Kyoung-Ryul Julian Chun
Cardioangiologisches Centrum Bethanien (CCB)
Markus Krankenhaus, Med. Klinik III
Frankfurt am Main, Germany
How to improve procedural
outcome of cryoballoon ablation in
persistent AF – Experience from Redo
procedures
DISCLOSURES
Activity Company
Advisory Board Medtronic
Research Grant Biosense Webster
CardioFocus
Medtronic
Biotronik
Speaker‘s Honoraria Boston Sci
CardioFocus
Medtronic
1. Definition of persistent AF
2. Ablation strategies in persistent AF
3. Status Cryoballoon and PVI
4. Role Cryoballoon in Redo (persistent) AF
Persistent AF-Cryoballoon-Redo procedures
CENTRAL QUESTIONS
Kirchhof et al. European Heart J 2016
NEW AF DEFINITIONS
Persistent AF-Cryoballoon-Redo procedures
HRS/EHRA/ECAS/APHRS/SOLAECE
NEW DEFINITION 2017
Persistent AF Ablation
EARLY PERSISTENT AF
„Early persistent AF is defined as AF that is
sustained beyond 7 days but less than 3 months
in duration”
Calkins H et al. Heart Rhythm 2017
PV Trigger across AF Types (n=2168 pts)
AF Mapping, Non PV Trigger
Santangelii et al. Heart Rhythm. 2015 Oct 15. pii: S1547-5271(15)01304-1
STAR AF II
Persistent AF Ablation
Verma A et al. N Engl J Med. 2015 May 7;372(19):1812-22
Verma A et al. N Engl J Med. 2015 May 7;372(19):1812-22
Persistent AF Ablation
STAR AF II
STAR AF II, AF TERMINATION NO PREDICTOR
Persistent AF Ablation
Kochhä user et al. Heart Rhythm 2017;14:476–483
CHASE AF: PVI vs. PVI + step wise (n=153 pts)
VHF Ablation: Hochfrequenzstrom oder Ballon?
Vogler J et al. JACC 2015
ENDPOINT AF ABLATION 2017
Persistent AF-Cryoballoon-Redo procedures
Calkins H et al. Heart Rhythm. 2017
Kirchhof P et al. European Heart J 2016
J Cardiovasc Electrophysiol, 26,pp 371-377, April 2015
≥ 3 AF RFC Ablation procedures
92% (156/169) pts:
recovered PV conduction...!!
AF Ablation, ESC Guidelines 2016
METHODS, 2. Generation CB
Cyroballoon AF ablation
CCB-EP Frankfurt: CRYOBALLOON
Providencia et al. Europace 2016
FRENCH AF: CB vs. RFC
VHF Ablation: Hochfrequenzstrom oder Ballon?
EFFICACY: Durable PVI
Permanent PVI
Kuck et al 2016, GAP AF Study Reddy et al 2015, SUPIR AF
93 patients 19 patients
RFC PVI CB2 PVI
Remapping 3 months after
index procedure
Remapping 3.4 months after
index procedure
30%
70% 79%
21%
Low rate of PV reconnection
Total Parox. AF Pers. AF
91 % 56 % 34 %
0 PV Reconnected
51 56 28 50 22 65
1 PV
Reconnected29 32 21 38 8 24
2 PV Reconnected
10 11 7 13 3 9
3 PV Reconnected
1 1 0 0 1 3
4 PV Reconnected
0 0 0 0 0 0
AF REDO FINDINGS -- 2. GENERTION CB
Data @CCB Frankfurt
88
78
0
95
85
33
85
0
10
20
30
40
50
60
70
80
90
100
RIPV RSPV RCV LIPV LSPV LCPV Overall
Durable PVI rate (%) (n=91pts, 357 PVs)
Total PV PV Iso PV Reconection % Iso
RIPV 91 80 11 88
RSPV 90 70 20 78
LIPV 85 81 4 95
LSPV 85 72 13 85
LCPV 6 2 4 33
Overall 357 305 52 85
REDO FINDINGS -- 2. GENERTION CB
Data @CCB Frankfurt
8588
0
97
81
67
87
0
10
20
30
40
50
60
70
80
90
100
RIPV RSPV RCV LIPV LSPV LCPV Overall
Durable PVI rate (%) in persistent AF (n=34 pts)
REDO FINDINGS -- 2. GENERTION CB, persistent AF
Data @CCB Frankfurt
Atrial Fibrillation = Atrial Fibrillation ???
Persistent AF-Cryoballoon-Redo procedures
Marrouche NF et al. JAMA 2014
SCAR AF - Role of AF Substrate
LA Fibrosis
Marrouche NF et al. JAMA 2014
SCAR AF - Role of AF Substrate
LA Fibrosis
SCAR AF - Role of AF Substrate
LA Fibrosis
Marrouche NF et al. JAMA 2014
• Low Voltage Zone (LVZ):
• bipolar 0.1-0.4mV
• Transitional Zone (TZ):
• bipolar 0.4-1.3mV
• SR Abnormal Electrogram (SR-AE)
• >300 points LA map
SCAR AF - Role of AF Substrate
Gang Yang et al., Circulation AEP 2016
SCAR AF - Role of AF Substrate
Gang Yang et al., Circulation AEP 2016
SCAR AF - Role of AF Substrate
Gang Yang et al., Circulation AEP 2016
„Step wise“ vs. Substrate Ablation
69.8%
51.3%
Persistent AF Ablation
Bordignon S et al. DGK 2017
• Patient in SR Carto bipolar map
• Patient in AF 2 CV attempts, if no SR: exclusion
• Time to LAA in SR
• AF Cycle length in 4 PVs, LAA + CS
Seite 29
METHODS
SCAR AF Study (PAF + persistent AF)
Persistent AF Ablation
Persistent AF Ablation
PATIENTS
Bordignon S et al. DGK 2017
Persistent AF Ablation
Bordignon S et al. DGK 2017
RESULTS – PRIMARY ENDPOINT
Persistent AF Ablation
Bordignon S et al. DGK 2017
PVI: No Substrate vs. Substrate
„SMART“ Lines....
AF Substrate
Bordignon et al. DGK HT 2015
SUGGESTION
Persistent AF Ablation
PV Isolation Responder vs. PV Isolation
Non-Responder
Koektuerk B et al., Circulation AEP 2015
Cryoballoon AF
Persistent AF (n=100pts)
Laser Balloon or
Radiofrequency Ablation for
Persistent Atrial Fibrillation
Boris Schmidta, MD, Peter Neuzilb, MD, Armin Luikc, MD, Joaquin
Osca Asensid, MD, Jan Wilko Schrickele, MD, Thomas Denekef, MD,
Stefano Bordignona, MD, Jan Petrub, MD, Matthias Merkelc, MD, Lucie
Sedivab, PhD, Annemarie Klostermanna , Laura Perrottaa, MD, Oscar
Canod, MD and KR Julian Chuna, MD
aCardioangiologisches Centrum Bethanien, Frankfurt, Germany; bNa
Homolce Hospital, Prague, Czech Republic; cStä dtisches Klinikum, Karlsruhe, Germany; dHospital Universitari i Politè cnic la Fe,
Valencia, Spain; eUniversity Hospital, Bonn, Germany; fHerzzentrum, Bad Neustadt, Germany
LASER VERSUS RF IN PERS AF
Enrolled and Randomized(n = 152)
LB (n = 75) RF (n = 77)
Successful PVI (n = 72)
Successful PVI (n = 73)
- 2 screening failures (1 AT, 1 anatomic reasons)- 3 withdrew consent
- 1 screening failure (PAF)- 1 withdrew consent
12 Month follow-upcompleted
(n=68)
12 Month follow-upcompleted
(n=66)
RESULTS – STUDY FLOW
R
Schmidt B et al., … KRJ Chun LBCT DGK 2017
RESULTS – PRIMARY ENDPOINT
LASER VERSUS RF IN PERS AF
Schmidt B et al., … KRJ Chun LBCT DGK 2017
Di Biase et al. Circulation. 2010 Jul 13;122(2):109-18.
Persistent AF Ablation
Di Biase L et al. JACC 2016
BASELINECHARACTERISTICSMale 14/20(70%)
Age(years) 68±10Diagnosis
- PAF- PersAF- ATfromLAA
5/20(25%)14/20(70%)1/20(5%)
HistoryofAF(years) 3.4±3.,3
Arterialhypertension 16/20(80%)Diabetesmellitus 2/20(10%)
Historyofstroke/TIA 3/20(15%)NYHA>I 2/20(10%)
Coronaryarterydisease 7/20(35%)LAdiameter(mm) 44±7
Leftventricular(EF) 62±5Procedurenumber 2.6±1.,3
LAA Isolation in PVI Non Responder
Bordignon S. et al., …Chun KRJ submitted
Persistent AF-Cryoballoon-Redo procedures
LAA Isolation in PVI Non Responder
Bordignon S. et al., …Chun KRJ submitted
Persistent AF-Cryoballoon-Redo procedures
LAAI-PROCEDURALDATAProcedureTime(min) 67±33
FluoroscopyTime(min) 9,0±6,2LAASpikeVisualization 20/20(100%)
LAARealTimeIsolation- sustainedLAAI- nonsustainedLAAI
16/20(80%)11/16(69%)5/16(31%)
LAATimetosustainedblock(s) 94±57
LAATemperatureattimetosustainedblock(°C) -44±7LAATimetonon-sustainedblock(s) 142±64
LAATemperatureattimetonon-sustainedblock(°C) -48±3LAAtotalfreezeapplications(n) 2.0±1.6
LAAbonusapplications(n) 8/20(40%)LAAmeanocclusiongrade 3.,9±0,.2
LAAmeanminimaltemperature(°C) -50,0±54,7LAAmeanfreezeduration(s) 214±37
LAA Isolation in PVI Non Responder
Bordignon S. et al., …Chun KRJ submitted
Persistent AF-Cryoballoon-Redo procedures
Bordignon S. et al. Europace Vienna 2017
Bordignon S. et al. Europace Vienna 2017
LAA ISOLATION PATIENTS
Persistent AF-Cryoballoon-Redo procedures
Bordignon S. et al. Europace Vienna 2017
COMPLICATIONS
Persistent AF-Cryoballoon-Redo procedures
LAA ISOLATION IMPROVES RHYTHM OUTCOME
Persistent AF-Cryoballoon-Redo procedures
Bordignon S. et al. Europace Vienna 2017
• PVs are critical sites in persistent AF
• High rate of permanent PVI (1. procedure)
• After durable PVI:
– Substrate modification (EP endpoint)
– Cryoballoon LAA isolation feasible
• Durable LAA isolation linked to sinus rhythm
• The role of LAA merits investigation
CONCLUSIONS
Persistent AF-Cryoballoon-Redo procedures
Thanks for your attention!
TEAM FFM
Localized Reentry with Activity >70% AF
Cycle Length at Low Voltage Area
CL=155ms
Regional Activity >70%
AF Cycle Length
Voltage <0.5mV
in AF
0.5mV
AF Termination
120ms
Fig. S1
Jadidi et al.
SCAR AF - Role of AF Substrate
Jadidi A. et al. CircEP 2016
Selective Voltage guided Ablation of persistent AF
Jadidi A. et al. CircEP 2016
RESULTS – PRIMARY ENDPOINT
Persistent AF Ablation
STAR AF II, AF TERMINATION NO PREDICTOR
Persistent AF Ablation
Kochhä user et al. Heart Rhythm 2017;14:476–483
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