Risultati e complicanze dell’ablazione transcatetere della fibrillazione atriale

Dott. Giovanni CarrerasU.O.S.Aritmologia Ospedale S. Maria

Terni

• The most common significant heart rhythm disturbance

• Incidence increases with age and the development of structural heart disease

• Common cause of stroke (10-15% of all strokes)• Associated with significant cardiovascular morbidity

and mortality• Tends to recur in at least half the patients treated

with antiarrhythmic drug therapy

Atrial Fibrillation

AF is associated with a high risk of mortality

2.3 million US adults currently have AF. This will increase to more than 5.6 million by the year 2050.

Purpose of the study: to provide a systematic multicenter survey on the incidence and causes of DEATH occurring in the setting of or a consequence of Catheter Ablation of Atrial Fibrillation (1995-2006)

546 centers worldwide identified / 162 partecipating

45.115 procedures / 32.569 patients

Survey - Main Carachteristics• Male patients: 61,9 %

• Proportion of centers based on Nr. Of Procedures/Year:

<20 35%21-50 28%51-100 24%>100 13%

Proportion of centers w. Experience in one ablation technique:

Lasso Technique 27%Carto-guided TechniqueTechnique 48%Other Techniques 4%Combination 22%

Effects of sex on the incidence of cardiac tamponade after catheter ablation of atrial fibrillation: results from a

worldwide survey in 34 943 atrial fibrillation ablation procedures.

• CONCLUSIONS: Tamponade during AF ablation procedures is relatively rare. Women have an ≈2-fold higher risk for developing this complication. The risk of tamponade among women decreases substantially in high-volume centers. Surgical backup and acute management skills for treating tamponade are important in centers performing AF ablation.

Clinical and procedural predictors of early complications of ablation for atrial fibrillation: Analysis

of the national registry data.

• CONCLUSION • The risk of early complications is increased by female

sex, hypertrophic cardiomyopathy, valvular heart disease, deep sedation, and complex fractionated atrial electrocardiogram ablation. It is decreased by preprocedural transesophageal echocardiography, periprocedural novel oral anticoagulant,

come ridurre il rischio?

• Effettuare la procedura in regime di anticoagulazione

• Utilizzo NOA durante e dopo la procedura • Utilizzare TAC o RMN• Utilizzo ICE o TEE • Monitoraggio attento parametri vitali• Controllo temperatura esofagea• Valutare età e comorbidità del paziente

A novel radiofrequency ablation catheter using contact force sensing: Toccata study.

Kuck KH1, Reddy VY, Schmidt B, Natale A, Neuzil P, Saoudi N, Kautzner J, Herrera C, Hindricks G, Jaïs P,

Nakagawa H, Lambert H, Shah DC.

• CONCLUSIONS: Catheter ablation using real-time CF technology is safe for the treatment of SVT and AF. High CFs may occur during catheter manipulation and not just during ablation, suggesting that measuring CF may provide additional useful information to the operator for safe catheter manipulation. In the future, CF-sensing catheters may also increase the effectiveness of RF ablations by allowing better control of the RF lesion size

Paroxysmal AF catheter ablation with a contact force sensing catheter: results of the prospective, multicenter SMART-AF trial.

Natale A1, Reddy VY2, Monir G3, Wilber DJ4, Lindsay BD5, McElderry HT6, Kantipudi C7, Mansour MC8, Melby DP9, Packer DL10, Nakagawa H11,

Zhang B12, Stagg RB12, Boo LM12, Marchlinski FE13.

• CONCLUSIONS: The SMART-AF trial demonstrated that this irrigated CF-sensing catheter is safe and effective for the treatment of drug refractory symptomatic PAF, with no unanticipated device-related adverse events. The increased percent of time within investigator-targeted CF ranges correlates with increased freedom from arrhythmia recurrence. Stable CF during radiofrequency application increases the likelihood of 12-month success.

Atrial Fibrillation Mechanisms

SUBSTRATO GANGLI VAGALI

meccanismi operativi

RF

TRIGGERS

ROTORI

triggers dalle Vene Polmonari

Haissaguerre, NEJM ‘’98

Firing VPSL

RF

Dominant source of triggers Role in the maintenance• Firiing focali a scarica continua (Jaïs)

• Firiing focali intermittenti (O’Donnell, Kumagai, Oral)

• Rientro (Arora, Hocini, Wu, Mansour, Jais)

One shot to PVI

Risultati ablazione FA parox

• Considerando i risultati dei vari studi pubblicati negli ultimi 10 anni la percentuale di successo nel trattamento della fibrillazione atriale parossistica, inteso come mantenimento stabile di ritmo sinusale si attesta tra il 70 ed il 90% in assenza di terapia antiaritmica

Come aumentare la percentuale di successo

• Mappaggio accurato• Ricerca foci extrapolmonari• Validare stabilità del risultato mediante

adenosina e/o isoprenalina• Controllo blocco in uscita ed entrata• Utilizzo tecnologia contact force • Evitare jump durante rogazione

J Cardiovascular Electrophysiol Vol 16 November 2005

ConclusionsTermination of long-lasting persistent AF can be achieved in 87% of patients by catheter ablation.

Contemporary Challenges of Catheter Ablation for Atrial Fibrillation.

Weerasooriya R1, Shah AJ2, Hocini M2, Jaïs P2, Haïssaguerre M2

• The use of contact force-sensing technology, adenosine testing after ablation, and pace capture-guided ablation all have the potential for achieving more durable ablation. Selection of patients suitable for ablation of persistent AF may be improved by assessing the extent of atrial fibrosis with delayed enhancement imaging with cardiac magnetic resonance or by assessing the pattern of atrial electrical activity with the use of complex atrial electrograms. Advances in treatment are likely to result from the recognition of localized rotors and focal sources as primary sustaining mechanisms for all types of human AF and in the use of noninvasive mapping for their identification. Linear ablation to supplement PVI may improve the results of AF ablation.

• IMPLICATIONS: • Rapidly unfolding advances in the techniques of AF ablation and the

understanding of mechanisms of AF hold promise for improving the durability of PVI and for extending the technique to carefully selected patients with persistent AF.

Pulmonary veins to left atrium cycle length gradient predicts procedural and clinical outcomes of persistent

atrial fibrillation ablation.Pascale P1, Shah AJ2, Roten L2, Scherr D2, Komatsu Y2, Ramoul K2, Daly M2,

Denis A2, Derval N2, Sacher F2, Hocini M2, Jaïs P2, Haïssaguerre M2

• BACKGROUND: • Rapid pulmonary vein (PV) activity has been shown to

maintain paroxysmal atrial fibrillation (AF). We evaluated in persistent AF the cycle length (CL) gradient between PVs and the left atrium (LA) in an attempt to identify the subset of patients where PVs play an important role.

• CONCLUSIONS: • The PV to LA CL gradient may identify the subset of

patients in whom persistent AF is likely to terminate after PV isolation or limited substrate ablation and better long-term outcomes are achieved

Tailored Atrial Substrate Modification Based On Low-Voltage Areas in Catheter Ablation of Atrial

Fibrillation.Rolf S1, Kircher S2, Arya A2, Eitel C2, Sommer P2, Richter S2, Gaspar T2,

Bollmann A2, Altmann D2, Piedra C2, Hindricks G2, Piorkowski C2.

• CONCLUSIONS: -LVAs can be found at preferred sites in 10% of patients with paroxysmal AF, and in 35% of patients with persistent AF. This is the first clinical report describing a consistent voltage-based approach for substrate modification in addition to circumferential PVI irrespective of AF type. Application of this limited individualized approach may have the potential to compensate for the impaired 12-months outcome of patients with endocardial structural defects.

Randomized ablation strategies for the treatment of persistent atrial fibrillation: RASTA

study.Dixit S1, Marchlinski FE, Lin D, Callans DJ, Bala R, Riley MP, Garcia FC, Hutchinson MD, Ratcliffe SJ, Cooper JM,

Verdino RJ, Patel VV, Zado ES, Cash NR, Killian

• CONCLUSIONS • These data suggest that additional

substrate modification beyond PVI does not improve single-procedure efficacy in patients with persistent AF

The atrial fibrillation ablation pilot study: a European Survey on Methodology and results of catheter ablation for atrial

fibrillation conducted by the European Heart Rhythm Association.

• Success without antiarrhythmic drugs was achieved in 40.7% of patients (43.7% in paroxysmal AF; 30.2% in persistent AF; 36.7% in long-lasting persistent AF). A second ablation was required in 18% of the cases and 43.4% were under antiarrhythmic treatment. Thirty-three patients (2.5%) suffered an adverse event, 272 (21%) experienced a left atrial tachycardia, and 4 patients died (1 haemorrhagic stroke, 1 ventricular fibrillation in a patient with ischaemic heart disease, 1 cancer, and 1 of unknown

• CONCLUSION: The AFib Ablation Pilot Study provided crucial information on the epidemiology, management, and outcomes of catheter ablation of AFib in a real-world setting. The methods used to assess the success of the procedure appeared at least suboptimal. Even in this context, the 12-month success rate appears to be somewhat lower to the one reported clinical trials.

A-Fib vs. EP Labs