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Section III: Catheter Ablation for the Treatment of AFib. Section III. Catheter Ablation for the Treatment of AFib. Left atrial (LA) and pulmonary vein (PV) anatomy Catheter ablation techniques Technological issues Success rates Complication rates Cost-effectiveness

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section iii catheter ablation for the treatment of afib2
Section III. Catheter Ablation for the Treatment of AFib
  • Left atrial (LA) and pulmonary vein (PV) anatomy
  • Catheter ablation techniques
  • Technological issues
  • Success rates
  • Complication rates
  • Cost-effectiveness
  • Indications for catheter ablation
  • Centre experience
slide4

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

PV

PV

PV

Non-uniform PV sleeve

PV

Uniform PV sleeve

macroscopic anatomy of the myocardial sleeves and the pulmonary veins
Macroscopic Anatomy of the Myocardial Sleeves and the Pulmonary Veins

Uniform

sleeve

Non-uniform

sleeve

Atrial-PV border

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

microscopic anatomy of pulmonary veins
Microscopic Anatomy of Pulmonary Veins

PERMISSION TO USE PHOTO BEING REQUESTED

Myocardial sleeve

Myocardial sleeve

Myocardial sleeve

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

transverse section perpendicular to the axis of the pulmonary vein
Transverse Section Perpendicular to the Axis of the Pulmonary Vein

PERMISSION TO USE PHOTO BEING REQUESTED

Groups of myocardial cells in different orientations

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

length of myocardial sleeves in the 4 pulmonary veins
Length of Myocardial Sleeves in the 4 Pulmonary Veins

*

16

*

*p<0.01

14

*

*

*

12

10

Length of myocardialsleeves (mm)

8

6

4

2

0

LSPV

RSPV

LIPV

RIPV

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

schematic representation of superficial myocardial fibres of the la
Schematic Representation of Superficial Myocardial Fibres of the LA

SVC

RA

LA

RSPV

LSPV

LLPV

RIPV

IVC

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

myocardial fibre orientation in the la and pv predominant vertical fibre pattern
Myocardial Fibre Orientation in the LA and PV – Predominant Vertical Fibre Pattern

RSPV

LSPV

LIPV

RIPV

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

myocardial fibre orientation in the la and pv predominant horizontal fibre pattern
Myocardial Fibre Orientation in the LA and PV – Predominant Horizontal Fibre Pattern

LSPV

RSPV

LMPV

RMPV

RIPV

LIPV

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

myocardial fibre orientation in the la and pv predominant oblique fibre pattern
Myocardial Fibre Orientation in the LA and PV – Predominant Oblique Fibre Pattern

SVC

LA

RSPV

LSPV

RIPV

LIPV

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

myocardial fibre orientation in the la and pv mixed fibre pattern
Myocardial Fibre Orientation in the LAand PV – Mixed Fibre Pattern

SVC

LSPV

RSPV

RIPV

LIPV

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

pv left atrial connections
PV-Left Atrial Connections

PERMISSION TO USE PHOTO BEING REQUESTED

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
Summary of Anatomical Changes in Patients with AFib
  • 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

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

Hassink RJ, et al. J Am Coll Cardiol (2003) 42: 1108

typical atypical branching pattern of pv anatomy
Typical & Atypical Branching Pattern of PV Anatomy

A

B

C

Typical

Short Common Left Trunk

Long Common Left Trunk

AFibControl

N=16N=18

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

N=2N=2

Right Middle PV

Two Right Middle PVs

Right Middle PVand Right “upper” PV

D

E

F

AFibControl

N=4N=3

N=1 N=0

N=1N=1

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

anatomy of the pulmonary veins
Anatomy of the Pulmonary Veins

LA appendage

RSPV

LSPV

RIPV

LIPV

Left PV

Right PV

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

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

anatomy of the pulmonary veins18
Anatomy of the Pulmonary Veins

PERMISSION TO USE PHOTO BEING REQUESTED

Transverse section from above

LA longitudinal section

Left pulmonary veins

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

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

right middle pv
Right Middle PV

PERMISSION TO USE PHOTO BEING REQUESTED

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

RMPV

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

pulmonary vein geometry
Pulmonary Vein Geometry

PERMISSION TO USE PHOTO BEING REQUESTED

Posterior View

Inferior View

LAO 45°

Ostium of left lower PV

Fluoroangiography

Magnetic Resonance Angiography

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

average pulmonary vein ostium diameters
Average Pulmonary Vein Ostium Diameters

Maximum(mm)

Minimum(mm)

Range(mm)

Projected(mm)

n

Ratio

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)

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

distribution of autonomic nerves at the pv la junction
Distribution of Autonomic Nerves at the PV-LA Junction

Anteriorjunction

Posteriorjunction

AO

SVC

PA

RS

LS

AnteriorLA

PosteriorLA

RI

LI

IVC

VOM

CS

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

1994 reproduction of cox procedure using catheter ablation by schwarz
1994: Reproduction of Cox Procedure using Catheter Ablation by Schwarz
  • Traditional Cox-Maze surgical procedure

RAA

LAA

LA

IVC

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

1994 right atrium linear lesions
1994: Right Atrium Linear Lesions
  • 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

SVC

1

3

Right atrium

2

T

IVC

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

1996 technique extended to right and left atrial ablation
1996: Technique Extended to Right and Left Atrial Ablation
  • 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

4

1

2

3

4

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

1998 ablation of pv foci
1998: Ablation of PV Foci

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

  • 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%)
pv foci triggering afib
PV Foci Triggering Afib
  • 94% of foci located inside PV (2-4 cm from ostium)
    • 45% in LSPV, 25% in RSPV, 16% in LIPV, 9% in RIPV

Right Atrium

Left Atrium

Superiorvena cava

Septum

25%

45%

PulmonaryVeins

Fossaovalis

Inferiorvena cava

9%

16%

Coronarysinus

94%

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

ectopic beats initiating afib from foci in the ri and ls pvs
Ectopic Beats Initiating AFib from Foci in the RI and LS PVs

Ectopic beats (arrowed)

RIPV

LSPV

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

pv foci ablation results and conclusions
PV Foci Ablation: Results and Conclusions
  • Radiofrequency ablation of ectopic foci was associated witha 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
2000: Ostial PV Isolation

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

  • 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
ostial pv isolation
Ostial PV Isolation

Discharges from PV

Atrial activation preceding PVP

Local PV activity dissociated distally at a slow rate

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

ostial pv isolation results and conclusions
Ostial PV Isolation: Results and Conclusions
  • 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)

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

2000 circumferential pv ablation
2000: Circumferential PV ablation

Circumferential Radiofrequency Ablation of Pulmonary Vein Ostia

A New Anatomic Approach for Curing Atrial Fibrillation

Pappone, C, Rosanio, S, Oreto, G, et al.

Circulation (2000) 102: 2619-28

  • 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 pv ablation
Circumferential PV ablation

Voltage maps

Post-ablation

Pre-ablation

  • 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)

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

circumferential pv ablation results and conclusions
Circumferential PV ablation : Results and conclusions
  • 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

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

2003 non pulmonary vein foci
2003: Non-Pulmonary Vein Foci

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

  • Most of the ectopic beats initiating paroxysmal AFib (PAF) originate from the PV.
  • Lin et al. investigated PAF originating from non-PV areas
non pulmonary vein foci
Non-Pulmonary Vein Foci
  • 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)

MultipleAF Foci(%)

LateRecurrence(%)

Patients(n)

Age(y)

History(y)

Other SHD(%)

LA size(mm)

Group

SHD indicates structural heart disease

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

ablation of n on pv ectopy
Ablation of non-PV Ectopy

Ablation of ectopic triggers from the ligament of Marshall

Before

After

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

ablation of n on pv ectopy results and conclusions
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
2004: PV Antrum Isolation

Pulmonary Vein Antrum Isolation: Intracardiac Echocardiography-Guided Technique

Verma, A, Marrouche, NF, and Natale, A

J Cardiovasc Electrophys (2004) 15: 1335-40

  • 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
pv antrum isolation
PV Antrum Isolation

3D multi-slice images of PVs

Tubular ostium defined by PV angiography

Actual PV antrum extends more posteriorly

Antral borders defined by ICE

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

pv antrum ablation
PV Antrum Ablation

Phased-Array Intracardiac Echocardiography Monitoring During Pulmonary Vein Isolation in Patients with Atrial Fibrillation

Impact on Outcome and Complications

Marrouche, NF, Martin, DO, Wazni, O, et al.

Circulation (2003) 107: 2710

  • 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)
pv antrum ablation results

Group 1 (n=56)

Group 2 (n=107)

Group 3 (n=152)

Group 1 vs Group 3; p=0.009

Group 1 vs Group 2; p=0.08

Group 2 vs Group 3; p=0.08

PV Antrum Ablation: Results

100

90

80

70

Freedom from recurrent AF (%)

60

50

40

0

30

150

270

390

510

630

750

870

Follow-up (days)

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

pv antrum ablation results47
PV Antrum Ablation: Results
  • Intracardiac echocardiography improves the outcomeof cooled-tip PV isolation

100

ICE (n=259)

No ICE (n=56)

90

80

70

Freedom from recurrent AF (%)

60

50

p=0.01

40

0

30

150

270

390

510

630

750

870

Follow-up (days)

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

slide48

2004: Double LASSO® Catheter Ablation

Complete Isolation of Left Atrium Surrounding the Pulmonary Veins

New Insights from the Double-Lasso Technique in Paroxysmal Atrial Fibrillation

Ouyang, F, Bänsch, D, Ernst, S, et al.

Circulation (2004) 110: 2090

  • Isolates pairs of pulmonary veins using two LASSO®catheters
  • Continuous circular lesions (CCLs) around PVs guided by 3D mapping
slide49

2004: Double LASSO® Catheter Ablation

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

slide50

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

slide51

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

slide52

2004: Complex Fractionated Electrograms (CFAEs) Site Ablation

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

  • 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
slide53

2004: Complex Fractionated Electrograms (CFAEs) Site Ablation

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

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

slide54

CFAEs Site Ablation

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

slide55

CFAEs Site Ablation

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

slide56

CFAEs Site Ablation: Results and Conclusions

  • 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

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

slide57

2004: Spectral Analysis to Guide Catheter RF Ablation

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

  • 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)
slide58

Spectral Analysis to Guide Catheter RF Ablation

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

slide59

Spectral Analysis to Guide Catheter RF Ablation

  • 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

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

slide60

Identification of an Atrial Frequency Gradient using Dominant Frequencies

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

  • Investigated whether patients with AFib manifest a left-to-right atrial frequency gradient
slide61

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

slide62

Ablation of Sites of Dominant Frequency Activation using Spectral Analysis

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

  • 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
slide63

Ablation of Sites of Dominant Frequency Activation using Spectral Analysis

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.

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

ablation of sites of dominant frequency activation using spectral analysis
Ablation of Sites of Dominant Frequency Activation using Spectral Analysis
  • Greater clustering of DF sites seen in paroxysmal AFib

Paroxysmal AF

Permanent AF

Anterior

Anterior

MV

TV

MV

TV

LAA

LAA

RAA

RAA

SVC

SVC

CS

CS

IVC

IVC

Posterior

Posterior

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

slide65

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

slide66

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

  • 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

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

slide67

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

Technique and Results of Linear Ablation at the Mitral Isthmus

Jaïs, P, Hocini, M, Hsu, L-F, et al.

Circulation (2004) 110: 2996

  • Prospective, randomised study of mitral isthmus ablation vs PV isolation alone
slide68

Linear Ablation at the Mitral Isthmus

Completely blocked mitral isthmus

Incomplete block

Complete block during CS pacing

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

slide69

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

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

slide70

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

  • 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
Linear Block at the LeftAtrial Roof

I

II

III

4

3

2

1

V1

RSPV

Map

LSPV

1

2

RIPV

3

LIPV

4

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

slide72

Linear Block at the Left Atrial Roof

  • 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

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

slide73

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

  • Ablation of all evoked vagal reflexes around all PV ostia (complete vagal denervation)
slide74
2004: Adjunctive PV Denervation during Circumferential PV Ablation

Vagal reflexes evoked (blue dots)

reproduced with permission, Pappone C, et al. Circulation (2004) 109: 327

slide75

Pre- and post-ablation voltage maps

Adjunctive PV denervation During Circumferential PV Ablation

vagal reflexes abolished after ablation

reproduced with permission, Pappone C, et al. Circulation (2004) 109: 327

slide76

Adjunctive PV Denervation During Circumferential PV Ablation

1.0

0.8

Vagal reflexes

0.6

No vagal reflexes

Cumulative proportionof patients

0.4

0.2

Log-rank p=0.0002

0

0

2

4

6

8

10

12

AFib Recurrence(months)

# at risk

102

101

101

101

101

101

101

Vagal reflexes

No vagalreflexes

195

166

166

166

166

166

166

Pappone C, et al.Circulation (2004) 109: 327

slide77
Adjunctive PV Denervation: Results and Conclusions
  • 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

Pappone C, et al. Circulation (2004) 109: 327

slide78

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

AFib

Substrate -

Atrial tissue

Trigger -

Ectopic Foci

Autonomic Nervous System

CFAEs Ablation

Linear Lesions

(e.g. mitral isthmus, roof)

PV & non-PV Foci Ablation,

PV Isolation

Vagal Denervation (parasympathetic ganglia ablation)

slide79

A Tailored Approach to Catheter Ablation of Paroxysmal Atrial Fibrillation

Oral, H, Chugh, A, Good, E, et al.

Circulation (2006) 113: 1824

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
slide80
Tailored Approach to Catheter Ablation
  • 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

slide81
Tailored Approach to Catheter Ablation: Results and Conclusions
  • 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

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

slide82
Tailored Approach to Catheter Ablation

Long-term Evaluation of Atrial Fibrillation Guided by Noninducibility

Jaïs, P, Hocini, M, Sanders, P, et al.

Heart Rhythm (2006) 3: 140

  • 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
tailored approach to catheter ablation
Tailored Approachto Catheter Ablation
  • Step 1

Inducible or persisting arrhythmia after step 1 ?

Yes

No: stop

  • Step 2

Inducible or persisting arrhythmia after step 2 ?

  • or

Yes

No: stop

  • Step 3

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

slide84
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

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

technological aspects of catheter ablation
Technological Aspects of Catheter Ablation
  • Ablation catheters
  • Energy sources
  • Mapping catheters
  • Electrophysiological mapping systems
  • Cardiac imaging technologies
ablation catheters
Ablation Catheters
  • Non-irrigated tip catheters
    • 4mm and 8mm
  • Irrigated tip catheters
    • open shower, chilled
  • Balloon catheters
    • ultrasound, laser
ablation catheters89
Ablation Catheters
  • Irrigated RF catheters
    • Permit use of higher radiofrequency energy
    • Ablation temperatures reduced
    • Char formation minimized
energy sources
Energy Sources
  • Radiofrequency
    • Most common source
  • Cryoablation
  • Ultrasound
  • Laser
  • Microwave
special mapping catheters
Special Mapping Catheters
  • Circular multi-electrode mapping catheter (LASSO® Catheter)
  • Other multi-electrode mapping catheters
    • BASKET, MESH, PENTARAY™ Catheter
slide94

Circular Mapping Catheter (LASSO® Catheter)

  • Precise mapping of potentials and exit sites at PVs

Fully Contracted

15 mm

Fully Expanded

25 mm

RSPV mapping

LSPV mapping

10

2

9

1

3

1

4

8

2

10

5

3

7

9

6

4

6

8

5

7

slide95

E

A

D

B

A

C

B

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

  • 5 radiating spines (markers on spine A and B)
  • 20 localized electrodes
  • Central irrigation lumen
electrophysiological mapping systems
Electrophysiological Mapping Systems
  • 3D-electroanatomic mapping
    • CARTO™ System / CARTOMERGE™ Image Integration Software Module
  • Robotic magnetic navigation
    • Stereotaxis
c arto system
CARTO™ System
  • Localization of catheter to within 1 mm
  • Increase safety margin during ablation
slide99

Anatomic Maps Using CARTO™ System

  • 3D-electroanatomic maps (CARTO™ System) showing ablation points encircling PVs
circumferential electroanatomical ablation around pv ostia
Circumferential Electroanatomical Ablation around PV Ostia
  • 3D-electroanatomic maps (CARTO™ System) showing pre- and post-ablation electrical activity
  • Endpoint is complete electrical isolation of left atrium

Pre-ablation

Post-ablation

Point by point

RF lesions

Delayed

activation

reproduced with permission, Pappone C, et al. Circulation (2001) 104: 2539