AF and those with
severe atrial dilation.
 Important alternatively to his bundle ablation
& pacemaker insertion.
 Risk overall 2-4 %
 complications pulmonary vein stenomia,
atrioesophageal fistula, systematic embolic
perfozation/ tempenade.
 ABLATE & PACE
 Percutenenis ratio frequency abalation of AVN
is highly effective for drug refractory rate
control in AF.
 It produce complete heart block so permanent
pacemaker is needed.
 Atrial contraction are not restored and long
term anticoagulation treatment is needed.