Substrate ablation cafe a promising or vanishing technique
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Substrate Ablation (CAFE) A Promising or Vanishing Technique. Walid I. Saliba, M.D. Director, Atrial Fibrillation Center Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine THE CLEVELAND CLINIC FOUNDATION Cleveland, Ohio. Goal. To confuse you.

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Substrate Ablation (CAFE) A Promising or Vanishing Technique

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Substrate ablation cafe a promising or vanishing technique

Substrate Ablation (CAFE)A Promising or Vanishing Technique

Walid I. Saliba, M.D.

Director, Atrial Fibrillation Center

Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine

THE CLEVELAND CLINIC FOUNDATION

Cleveland, Ohio


Substrate ablation cafe a promising or vanishing technique

Goal

To confuse you


Natural history of af dual substrate model

Ablation of Triggers

Modification of Substrate

Atrial remodeling:

↓Refractory Period ↓ Conduction velocity

Favors Arrhythmia

Natural History of AF Dual Substrate Model

Persistent

Sinus can be restored electrically or chemically

Paroxysmal

Self terminating AF episodes

Permanent

Sinus cannot be maintained

“AF begets AF”

Substrate maintenance

Trigger initiation


Alternative strategies

More Ablation

Where?

Why?

How much more?

CAFE

Dominant Frequency

Ganglionic Plexi

Stepwise/Tailored

AF Nest

SVC / CS / Septum / Crista

LAA, LoM

Flutter? CTI

Lines, circles …

Alternative Strategies

Primary therapy

Adjunctive therapy to PVI


What are caf s

What are CAFÉ’s

  • EGMs with CL < 120 ms

  • EGMs with continuous electrical activity

  • EGMs with low amplitude and more than 2 deflections

  • EGMs with CL shorter than in the CS or LAA


Mechanisms underlying cafe

Mechanisms Underlying CAFE

  • Pathological anisotropic conduction

  • Slow conduction , Pivot and anchor points or Collision of the wavelets (Alessie 1996)

  • Focal microreentry (Gardner/Alessie 1985)

  • Wave break and fibrillatory conduction at the Borderzone of the mother rotors and areas of dominant frequencies. (Kalifa et al Circ 2006)

  • Calcium transient triggering activities from hyperactive autonomic ganglionic plexi with shortening of the RP (Scherlag et al. 2004)


Caf s in atrial fibrillation ablation

CAFÉ’s in Atrial Fibrillation Ablation

  • Stand Alone Targets ( Nademaneee)

  • Hybrid approach with PVI


Substrate guided ablation caf s

Substrate-Guided Ablation: CAFÉ’s

Nademanee et al, JACC 2004

Rationale

  • Target key atrial regions responsible for perpetuating AF rather than targeting the triggers in the PV’s

    End Points

  • Complete elimination of areas with CFAE’s

  • Conversion of AF to SR


Substrate guided ablation cfae

Substrate-Guided Ablation: CFAE

  • Fractionated electrograms composed of 2 deflections or more and continuous deflection of baseline

  • Atrial EGMs with very short CL <120 msec

Nademanee et al, JACC 2004


Substrate guided ablation cfae s

Substrate-Guided Ablation: CFAE’s

Median RF lesions: 64

  • 60% patients had CFAEs clustered around PV’s

  • 87% patients had CFAEs clustered around septum and roof, close to PVs.

Nademanee et al, JACC 2004


Substrate guided ablation cfae s only

Substrate-Guided Ablation: CFAE’s Only

121 pts

(51 PAF, 64 Chronic AF)

91% of pts free of arrhythmia

23% required a 2nd. Ablation

13% on AAD

Nademanee et al, JACC 2004


Stepwise ablation approach

Stepwise Ablation Approach

Haissaguerre et al. JCE 2005

Ablation of CAFÉ’s as part of a stepwise approach to achieve conversion to SR

Rationale:

  • Structures contributing to initiation and maintenance of AF are sequentially targeted

  • With increasing ablation of left atrial structures, there is a cumulative increase in AFCL resulting in “AF termination” with each ablation step performed.


The stepwise ablation approach

The Stepwise Ablation Approach

Lasso GuidedPV Isolation

Roof LineAblation

Ablation ofCS & Complex LA activities

Mitral IsthmusAblation

Right Atrial / SVCAblation

Cardioversion


Egm based ablation

EGM Based Ablation

Haissaguerre et al. J CardiovascElectrophysiol2005;16:1125-37


Stepwise ablation approach1

Stepwise Ablation Approach

60 pts with Non-PAF

  • 87% (52) had AF termination during ablation (SR:7 ; AT:45)

  • 60% success rate with a single procedure

    (40% required repeat ablation)

  • 95% success rate with multiple procedures

    • Sinus rhythm at 11±6 months f/u,without AAD’s

    • Good atrial transport function

Haissaguerre et al., J C E, Vol. 16, pp. 1138 Nov 2005


Some observations

Some Observations

  • The greatest magnitude of prolongation of fibrillatory cycle length occurred during ablation at the

    • PV-LA junction (Antrum)

    • Coronary sinus

    • Anterior LA

  • Almost half of the residual atrial tahycardias originated these same sites.


Substrate ablation cafe a promising or vanishing technique

  • 100 pts with Chronic AF

  • RF ablation of CAFÉ’s in PV’s, LA and CS

  • End point: All CAFÉ’s eliminated or AF termination

Circulation.2007;115:2606


Caf s

CAFÉ’s

  • CFAEs EGM:

  • CL< 120 msec

  • CL < CL n CS

  • Fractionated and/or continuous electric activity

  • 1 PV 46%

  • CS 55%

  • Septum/roofAll


Results

Results

  • 33% in SR after a single ablation procedure

  • Repeat ablation in 44%

    • CAFÉ’s in antrum, PV tachycardia, Macroreentrant flutter and circuits……

  • 57% in SR at ~1 year follow up.


  • Substrate ablation cafe a promising or vanishing technique

    • “The modest efficacy attained in this study despite extensive ablation of left atrial and coronary sinus CFAEs suggests either that CFAEs do not accurately identify sites that are critical to the maintenance of chronic AF or that ablation of CFAEs is not sufficient to eliminate the driving mechanisms of chronic AF in a large proportion of patients.”


    Substrate ablation cafe a promising or vanishing technique

    A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF

    n=119

    • Group A:

    • Termination with PVAI (n=19)

    • Group B:

    • No Termination→Cardioversion (n=50)

    • Group C:

    • No termination →CFAE* (n=50)

    *LA and CS for up to 2 hrs additional ablation

    Oral et al. J Am Coll Cardiol 2009;53:782–9)


    Caf la sites

    CAFÉ: LA sites


    Substrate ablation cafe a promising or vanishing technique

    A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF

    After a single Ablation

    SR at 10 months

    • Group A:

    • Termination with PVAI (n=19)

    • Group B:

    • No Termination→Cardioversion (n=50)

    • Group C:

    • No termination →CFAE (n=50)

    79%

    36%

    P=0.84

    34%

    Up to 2 h of additional ablation of CFAEs after PVAI

    does NOT appear to improve clinical outcomes in patients with long-lasting persistent AF.

    Oral et al. J Am Coll Cardiol 2009;53:782–9)


    Repeat ablation in 34 randomized patients

    Repeat Ablation in 34 randomized patients.

    SR at 9 months

    • Group B:

    • No Termination→Cardioversion (n=50)

    • Group C:

    • No termination →CFAE (n=50)

    68%

    P=0. 4

    60%

    No Difference even with repeat ablation

    Oral et al. J Am Coll Cardiol 2009;53:782–9)


    Substrate ablation cafe a promising or vanishing technique

    Elayi et al. ;Heart Rhythm. 2008 5(12):1665

    • Methods

    • 144 patients with permanent AF randomized to:

    • Group I: Pulmonary Vein Antrum Isolation .(PVAI) n=48

    • Group II: Hybrid approach. (CFAE’s + PVAI) n=49

      • Initial defragmentation: targeting bi-atrial and CS CFAE, and started randomly in the right or left atrium followed by PVAI

    • Group III: Large area circumferential ablation. (LACA) n=47

      • Targeting voltage reduction using electroanatomic mapping. (CARTO)


    Substrate ablation cafe a promising or vanishing technique

    Acute Results

    Group I

    Group II

    • Defragmentation alone did not have a significant effect on AF organization.

    • Defragmentation as an adjunctive strategy to PVAI increases the rate of conversion from AF to organized arrhythmias.


    Substrate ablation cafe a promising or vanishing technique

    Long Term Results

    Better success rate when defragmentation was performed in conjunction with PVAI


    Substrate ablation cafe a promising or vanishing technique

    LAA

    Cristal Terminalis

    CS Pre RF

    CS Post RF


    Substrate ablation cafe a promising or vanishing technique

    Presenting for Ablation

    LSPV

    Post Antral Isolation

    Post CS & LA-CAFE

    AT Ablation


    Substrate ablation cafe a promising or vanishing technique

    In high-burden paroxysmal/persistent AF,

    PVI+CAFE has the highest freedom from AF

    versus PVI or CAFE alone after one procedure.

    CAFE alone has the lowest procedure success rates with a higher incidence of repeat procedures

    Substrate vs. Trigger Ablation for Reduction of AF: An International, Multicenter, Randomized Trial (STAR-AF)

    • Comparison of 3 strategies of AF ablation:

    • (n=100 pts, 35% persistent)

      • CFE ablation alone

      • PVI ablation alone

      • PVI+CFE hybrid ablation

    74%

    47%

    Freedom from AF

    29%

    Verma et al, HRS LBT 2009


    Substrate ablation cafe a promising or vanishing technique

    Outcomes of Different Ablation Approaches That Incorporated CFAE Ablation in Patients With Persistent AF

    After 1-2 ablations

    F/U ~1 year


    Does caf substrate modification offer additional success

    Conclusion

    Does CAFÉ substrate modification offer additional success?

    • Different techniques, Different Operators, Different Skills, Different interpretations, Different endpoints, different experiences, different follow up’s:

      • Can we generalize the information

      • Can we trust the data: Is this Science?

    • Significance of CAFÉ: Active vs Passive role?

    • Is it just more Controlled Debulking? (CEDCA)

    • I will let you draw your own conclusion


    Substrate ablation cafe a promising or vanishing technique

    PV Antrum Isolation


    Overlap of cfae and pvi

    Overlap of CFAE and PVI?

    • Majority of ablated CFAE in tailored approach were in the LA

    • Extensive “fixed” PV antral isolation includes most areas of CAFÉ.


    Is more ablation better

    Is More ablation better?

    • More Ablation: Potential for More atrial Flutter

    • More ablation: Compromise LA mechanical function

    • More ablation: Interatrial / intraatrial dyssynchrony

    • More ablation: More fluoro / More potential complications


    Substrate ablation cafe a promising or vanishing technique

    OK,but

    what else

    can we ablate?…

    ﺒﻜﻔﻱ

    CAFE


    Substrate ablation cafe a promising or vanishing technique

    END


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