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Atrial Fibrillation Ablation. Cardiology Symposium December 6, 2004 Paul R. Steiner, M.D. Cardiac Electrophysiology. Case Background:. 46 yr old athletic woman (cyclist, runner) 3 yr h/o increasingly frequent rapid palpitations paroxysmal AF Often immediately following exercise

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atrial fibrillation ablation
Atrial Fibrillation Ablation

Cardiology Symposium

December 6, 2004

Paul R. Steiner, M.D.

Cardiac Electrophysiology

case background
Case Background:

46 yr old athletic woman (cyclist, runner)

3 yr h/o increasingly frequent rapid palpitations paroxysmal AF

  • Often immediately following exercise
  • More recently may occur randomly

No other medical conditions

initial evaluation
Initial Evaluation:
  • ECG : Sinus bradycardia at rest 54 bpm, normal morphology
  • Labs : T4, TSH, lytes, etc. are WNL
  • Echo : Structurally normal heart
  • Holter : Frequent APCs, occas PVCs; salvos of AT and AF, some that are associated w/ symptoms on the patient log.
    • Heart rate range (in sinus):46 – 138 bpm
treatment history
Treatment History:

Rate control strategy:

  • Digoxin
  • β – blockers
  • CCBs

Rhythm control strategy:

  • Propafenone (Rhythmol)
  • Flecainide

What next?

question
Question:

What would you do next to effectively treat her life-style altering paroxysmal AF?

[ A ] Trial of a class IA drug (ex. quinidine).

[ B ] Amiodarone treatment (with regular careful monitoring).

[ C ] Referral for AV junction ablation and high-quality pacemaker

[ D ] Refer for atrial defibrillator implant

[ E ] Refer for catheter ablation of AF

atrial fibrillation ablation what we did
Atrial Fibrillation Ablation(What we did…)

[ E ]

FOR WHOM?(Paroxysmal or Persistent)

AF w/ “significant symptoms” associated

Refractory to AADs

Absence of severe structural heart dz.

left atrium posterior basal view
Left AtriumPosterior Basal View

R. pulmonary artery

L. pulmonary artery

R. superior pulmonary vein

L. auricle

L. superior pulmonary vein

L. atrium

R. inferior pulmonary vein

L. inferior pulmonary vein

Coronary sinus

Netter F. Atlas of Human Anatomy. 1989;Plate 202.

slide8

Left Atrium, Posterior Wall

Variable Anatomy(Common)

SVC

RAA

LAA

RSPV

LSPV

RIPV

LIPV

IVC

Nathan, Circ Res, 1969?

slide11

Left Atrium, Posterior Wall

Pulmonary Vein Isolation

Nathan, Circ Res, 1969?

mediastinum axial superior view
MediastinumAxial Superior View

Azygous Vein

Esophagus

Aorta

Left Pulmonary Veins

Right Pulmonary Veins

Left Atrium

Right Atrium

Netter F. Atlas of Human Anatomy. 1989;Plate 230.

slide13

T8 Axial View

Aorta

Esophagus

Left PVs

Right PVs

LeftVentricle

Courtesy of M. Ramsey, PhD, CEO CardioCommand

atrial fibrillation ablation technique
Atrial Fibrillation AblationTechnique

Combined ModalityImaging

Fluoroscopy (biplane, for rapid 3-D estimates)

High resolution gated CT or MRI

3-D electroanatomic mapping

Intracardiac echo

In the future:

Multi-modality image co-registrationcombining real-time anatomy and function…

Current

left atrium la and pulmonary vein anatomy
Left Atrium (LA) andPulmonary Vein Anatomy

Esophagus

Left PVs

Right PVs

LA Roof

LA Appendage

3-D CT Reconstruction(Extreme PA Cranial View)

side by side geometry electroanatomic map 3 d ct cranial view
Side-by-Side GeometryElectroanatomic Map & 3-D CT: Cranial View

Esophagus

Left PVs

Right PVs

LA Roof

LAA

ESI Nav-X 3-D Geometry

3-D CT via CardEP

(Cranial View)

side by side geometry rf catheter pointing away from esophagus
Side-by-Side GeometryRF catheter pointing away from esophagus

ESI Nav-X 3-D Geometry

3-D CT via CardEP

pulmonary vein isolation segmental approach
Pulmonary Vein IsolationSegmental Approach

Going…

Going…

Gone !

Haïssaguerre, M. et al., Circulation. 2000;102:2463–2465.

la mapping and catheter ablation visualization intracardiac ultrasound
LA Mapping and Catheter AblationVisualization:Intracardiac Ultrasound
  • Facilitate transeptal access to LA
  • Visual guidance of catheters at PV ostium
  • RF energy delivery titration via “bubble” monitoring
  • Doppler PV flow (assess for size and stenosis)
  • Direct visualization of:
        • PV ostial size
        • Anatomic abnormalities
        • Pericardial effusion
        • Thrombus
left atrial mapping and catheter ablation visualization intracardiac ultrasound
Left Atrial Mapping and Catheter AblationVisualization:Intracardiac Ultrasound

Tenting of theintra-atrialseptum duringtranseptalcatheterization

Transeptal Access to LA

AcuNav 10 Fr Phased Array Diagnostic Ultrasound Catheter (by Acuson)

left atrial mapping and catheter ablation visualization intracardiac ultrasound21
Left Atrial Mapping and Catheter AblationVisualization : Intracardiac Ultrasound

Optimizing Catheter Placement at PV Os

slide22

Caution

STOP !

Marrouche N and Natale A. Electromedica 70 (2002) no. 1

summary atrial fibrillation ablation
SUMMARYAtrial Fibrillation Ablation

FOR WHOM?(Paroxysmal or Persistent)

AF w/ “significant symptoms” associated

Refractory to AADs

Absence of severe structural heart dz

HOW?

Electrical isolation of pulmonary veins

Atrial tissue substrate modification

Accomplished via catheter ablation combined w/ multiple imaging modalities

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