Section III: Catheter Ablation for the Treatment of AFib.

Section III:Catheter Ablation for the Treatment of AFib

Section III. Catheter Ablation for the Treatment of AFib

1. Left atrial (LA) and pulmonary vein (PV) anatomy

2. Catheter ablation techniques

3. Technological issues

4. Success rates

5. Complication rates

6. Cost-effectiveness

7. Indications for catheter ablation

8. Centre experience

1. Left Atrial (LA) and Pulmonary Vein (PV) Anatomy

Macroscopic Anatomy of the Myocardial Sleeves and the Pulmonary Veins and Sleeves

Uniform PV sleeve

Non-uniform PV sleeve

PV

PV

PV

PV

Macroscopic Anatomy of the Myocardial Sleeves and the Pulmonary Veins

reproduced with permission, Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888

Non-uniform

sleeve

Uniform

sleeve

Atrial-PV border

Microscopic Anatomy of Pulmonary Veins

Myocardial sleeve

Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888

Myocardial sleeve

Myocardial sleeve

PERMISSION TO USE PHOTO BEING REQUESTED

Transverse Section Perpendicular to the Axis of the Pulmonary Vein

Groups of myocardial

cells in different

orientations



Length of Myocardial Sleeves in the 4 Pulmonary Veins


Len

gth

of

myocard

ial sle

eves (

mm

)

LSPV RSPV LIPV RIPV

*p<0.01

0

2

4

8

12

16

14

10

6

* **

*

*

Schematic Representation of Superficial Myocardial Fibres of the LA

adapted from Nathan H & Eliakim M Circulation (1966) 34: 412

LSPV

LLPV

LARA

SVC

RSPV

RIPV

IVC

Myocardial Fibre Orientation in the LA and PV – Predominant Vertical Fibre Pattern


LIPV

LSPV

RSPV

RIPV

Myocardial Fibre Orientation in the LA and PV – Predominant Horizontal Fibre Pattern


LSPV

LMPV

LIPVRIPV

RMPV

RSPV

Myocardial Fibre Orientation in the LA and PV – Predominant Oblique Fibre Pattern


LA

LSPV

SVC

LIPV

RSPV

RIPV

Myocardial Fibre Orientation in the LAand PV – Mixed Fibre Pattern


LIPV

LSPV

SVC

RSPV

RIPV

PV-Left Atrial Connections

Pattern 1 – no connections

Pattern 2 – partial connections

Pattern 3 – good connections

Tan AY, et al. J Am Coll Cardiol (2006) 48: 132


Summary of Anatomical Changes in Patients with AFib

Tan AY, et al. J Am Coll Cardiol (2006) 48: 132Hassink RJ, et al. J Am Coll Cardiol (2003) 42: 1108

•Atrial myocardium is more often present in the PV of patients with AFib compared with patients without AFib

• In the first group the atrial myocardium in the PV is characterized by more severe discontinuity, hypertrophy and fibrosis

•Muscular discontinuities and abrupt fibre orientation change are present in more than 50% of PV-LA segments, creating significant substrates for re-entry

•Adrenergic and cholinergic nerves have highest densities within 5mm of the PV-LA junction but are highly co-located

Typical & Atypical Branching Pattern of PV Anatomy

Typical Short Common Left Trunk Long Common Left Trunk

Right Middle PV Two Right Middle PVs Right Middle PVand Right “upper” PVD E F

A B C

N=16N=18

N=7 (including 3 of D)N=5 (including 2 of D)

N=2N=2

N=4N=3

N=1 N=0

N=1N=1

AFibControl

AFibControl

adapted from Kato R et al. Circulation (2003) 107: 2004

Anatomy of the Pulmonary Veins

reproduced with permission, Kato R, et al. Circulation (2003) 107: 2004

RIPV

RSPV

LSPV

LIPV

LA appendage

Right PV Left PV

• Nuclear magnetic resonance image of the ostia of the right and left superior and inferior PVs and the left atrial appendage

Anatomy of the Pulmonary Veins

Ho YS, et al. Heart (2001) 86: 265

• Note the common opening of the LPV and separate origins of the two RPV

Left pulmonary veins

LA longitudinal section Transverse section from above


Right Middle PV

Kato R, et al. Circulation (2003) 107: 2004

RMPV

• Nuclear magnetic resonance image showing a right PV with a separate origin to the right superior and inferior PVs


Wittkampf FH, et al. Circulation (2003) 107: 21

Pulmonary Vein Geometry

Posterior View Inferior View LAO 45°

Ostium of left lower PV

Magnetic Resonance Angiography Fluoroangiography


Left superior 38 18.7 ± 2.9 13.9 ± 3.7 1.4 ± 0.4 1.0-3.0 17.5 ± 2.9

Left inferior 38 15.9 ± 3.1 11.2 ± 3.1 1.5 ± 0.4 1.0-2.3 15.0 ± 2.7

Both left 76 1.5 ± 0.4

Right superior 42 18.8 ± 2.7 16.0 ± 2.0 1.2 ± 0.1 1.0-1.5 17.5 ± 2.1

Right inferior 42 17.9 ± 2.9 15.1 ± 3.0 1.2 ± 0.2 1.0-1.7 16.9 ± 3.1

Both right 84 1.2 ± 0.1

Left common 4 27.3 ± 6.2 18.7 ± 6.7 1.6 ± 0.5 1.0-2.2 26.5 ± 4.8

Right middle 4 7.6 ± 3.1 5.6 ± 2.1 1.4 ± 0.4 1.0-2.0 7.0 ± 1.9

nMaximum

(mm)Projected

(mm)Minimum

(mm) RatioRange(mm)

Dimensions of PV ostia measured with MRA. The ratio between maximal and minimal ostiumdiameters is a measure of the ovality of the PV ostia.* Differences in ovality were only significant between right and left PV ostia (p<0.005)

Average Pulmonary Vein Ostium Diameters

Wittkampf, FH et al. Circulation (2003) 107: 21

Parasympathetic Ganglia

Fat pads

Distribution of Autonomic Nerves at the PV-LA Junction

AnteriorLA

VOM

LIRI

LS RSPA

AO SVC

IVC

CS

PosteriorLA

Adrenergic Nerve Density

Grade 4: 45-60 x 103 m2/mm2

Grade 3: 30-45 x 103 m2/mm2

Grade 2: 15-30 x 103 m2/mm2

Grade 1: 0-15 x 103 m2/mm2

Cholinergic Nerve Density

Grade 4: 4.5-6.0 x 103 m2/mm2

Grade 3: 3.0-4.5 x 103 m2/mm2

Grade 2: 1.5-3.0 x 103 m2/mm2

Grade 1: 0-1.5 x 103 m2/mm2

Anteriorjunction

Posteriorjunction

S = Superior; I = Inferior; AS = Anterosuperior;PI = Postinferior; AI = Anteroinferior; PS = Postsuperior

reproduced with permission, Tan AY, et al. J Am Coll Cardiol (2006) 48: 132

3. Catheter Ablation Techniques

From the first procedures to today

Maze reproduction Schwarz 1994

Right atrial linear lesions Haïssaguerre 1994

Right and left atrial linear lesions Haïssaguerre 1996

PV foci ablation Jaïs / Haïssaguerre 1997/8

Ostial PV isolation Haïssaguerre 2000

Circumferential PV ablation Pappone 2000

Ablation of non-PV foci Lin 2003

Antral PV ablation Maroucche / Natale 2004

Double Lasso technique Ouyang / Kuck 2004

CFAE sites ablation Nademanee 2004

Ostial or circumferential or antral PV ablation plus extra lines (mitral isthmus, posterior wall, roof)

Jaïs / Hocini 2004/5

Circumferential PV ablation with vagal denervation

Pappone 2004

Technique Publication date

Landmarks in Catheter Ablation Techniques and Success Rates

1994: Reproduction of Cox Procedure using Catheter Ablation by Schwarz

• Traditional Cox-Maze surgical procedure

adapted from Cox JL, et al. J Thor Cardivasc Surg (1991) 101: 569

RAALAA

LA

IVC

1994: Right Atrium Linear Lesions

adapted from Haïssaguerre M, et al. J Cardiovasc Electrophysiol (1994) 5: 1045

• In the same year, Haïssaguerre placed three linear lesions in the right atrium using radiofrequency energy

• 46-year old patient: AF-free with no AADs after 3-months

Right atrium

SVC

IVC

1

2

3

T

1996: Technique Extended to Right and Left Atrial Ablation

adapted from Haïssaguerre M, et al. J Cardiovasc Electrophysiol (1996) 7: 1132

• In 1996 Haïssaguerre modified the procedure extending linear lesions to the left atrium

• Aim was to isolate compartments of atrial tissue as in the Cox procedure

1 2 3 41 2 3 4

1998: Ablation of PV Foci

• Using multi-electrode catheter mapping Haïssaguerre identified atrial foci triggering AFib in 45 patients refractory to drug treatment

– Single focus in 29 patients (64%)

– 2 foci in 9 patients (20%)

– 3 to 4 foci in 7 patients (16%)

Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins

Haïssaguerre, M, Jaïs, P, Shah, DC, et al.N Engl J Med (1998) 339: 659

PV Foci Triggering Afib

reproduced with permission, Haïssaguerre M, et al. N Engl J Med (1998) 339: 659

Superiorvena cava

Inferiorvena cava

Fossaovalis

Septum

Coronarysinus

94%

25% 45%

9% 16%

PulmonaryVeins

Right Atrium Left Atrium

• 94% of foci located inside PV (2-4 cm from ostium)– 45% in LSPV, 25% in RSPV, 16% in LIPV, 9% in RIPV

Ectopic Beats Initiating AFib from Foci in the RI and LS PVs

reproduced with permission, Haïssaguerre M, et al. N Engl J Med (1998) 339: 659

Ectopic beats (arrowed)

RIPV

LSPV

PV Foci Ablation: Results and Conclusions

• Radiofrequency ablation of ectopic foci was associated with a 62% success rate (absence of recurrence at 8 6m follow-up)

Haïssaguerre M, et al. N Engl J Med (1998) 339: 659

2000: Ostial PV Isolation

• Key study in 90 patients to investigate whether complete isolation of PV ectopic foci correlates with improved success

•End point was elimination of ectopy, spontaneous or induced, and elimination of PV muscle conduction

Electrophysiological End Point for Catheter Ablation of Atrial Fibrillation Initiated from Multiple Venous Foci

Haïssaguerre, M, Jaïs, P, Shah, DC, et al.Circulation (2000) 101: 1409--177

Ostial PV Isolation

reproduced with permission, Haïssaguerre M, et al. Circulation (2000) 101: 1409

Atrial activation preceding PVP

Discharges from PV

Local PV activity dissociated

distally at a slow rate

Ostial PV Isolation: Results and Conclusions

Haïssaguerre M, et al. Circulation (2000) 101: 1409

•Success, defined by elimination of AFib without drugs, was correlated with the procedural end point of abolition of distal PV potentials– After a mean follow-up of 8+5 months, AFib was

completely eliminated in 64 patients (71%) without AADs

– Anticoagulants were interrupted in 52 cases

– The other 26 patients were prescribed a drug that was ineffective before ablation, resulting in total elimination of AFib in 12 of 26

•Recovery of local PV potential and the inability to abolish it were significantly associated with AF recurrences (90% success rate with versus 55% without PV potential abolition)

2000: Circumferential PV ablation

• Anatomical approach guided by a non-fluoroscopic mapping system to generate 3D electroanatomic maps in 26 patients and to perform circular linear lesions around the ostium of the PV

Circumferential Radiofrequency Ablation of Pulmonary Vein OstiaA New Anatomic Approach for Curing Atrial Fibrillation

Pappone, C, Rosanio, S, Oreto, G, et al.Circulation (2000) 102: 2619-28

Circumferential PV ablation

reproduced with permission, Pappone C, et al. Circulation (2000) 102: 2619

• Color coding represents activation times. In all maps, earliest activation (red) is located at pacing site. After ablation, conduction delay is characterized by abrupt color change from shades of yellow or green to blue or purple (latest activation)

Pre-ablation Post-ablationVoltage maps

Circumferential PV ablation : Results and conclusions

Pappone C, et al. Circulation (2000) 102: 2619

• Among 14 patients with AFib at the beginning of the procedure, 64% had sinus rhythm restoration during ablation

• PV isolation was demonstrated in 76% of 104 PVs treated

• After 9+3 months, 22 patients (85%) were free of AFib (62% not on AADs), with no difference between paroxysmal and permanent AFib

2003: Non-Pulmonary Vein Foci

•Most of the ectopic beats initiating paroxysmal AFib (PAF) originate from the PV.

•Lin et al. investigated PAF originating from non-PV areas

Catheter Ablation of Paroxysmal Atrial Fibrillation Initiated by Non-Pulmonary Vein Ectopy

Lin, W-S, Tai, C-T, Hsieh, M-H, et al.Circulation (2003) 107: 3176

LPFW 27 (37%) 63 ± 14 5.2 ± 4.0 50 39.5 ± 5.9 100 56

SVC 27 (37%) 57 ± 12 4.7 ± 4.8 22 36.8 ± 5.1 44 26

CT 10 (14%) 63 ± 12 4.1 ± 3.2 0 29.7 ± 5.0 40 20

LOM 6 (8%) 66 ± 13 3.1 ± 2.5 50 41.3 ± 1.5 83 50

CSO 1 (1.4%) 67 1 0 - - 0 0

IAS 1 (1.4%) 44 2 100 - - 100 100

Patients(n)

Age(y)

LateRecurrence

(%)History

(y)LA size(mm)

MultipleAF Foci

(%)Group

SHD indicates structural heart disease

Other SHD(%)

Non-Pulmonary Vein Foci

Lin W, et al. Circulation (2003) 107: 3176

•Non-PV foci identified in 28% of patients: – left atrial posterior free wall (LPFW), superior vena cava (SVC),

crista terminalis (CT) ligament of Marshall (LOM) coronary sinus ostium (CSO), interatrial septum (IAS)

Ablation of non-PV Ectopy

reproduced with permission, Lin W, et al. Circulation (2003) 107: 3176

Ablation of ectopic triggers from the ligament of Marshall

Before After

Ablation of non-PV Ectopy: Results and conclusions

•Catheter ablation eliminated AFib with acute success rates of 63%, 96%, 100%, 50%, 100%, and 0% in left atrial posterior free wall, superior vena cava, crista terminalis, ligament of Marshall, coronary sinus ostium, and interatrial septum, respectively

•During a follow-up period of 22+11 months, 43 patients (63.2%) were off AADs without AFib recurrence

Lin W, et al. Circulation (2003) 107: 3176

2004: PV Antrum Isolation

• Isolation of PVs guided by ICE and circular mapping catheter in order to more precisely identify border of the PV antrum and reduce risk of PV stenosis

Pulmonary Vein Antrum Isolation: Intracardiac Echocardiography-Guided Technique

Verma, A, Marrouche, NF, and Natale, AJ Cardiovasc Electrophys (2004) 15: 1335-40

PV Antrum Isolation

3D multi-slice images of PVs

reproduced with permission, Verma A, et al. J Cardiovasc Electrophys (2004) 15: 1335

Tubular ostium defined by PV angiography

Actual PV antrum extends more posteriorly

Antral borders defined by ICE

PV Antrum Ablation

•315 patients undergoing ostial isolation of all PVs using either:– Circular-mapping (CM) alone (group 1, n=56)– CM and intracardiac echocardiography (ICE) (group 2,

n=107)– CM and ICE with titration of RF energy based on

visualization of microbubbles (group 3, n=152)

Phased-Array Intracardiac Echocardiography Monitoring During Pulmonary Vein Isolation in Patients with Atrial FibrillationImpact on Outcome and Complications

Marrouche, NF, Martin, DO, Wazni, O, et al.Circulation (2003) 107: 2710

PV Antrum Ablation: ResultsFre

ed

om

fro

m r

ecu

rren

t A

F (

%)

30

Follow-up (days)

150 270 390 510 750630 8700

100

90

70

50

80

60

40

Group 1 (n=56)Group 2 (n=107)Group 3 (n=152)

Group 1 vs Group 3; p=0.009Group 1 vs Group 2; p=0.08Group 2 vs Group 3; p=0.08

Marrouche NF, et al. Circulation (2003) 107: 2710

PV Antrum Ablation: ResultsIntracardiac echocardiography improves the outcomeof cooled-tip PV isolation

Fre

ed

om

fro

m r

ecu

rren

t A

F (

%)

30

Follow-up (days)

150 270 390 510 750630 8700

100

90

70

50

80

60

40

ICE (n=259)No ICE (n=56)

p=0.01

Marrouche NF, et al. Circulation (2003) 107: 2710

2004: Double LASSO® Catheter Ablation

• Isolates pairs of pulmonary veins using two LASSO® catheters

• Continuous circular lesions (CCLs) around PVs guided by 3D mapping

Complete Isolation of Left Atrium Surrounding the Pulmonary VeinsNew Insights from the Double-Lasso Technique in Paroxysmal Atrial Fibrillation

Ouyang, F, Bänsch, D, Ernst, S, et al.Circulation (2004) 110: 2090

2004: Double LASSO® Catheter Ablation

reproduced with permission, Ouyang F, et al. Circulation (2004) 110: 2090

Double LASSO® Catheter Ablation

• Automatic activity and PV tachycardia provide an arrhythmogenic substrate for AFib

• This activity could be eliminated in the majority of patients by isolating all PVs with closed circular lesions

reproduced with permission, Ouyang F, et al. Circulation (2004) 110: 2090

Double LASSO® Catheter Ablation: Results and Conclusions

• During a mean follow-up of 6 months, recurrence occurred in 10 patients. Nine patients underwent a repeat procedure

• Conduction gaps in the left CCL in 9 patients and in the right CCL in 2 patients were closed during the second procedure

• No AFib recurred in 39 patients after PV isolation during follow-up

• These results strongly support the hypothesis that it is necessary to isolate all PVs to prevent recurrence and stress the importance of the PV-LA junction in the initiation and perpetuation of PAF

Ouyang F, et al. Circulation (2004) 110: 2090

2004: Complex Fractionated Electrograms (CFAEs) Site Ablation

• Complex fractionated electrograms (CFAEs) recorded during AFib used as target sites for ablation

• Based on CARTO™ System mapping, the biatrial replica could be divided into distinct areas where RF energy was delivered according to CFAE detection

A New Approach for Catheter Ablation of Atrial Fibrillation: Mapping of the Electrophysiologic Substrate

Nademanee, K, McKenzie, J, Kosar, E, et al. J Am Coll Cardiol (2004) 43: 2044

2004: Complex Fractionated Electrograms (CFAEs) Site Ablation

reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044

•Fractionated electrograms with continuous prolonged activation complex over posterior septal areas

CFAEs Site Ablation

reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044

CFAEs Site Ablation: Results and Conclusions

Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044

• Ablations of areas associated with CFAEs terminated AFib in 115 of 121 patients (95%)

• After one-year, 110 (91%) patients were free of AFib

• Areas with CFAEs are ideal target sites for ablation of AFib

2004: Spectral Analysis to Guide Catheter RF Ablation

• A new method for treating paroxysmal AFib by targeting AFib “nests” of “fibrillar” myocardium – areas of atrial substrate that can be identified by spectral analysis through fast Fourier transforms (FFTs)

A New Treatment for Atrial Fibrillation Based on Spectral Analysis to Guide the Catheter RF-Ablation

Pachon, JC, Pachon, EI, Pachon, JC, et al.Europace (2004) 6: 590

Spectral Analysis to Guide Catheter RF Ablation

reproduced with permission, Pachon JC, et al. Europace (2004) 6: 590

Spectral Analysis to Guide Catheter RF Ablation

Pachon JC, et al. Europace (2004) 6: 590

•Six control and 34 drug-refractory paroxysmal or persistent AFib patients were studied and treated

•RF was applied to all sites outside the pulmonary veins presenting right-FFT-shift (AFib nests)

•RF-ablation of AF nests, decreasing the fibrillar/compact myocardium ratio, eliminated 94% of the paroxysmal AFib in patients at 9.9+5 months of follow-up

•Paroxysmal AFib may be cured or controlled by applying RF in several places outside the PV, thus avoiding PV stenosis

Identification of an Atrial Frequency Gradient using Dominant Frequencies

• Investigated whether patients with AFib manifest a left-to-right atrial frequency gradient

Presence of Left-to-Right Atrial Frequency Gradient in Paroxysmal but Not Persistent Atrial Fibrillation in Humans

Lazar, S, Dixit, S, Marchlinski, FE, et al.Circulation (2004) 110: 3181

DF Atrial Gradients: Results and Conclusions

• In patients with paroxysmal AFib there is a significant left-to-right atrial DF gradient, with DF highest at the PV/LA junction, intermediate at the coronary sinus and lowest in the RA

• In patients with persistent AFib there are no significant differences between DF recorded from the LA/PV junction, CS, and RA

•These findings suggest that in induced paroxysmal AFib, the posterior LA may serve an important role in maintaining AFib

Lazar S, et al. Circulation (2004) 110: 3181

Ablation of Sites of Dominant Frequency Activation using Spectral Analysis

• Electroanatomic mapping performed in 32 patients with 5-second electrograms obtained at each point to determine the highest-amplitude frequency on spectral analysis and to construct 3D dominant frequency (DF) maps

• Ablation was performed with the operator blinded to the DF maps to determine the effect of ablation at sites with or without high-frequency DF sites

Spectral Analysis Identifies Sites of High-Frequency Activity Maintaining Atrial Fibrillation in Humans

Sanders, P, Berenfeld, O, Hocini, M, et al.Circulation (2005) 112: 789


reproduced with permission, Sanders P, et al. Circulation (2005) 112: 789

A: DF map in patient with paroxysmal AFib (6 hours). Note DF sites in each PV.

B: DF map in patient with permanent AFib (24 months). Maximal DF and atrial frequency are higher than in patient in A. In addition, many DF sites are located outside PVs.


Paroxysmal AF Permanent AF

Anterior Anterior

Posterior Posterior

IVC IVC

CS CS

LAA LAA

MV MVTV TV

RAA RAA

SVC SVC

adapted with permission, Sanders P, et al. Circulation (2005) 112: 789

Greater clustering of DF sites seen in paroxysmal AFib

Ablation of DF Sites using Spectral Analysis: Results and Conclusions

•The spatial distribution of the DF sites was different in patients with paroxysmal and permanent AFib

– In patients with paroxysmal AFib, the DF sources of activity are often localized to the PVs. In contrast, patients with permanent AFib demonstrate DF sites that are more often localized to the atria, including RA sites

•Ablation at these DF sites resulted in a significant slowing of the fibrillatory process and termination of sustained AFib in 87% of patients with paroxysmal AFib, confirming the role of localized sites of high frequency in the maintenance of AF

•All patients with persisting AFib had additional DF sites outside the ablated zones

Sanders P, et al. Circulation (2005) 112: 789

2004: Ostial or Circumferential or Antral PV Ablation plus Extra Lines

Jaïs P, et al. Circulation (2004) 110: 2996

• In addition to PV isolation, other investigators have shown that extra ablation lines may further improve results

- Mitral isthmus (Jaïs 2004)

- LA roof (Hocini 2005)

- Posterior wall

2004: Ostial or Circumferential or Antral PV Ablation plus Extra Lines

• Prospective, randomised study of mitral isthmus ablation vs PV isolation alone

Technique and Results of Linear Ablation at the Mitral Isthmus

Jaïs, P, Hocini, M, Hsu, L-F, et al.Circulation (2004) 110: 2996

reproduced with permission, Jaïs P, et al. Circulation (2004) 110: 2996

Incomplete block

Complete block during CS

pacing

Completely blocked mitral

isthmus

Linear Ablation at the Mitral Isthmus

Jaïs P, et al. Circulation (2004) 110: 2996

Linear Ablation at the Mitral Isthmus

• Bidirectional isthmus block was confirmed by demonstrating (1) a parallel corridor of double potentials during CS pacing (2) an activation detour by pacing either side of the line, and (3) differential pacing techniques

• At 1 year after the last procedure, 87/100 patients with mitral isthmus ablation and 69/100 without were arrhythmia free without AADs

• Cardiac tamponade was noted in 4% of patients

• Prospective, randomised study of roofline ablation vs PV isolation alone in 90 patients with paroxysmal AFib

• Roofline ablation joining the 2 superior PVs

Linear Block at the Left Atrial Roof

Techniques, Evaluation, and Consequences of Linear Block at the Left Atrial Roof in Paroxysmal Atrial Fibrillation: A Prospective Randomized Study

Hocini, M, Jaïs, P, Sanders, P, et al.Circulation (2005) 112: 3688

Linear Block at the LeftAtrial Roof

I

II

III

V1

1

2

3

4

MapLSPV

LIPV

RSPV

RIPV

1 2 3 4

adapted with permission, Hocini M, et al. Circulation (2005) 112: 3688

Hocini M, et al. Circulation (2005) 112: 3688

• Roofline ablation resulted in a significant increase in the fibrillatory cycle length and non-inducibility of AFib

• At 15+4 months, 87% of the roofline group and 69% with PV isolation alone were AFib-free without AADs

• Linear block of the LA roof may prolong the fibrillatory cycle and terminate AFib, and may be associated with better clinical outcome compared to PV isolation alone

Linear Block at the Left Atrial Roof

2004: Adjunctive PV Denervation during Circumferential PV Ablation

• Ablation of all evoked vagal reflexes around all PV ostia (complete vagal denervation)

Pulmonary Vein Denervation Enhances Long-Term Benefit After Circumferential Ablation for Paroxysmal Atrial Fibrillation

Pappone, C, Santinelli, V, Manguso, F, et al.Circulation (2004) 109: 327

2004: Adjunctive PV Denervation during Circumferential PV Ablation


Vagal reflexes evoked (blue dots)

Adjunctive PV denervation During Circumferential PV Ablation


• Pre- and post-ablation voltage mapsvagal reflexes abolished after ablation


0.8

0.6

0.4

0.2

0

Cu

mu

lati

ve p

rop

ort

ion

of

pati

en

ts

AFib Recurrence (months)

0 2 4 6 8 10 12

1.0

Vagal reflexesNo vagalreflexes

101101 101102 101 101

166166 166195 166 166

# at risk

101

166

Vagal reflexesNo vagal reflexes

Log-rank p=0.0002

Adjunctive PV Denervation During Circumferential PV Ablation


• In 297 patients undergoing circumferential PV ablation for paroxysmal AFib complete vagal denervation was achieved in 34.3% of cases

• Patients undergoing complete vagal denervation were less likely to have recurrence of AFib

• Only the percentage area of left atrial isolation and complete vagal denervation were predictors of AFib recurrence

Adjunctive PV Denervation: Results and Conclusions

Trigger -Ectopic Foci

PV & non-PV Foci Ablation,

PV Isolation

Autonomic Nervous System

AFib

CFAEs AblationLinear Lesions

(e.g. mitral isthmus, roof)

Substrate -Atrial tissue

A Combination of Techniques may be used Depending on the Type of AFib

Vagal Denervation

(parasympathetic ganglia ablation)

Tailored Approach to Catheter Ablation

•This study determined the feasibility of a tailored catheter ablation strategy guided by the electrophysiological characteristics of AFib, without the use of a standardized lesion set (PV isolation and/or encirclement with or without additional ablation lines)

•Primary end point was absence of frequent atrial ectopy and spontaneous AFib during isoproterenol infusion and non-inducibility of AFib

A Tailored Approach to Catheter Ablation of Paroxysmal Atrial Fibrillation

Oral, H, Chugh, A, Good, E, et al.Circulation (2006) 113: 1824


• Tailored ablation - after encircling of the right-sided pulmonary veins, left atrial ablation was performed to target high-frequency and/or complex electrograms.

reproduced with permission, Oral H, et al. Circulation (2006) 113: 1824

Tailored Approach to Catheter Ablation: Results and Conclusions

Oral H, et al. Circulation (2006) 113: 1824

•During follow-up, left atrial flutter developed in 19% of patients and was still present in 10% at 12 weeks of follow-up

•A repeat ablation procedure was performed in 18% of patients

•During a mean follow-up of 11+4 months, 77% of patients were free from AFib and/or atrial flutter without AADs

•Acute non-inducibility of AFib after ablation was associated with a better clinical outcome than in patients left with inducible AFib


•Evaluated a step-wise approach to achieve non-inducibility of AFib

•74 patients with paroxysmal AFib underwent PV isolation, if still inducible one or two additional linear lesions were placed at the mitral isthmus or LA roof

Long-term Evaluation of Atrial Fibrillation Guided by Noninducibility

Jaïs, P, Hocini, M, Sanders, P, et al.Heart Rhythm (2006) 3: 140

Tailored Approachto Catheter Ablation

No: stop

Inducible or persisting arrhythmia after step 1 ?

Yes

Step 1

No: stop

Inducible or persisting arrhythmia after step 2 ?

Yes

Step 2

Step 3

or

adapted from Jaïs P, et al. Heart Rhythm (2006) 3: 140

Jaïs P, et al. Heart Rhythm (2006) 3: 140

Tailored Approach to Catheter Ablation: Results and Conclusions

• In 42 patients (57%), PV isolation restored SR and AFib was non-inducible

• In the remaining 32 patients, a single linear lesion achieved non-inducibility in 20 patients

•An additional linear lesion was required in 12 patients, with 10 remaining non-inducible

•At 18+4 months follow-up, 91% of patients were free from AFib without AADs

3. Technological Aspects

Technological Aspects of Catheter Ablation

•Ablation catheters

•Energy sources

•Mapping catheters

•Electrophysiological mapping systems

•Cardiac imaging technologies


Ablation catheters and energy sources

Ablation Catheters

•Non-irrigated tip catheters

– 4mm and 8mm

• Irrigated tip catheters

– open shower, chilled

•Balloon catheters

– ultrasound, laser

Ablation Catheters

• Irrigated RF catheters

– Permit use of higher radiofrequency energy

– Ablation temperatures reduced

– Char formation minimized

Light Ring Inflatable Balloon Catheter

Energy Sources

•Radiofrequency

– Most common source

•Cryoablation

•Ultrasound

•Laser

•Microwave


Mapping catheters

Special Mapping Catheters

•Circular multi-electrode mapping catheter (LASSO® Catheter)

•Other multi-electrode mapping catheters

– BASKET, MESH, PENTARAY™ Catheter

Circular Mapping Catheter (LASSO®

Catheter)

1

2

3

45

6

7

8

910

RSPV mapping

Fully Expanded

25 mm

Precise mapping of potentials and exit sites at PVs

Fully Contracted

15 mm

LSPV mapping

12 3

4

5

67

89

10

• 5 radiating spines (markers on spine A and B)

• 20 localized electrodes

• Central irrigation lumen

High Density Multi-Electrode Mapping Catheter (PENTARAY™ Catheter)

AA

BB

CC

DD

EE

BB

AA


Electrophysiological mapping systems

Electrophysiological Mapping Systems

•3D-electroanatomic mapping

– CARTO™ System / CARTOMERGE™ Image Integration Software Module

•Robotic magnetic navigation

– Stereotaxis

CARTO™ System– Localization of catheter to within 1 mm

– Increase safety margin during ablation

Anatomic Maps Using CARTO™ System

• 3D-electroanatomic maps (CARTO™ System) showing ablation points encircling PVs

Circumferential Electroanatomical Ablation around PV Ostia


Pre-ablation Post-ablation

Delayedactivation

Point by pointRF lesions

• 3D-electroanatomic maps (CARTO™ System) showing pre- and post-ablation electrical activity

• Endpoint is complete electrical isolation of left atrium

Section III: Catheter Ablation for the Treatment of AFib.

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Transcript of Section III: Catheter Ablation for the Treatment of AFib.