2007 terni, workshop interattivo, in registro osservazionale terni sull'ablazione della...
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Transcript of 2007 terni, workshop interattivo, in registro osservazionale terni sull'ablazione della...
Stefano Nardi, MD, PhD
AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNIDIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE STRUTTURA COMPLESSA DI CARDIOLOGIA STRUTTURA COMPLESSA DI CARDIOLOGIA
UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE
Segmental Ostial Catheter Ablation (SOCA) of AFib using Segmental Ostial Catheter Ablation (SOCA) of AFib using virtual geometry reconstruction with NavX system. virtual geometry reconstruction with NavX system.
The TERNI (Terni Evaluation ofThe TERNI (Terni Evaluation ofPulmonaRy Vein IsolatioN with EnSIte System) registryPulmonaRy Vein IsolatioN with EnSIte System) registry
Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
SUBSTRATO GANGLI VAGALI
meccanismi operativi
RF
TRIGGERS
ROTORI
triggers dalle Vene Polmonari
Haissaguerre, NEJM ‘’98
Firing VPSL
RF
Dominant source of triggers Dominant source of triggers Role in the maintenanceRole in the maintenance• Firiing focali a scarica continua Firiing focali a scarica continua (Ja(Jaïïs)s)
• Firiing focali intermittenti Firiing focali intermittenti (O’Donnell, Kumagai, (O’Donnell, Kumagai, Oral)Oral)
• Rientro Rientro (Arora, Hocini, Wu, Mansour, Jais)(Arora, Hocini, Wu, Mansour, Jais)
HwangCirculation 2000
fibre critichefibre critiche
Sueda Sueda Ann Thorac Surg Ann Thorac Surg
19971997
Microcircuti Microcircuti di rientrodi rientro
HaissaguerreNEJM 1998
triggers dell’FAtriggers dell’FA
Electro-physiologic ApproachSOCA of all 4 veins
Pulmonary vein anatomy the 1st challenge
Left common trunk 3 right lower veins
Normal
Pulmonary vein anatomy the 1st challenge
Hocini M, Card. Res ’02 Hocini M, Circulation ‘02
The Antral Zonethe 2nd challenge
The Antral Zonethe 2nd challenge
Atrial Fibrillation ablationAtrial Fibrillation ablationanalisi Vene Polmonarianalisi Vene Polmonari
Virtual geometry reconstructionVirtual geometry reconstruction
Virtual geometry reconstructionVirtual geometry reconstruction
Virtual geometry reconstructionVirtual geometry reconstruction
What is success?
• Complete freedom of AF, off drug RX?• No symptoms, but drug Rx required?• Dramatic decrease in symptoms, but AADs
still required?• QoL• How do we detect asymptomatic episodes?• Anticoagulation ………………...?
QUESTIONSQUESTIONS
Esophageal contiguity with LA3D mapping system in AFib3D mapping system in AFib
Atrial Fibrillation approachAtrial Fibrillation approach
Ernst, JACC ‘03Ernst, JACC ‘03
Complete LesionsComplete LesionsA – 5% A – 5% B – 21% B – 21% C – C – 50% 50% D - 58-65% D - 58-65%OutcomeOutcome
• Complete lesion 74% Complete lesion 74% arrhythmia free w/o AADs arrhythmia free w/o AADs
• Incomplete lesion – almost Incomplete lesion – almost all recurrent arrhythmia all recurrent arrhythmia
Limitation of CLAALimitation of CLAA
• SEVERAL GAPS can be found within the ablation lines (2-4mm) exploring the “encircling line”.
• Studi recenti hanno dimostrato che FASCI di MUSCOLATURA PARIETALE presenti nella TONACA MEDIA delle VP possono rappresentare una sorgente dominante d’innesco (TRIGGER) della FA nell’uomo
• Evidenza indiretta a favore della presenza di SORGENTI MULTIPLE nelle diverse VP e nel contesto della vena singola
Innesco dell’FAInnesco dell’FAInnesco dell’FAInnesco dell’FA
Triggers dell’FA
Mantenimento Mantenimento dell’FAdell’FA
Mantenimento Mantenimento dell’FAdell’FA
Rimodellamento Rimodellamento atrialeatriale
Rimodellamento Rimodellamento atrialeatriale
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablation
Atrial Fibrillation ablationAtrial Fibrillation ablation
Atrial Fibrillation ablationAtrial Fibrillation ablationAnatomical considerations (fluoro)Anatomical considerations (fluoro)
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncture (fluoro)transeptal puncture (fluoro)
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncture (fluoro)transeptal puncture (fluoro)
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncture (fluoro)transeptal puncture (fluoro)
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncture (fluoro)transeptal puncture (fluoro)
Atrial Fibrillation ablationAtrial Fibrillation ablationTEE evaluationTEE evaluation
Atrial Fibrillation ablationAtrial Fibrillation ablationTEE evaluationTEE evaluation
Atrial Fibrillation ablationAtrial Fibrillation ablationTEE evaluationTEE evaluation
Inferomediale
Infero-laterale
VPIL
VPSL
VP s
up.
lat.
VP inf
. lat
.
VP s
up.
set.
VP inf
. s
et.
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
CT/MRI Scanner
DICOM 3 Slice Data
Worstation
Segmented 3D ModelSegmentation Module
User Interface
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Point-by-Point
Medium-Low
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
LSPV-LAA Junction
LA Medial-RPV Junction
RPV Carina
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Circumferential lesion pathway
PVPs
Atrial potentials
Lesion Validation (Preablation)Lesion Validation (Preablation)
Incomplete lesion
Lesion Validation Lesion Validation ((AblationAblation))
Complete lesion
Lesion Validation Lesion Validation ((AblationAblation))
Atrial potentials breakdown
PVPs disappearance
Lesion Validation Lesion Validation ((PVPs PVPs AbolitionAbolition))
≤ 0.1mV
≤0.05mV
Validazione delle lesioniValidazione delle lesioni ((abbattimento dei abbattimento dei potenzialipotenziali))
Circumferential lesion pathway
Type A AF (PV Tachycardia)
AF waves
Lesion Validation (Preablation)Lesion Validation (Preablation)
Incomplete lesion
Type A AF (PV Tachycardia)
Lesion Validation (Lesion Validation (AblationAblation))
Complete lesion
Lesion Validation (Lesion Validation (AblationAblation))
Atrial activity reduction
Type A AF (PV Tachycardia)
Abolition
Lesion ValidationLesion Validation Type A AF/PV Tachycardia AbolitionType A AF/PV Tachycardia Abolition
≤ 0.1mV
≤0.05mV
Validazione delle lesioniValidazione delle lesioni (abbattimento dei (abbattimento dei
potenziali)potenziali)
REGISTRO OSSERVAZIONALE
T.E.R.N.I.
AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNIDIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE STRUTTURA COMPLESSA DI CARDIOLOGIA STRUTTURA COMPLESSA DI CARDIOLOGIA
UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE
Procedure (min): 148±26 144±24 151± 29
Fluoroscopy (min): 59±17 58±16 66±19
Mapping (min): 35±8 33±9 38±4
Nr. Pulses of RF: 72±16
70±17 75±19
RESULTSRESULTS Global Pz.in SR Pz. in AF
TERNI RegistryTERNI Registry
629 VP treated (145 pts)
Acute Complete BlockAcute Complete Block
558 VP (89%)558 VP (89%)
Incomplete BlockIncomplete Block
71 VP (11%)71 VP (11%)
• 422 pts with symptomatic PaAF and PeAF referred to us between July ‘04 and September ’06. CA performed in 145/422 pts (34%).
TERNI registryTERNI registry
• At least one MONTHLY episode of Persistent symptomatic AF
• At least ONE WEEKLY episode of PaAF or PeAF
• At least Two or More AADs unable to control symptoms
• Age >75 yrs• Contraindications to ACT• Congestive HF• NYHA class III or IV• LVEF ≤35% • LA diameter ≥55mm• CARDIAC THROMBUS• Life expectancy <1 yr• CCH surgery <3 mo or
PROSTHETIC valves
Inclusion criteriaInclusion criteria Exclusion criteriaExclusion criteria
AFib PAROX. PERSIST. TOTALPatients 91 54 145 Age 62±13 67±8 64±15Sex (M/F) 61/26 37/21 98/47Duration 36±12N.episodes/mo 4±6LVEF (%) 55±6 51±9 53±9,7LA diameter 44±8 47±8 46±8CAD 15 21 36
TERNI registryTERNI registry
• NO major complication (including death, stroke or other thromboembolic events) observed.
• MILD pericardial effusion observed in 4 pts.
• ANGIOGRAFIC analysis of all PVs performed post- procedure in all pts (no PV stenosis).
Clinical OUTCOME
TERNI RegistryTERNI Registry
• TELEMETRY MONITORING from 24 to 36 hr. • Eparin Na+ iv for 24 to 36 h.• ACT started 24 h post RFCA • ECHO pre-discharge.• Discharged with ACT (maintained for ≥ 6 mo)• Discharged with AADs (maintained for ≥ 6 mo) (35% with propafenone and 65% with flecainide)
Post-ablation MANAGEMENT TERNI RegistryTERNI Registry
• After a mean FU Overall FREEDOM FROM AF (both PaAF and PeAF) was 60% (69% and 48%), w/o AADs and 72% (80% and 55%) with previous ineffective AADs.
Clinical OUTCOME
• The Kaplan-Meier statistical analysis probability of freedom from arrhythmia was maximal at 12 months
TERNI RegistryTERNI Registry
• Among UNIVARIATE predictors, the variables of age, sex, duration and frequency of AF, LVEF, LA size and structural heart disease, this approach revealed that an increased LA SIZE >50mm is an indipendet predictor of AF recurrence
TERNI RegistryTERNI Registry
• NO major complication (including death, stroke or other thromboembolic events) observed.
• MILD pericardial effusion observed in 4 pts.
• ANGIOGRAFIC analysis of all PVs performed post- procedure in all pts (no PV stenosis).
Clinical OUTCOME
TERNI RegistryTERNI Registry
• TELEMETRY MONITORING from 24 to 36 hr. • Eparin Na+ iv for 24 to 36 h.• ACT started 24 h post RFCA • ECHO pre-discharge.• Discharged with ACT (maintained for ≥ 6 mo)• Discharged with AADs (maintained for ≥ 6 mo) (35% with propafenone and 65% with flecainide)
Post-ablation MANAGEMENT TERNI RegistryTERNI Registry
• After a mean FU Overall FREEDOM FROM AF (both PaAF and PeAF) was 60% (69% and 48%), w/o AADs and 72% (80% and 55%) with previous ineffective AADs.
Clinical OUTCOME
• The Kaplan-Meier statistical analysis probability of freedom from arrhythmia was maximal at 12 months
TERNI RegistryTERNI Registry
• Among UNIVARIATE predictors, the variables of age, sex, duration and frequency of AF, LVEF, LA size and structural heart disease, this approach revealed that an increased LA SIZE >50mm is an indipendet predictor of AF recurrence
different Technologiesdifferent Technologies
MappingMapping• Point by pointPoint by point
• LassoLasso• SpiralSpiral• BasketBasket
TrackingTracking• XrayXray
• CARTOCARTO• LocaLisaLocaLisa• NavXNavX• RPMRPM
• ICEICE
AblationAblation• ConventionalConventional
• 8 mm tip8 mm tip• Irrigated tipIrrigated tip• InvestigationalInvestigational(balloon, cryo...)(balloon, cryo...)- Framework for ablationFramework for ablation
- Mapping guidanceMapping guidance
- Anatomic localizationAnatomic localization
- Tagging of ablation sites- Tagging of ablation sites- Determine Determine catheter contactcatheter contact
- Improved Improved efficiency of efficiency of power deliverypower delivery
Atrial Fibrillation approachAtrial Fibrillation approach
• 422 pts with symptomatic PaAF and PeAF referred to us between July ‘04 and September ’06. CA performed in 145/422 pts (34%).
TERNI registryTERNI registry
• At least one MONTHLY episode of Persistent symptomatic AF
• At least ONE WEEKLY episode of PaAF or PeAF
• At least Two or More AADs unable to control symptoms
• Age >75 yrs• Contraindications to ACT• Congestive HF• NYHA class III or IV• LVEF ≤35% • LA diameter ≥55mm• CARDIAC THROMBUS• Life expectancy <1 yr• CCH surgery <3 mo or
PROSTHETIC valves
Inclusion criteriaInclusion criteria Exclusion criteriaExclusion criteria
AFib PAROX. PERSIST. TOTALPatients 91 54 145 Age 62±13 67±8 64±15Sex (M/F) 61/26 37/21 98/47Duration 36±12N.episodes/mo 4±6LVEF (%) 55±6 51±9 53±9,7LA diameter 44±8 47±8 46±8CAD 15 21 36
TERNI registryTERNI registry
evolution of 3D mapping systemAtrial Fibrillation approachAtrial Fibrillation approach
Procedure (min): 148±26 144±24 151± 29
Fluoroscopy (min): 59±17 58±16 66±19
Mapping (min): 35±8 33±9 38±4
Nr. Pulses of RF: 72±16
70±17 75±19
RESULTSRESULTS Global Pz.in SR Pz. in AF
TERNI RegistryTERNI Registry
629 VP treated (145 pts)
Acute Complete BlockAcute Complete Block
558 VP (89%)558 VP (89%)
Incomplete BlockIncomplete Block
71 VP (11%)71 VP (11%)