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慢性房颤的导管消融治疗 -- 何时柳暗花明？

慢性房颤的导管消融治疗 -- 何时柳暗花明？. 刘少稳. 上 海 市 第 一 人 民 医 院 上海交通大学附属第一人民医院. 心内科. Reasons of Recurrence After AFib Ablation. --Mechanisms of AFib (1). Afib pathophysiology. ① Electrical Reconnection of PV and LA ② Atrial substrate modification

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慢性房颤的导管消融治疗 -- 何时柳暗花明？

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  1. 慢性房颤的导管消融治疗 --何时柳暗花明？ 刘少稳 上海市第一人民医院 上海交通大学附属第一人民医院 心内科

  2. Reasons of Recurrence After AFib Ablation --Mechanisms of AFib (1) Afib pathophysiology ① Electrical Reconnection of PV and LA ② Atrial substrate modification ③Non-PV drivers or firing foci are important for acute termination of AFib and for long-term success. --Miyazaki S, et al. Long-term clinical outcome of extensive PVI-based catheter ablation therapy in patients with paroxysmal and persistent AF. Heart. 2011;97(8):668-673.

  3. Reasons of Recurrence After AFib Ablation --Mechanisms of AFib (1) AFib: a developmental disease! Patients with first AFib and comorbidities are at higher risk for rapid progression to permanent AFib. Age, diabetes, and heart failure are independent predictors. Pappone C, Radinovic A, Manguso F, et al. AFib progression and management: a 5-year prospective follow-up study. Heart Rhythm. 2008;5(11):1501-1507. Factors account for the progression of AFib: New Triggers, More extensive atrial myocardium fibrosis (Substrate), Changing of Autonomic tone

  4. Reasons of Recurrence After AFib Ablation --Mechanisms of AFib (1) N=3966 (PAF 36%, PsAF 20%, LSP 44%)，Redo N=987(PAF 29%, PsAF 20%, LSP 51%)，LAA firing: 266 (27%) (PAF 18%, PsAF 23%, LSP 58%) Freedom from AF/AT Di Biase and Natale. LAA: an underrecognized trigger site of AF. Circulation. 2010;122(2):109-118 Months

  5. A B I II V1 SVC1 SVC2 SVC3 SVC4 SVC5 SVC6 HRA MRA LRA CSp CSd 400 ms 100 ms SVC-P SVC-P >500 bpm >500 bpm SVC-P SVC-P A A A 170 bpm 88 bpm 340 bpm380 bpm Afib AT Sinus rhythm SVC Isolation in patients with PsAF

  6. Reasons of Recurrence After AFib Ablation --Mechanisms of AFib (1) 确定肺静脉外起源异位兴奋灶-SVC Paroxysmal (n=46) and persistent (n=14) AF patients without structural heart disease who underwent CPVI. SVC sleeve length >30 mm and maximum amplitude of SVC potential >1.0 mV strongly predicted an SVC focus of AF (100% sensitivity, 94% specificity). Higuchi K, et al. SVC as initiator of AF: factors related to its arrhythmogenicity. Heart Rhythm. 2010;7(9):1186-1191.

  7. Tube PV PV Antrum Reasons of Recurrence After AFib Ablation --Related to Ablation Approaches (2) Haissaguerre M, et al. The "venous wave" hypothesis. JACC. 2004;43(12):2290-2292 Becker A et al. JCE 2001 Parkash R, et al. Catheter Ablation Technique of PAF and PsAF: A Meta-Analysis of the Randomized Controlled Trials. JCE. 2011;18:1540-8167.

  8. Additional linear ablation in patients with persistent AFib 右心房消融线--- 在PVI的基础上增加右心房消融线：右房后壁和间隔部连接上下腔静脉的消融线，以及上腔静脉电隔离，可使慢性房颤术后14月的复发率由39%降到15%（p=0.02）--Calo L, et al. LA ablation versus biatrial ablation for persistent and permanent AF: a prospective and randomized study. JACC 2006;47:2504-12. Takahashi Y, et al. Clinical characteristics of patients with persistent AF successfully treated by LA. Circ Arrhythm Electrophysiol. 2010;3(5):465-71. 三尖瓣狭部线性消融在经导管消融治疗慢性持续性房颤中的作用？! • CPVA+PVI plus additional linear ablation • LA roof line1,2, MA isthmus3,4, RA5,6 • Willems S, et al. Substrate modification combined with PVI improves outcome of ablation in PsAF: a prospective randomized comparison. Eur Heart J 2006;16:16. • Hocini M, et al. Techniques, evaluation, and consequences of linear block at the left atrial roof in PAF: a prospective randomized study. Circulation 2005;112:3688-96. • Fassini G, et al. Left mitral isthmus ablation associated with PVI: long-term results of a prospective randomized study. JCE 2005;16:1150-6. • Pappone C, et al. Prevention of iatrogenic atrial tachycardia after ablation of AF: a prospective randomized study comparing CPVA with a modified approach. Circulation 2004;110:3036-42. • Calo L, et al. LA ablation versus biatrial ablation for persistent and permanent AF: a prospective and randomized study. JACC 2006;47:2504-12. • Takahashi Y, et al. Clinical characteristics of patients with persistent AF successfully treated by LA. Circ Arrhythm Electrophysiol. 2010;3(5):465-71

  9. Shanghai First People’s Hospital, Jiao Tong University CAFEablation in patients with persistent AFib CFAE ablation provided only benefit for persistent AFib when combined with antral PVI (RR 0.55). Adjunctive CFAE ablation increased procedural, fluoroscopy, and RF application times, and the risk/benefit profile of adjunctive CFAE ablation deserves further evaluation. 1. Kong MH, Piccini JP, Bahnson TD. Efficacy of adjunctive ablation of CFAEs and PVI for the treatment of AF: a meta-analysis of randomized controlled trials. Europace. 2011;13(2):193-204. 2. Parkash R, et al. Approach to the Catheter Ablation Technique of Paroxysmal and Persistent AF: A Meta-Analysis of the Randomized Controlled Trials. JCE.. 2011;18:1540-8167. 3. Li WJ, et al. Additional Ablation of CFAEs After PVAI in Patients with AF: A Meta-Analysis. Circ Arrhythm Electrophysiol. Feb 8 2011. 4. Hayward RM, et al. PVI with CFAE Ablation for Paroxysmal and Nonparoxysmal AF: A Meta-Analysis. Heart Rhythm. 2011;9.

  10. Shanghai First People’s Hospital, Jiao Tong University Mechanisms of CFAE In human, CFAEs indicate localized rapid AFib sites in a minority of cases. The majority of CFAEs reflect far-field signals, AFib acceleration, or disorganization. Narayan SM, et al. Classifying fractionated electrograms in human AF using MAP and activation mapping. Heart Rhythm. 2011;8(2):244-253. AF patients have a higher prevalence of CFAE and short CL activation within the proximal CS than control patients with nonclinical AF. No difference in the DF during AF was seen. CS CFAEs are common in controls with induced AF. Teh AW, et al. Prevalence of CFAE in the CS: comparison between patients with PsAF or PAF and a control population. Heart Rhythm. 2010;7(9):1200-1204.

  11. Arrhythmia Research Institute University of Oklahoma GP ablation  CFAE Ablation. In CFAE ablation, targeting peripheral sites may only destroy axons and may be cause for failure -target cell bodies (GP) for highest success! Armour JA, Murphy DA, Yuan BX, et al. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec, 1997,247:289-298. Zhou J, Scherlag BJ, et al. Gradients of atrial refractoriness and inducibility of AFib due to stimulation of ganglionated plexi. J Cardiovasc Electrophysiol, 2007,18(1):83-91.

  12. Trigger Substrate Nerve Ectopy to start Afib Conditions that increase the likelihood of Afib induction or maintenance Conduction properties of atria to sustain Afib Vagal & sympathetic Mechanisms of AFib Afib pathophysiology Substrate: Maze, Linear Abl, CFAE, CPVA Trigger: PVI, Ablation of AFL, AT, PACs Autonomic Nerve: GP Abl、CPVA CPVATriggersSubstrateNerve 12

  13. Reasons of Recurrence After AFib Ablation --Related to Ablation Techniques (3) ①Cooled-tip catheter has a superior long-term outcome than the 4-mm-tip catheter in CPVI, which may be associated with the efficacy of transmural block Chang SL, et al. Comparison of cooled-tip versus 4-mm-tip catheter in the efficacy of acute ablative tissue injury during circumferential pulmonary vein isolation. J Cardiovasc Electrophysiol. 2009;20(10):1113-1118 ②The image-integration guided catheter ablation of paroxysmal or persistent AFib may provide a superior efficacy of over the long term Della Bella P, et al. Image integration-guided catheter ablation of AF: a prospective randomized study. JCE. 2009;20(3):258-265.

  14. Shanghai First People’s Hospital, Jiao Tong University Individualized CPVA Line RL LL Sup PA

  15. The use of 3DImage Integration improves single-procedure efficacy of PV isolation for AF. Variant PV anatomy was associated with a lower single-procedure success rate. Hunter RJ, et al. Impact of variant pulmonary vein anatomy and image integration on long-term outcome after catheter ablation for atrial fibrillation. Europace. 2010 Sep 7;2010:7. Recurrences After AFib Ablation n=226 n=107 n=240

  16. Reasons of Recurrence After AFib Ablation --Related to Ablation Techniques (3) ③Contact sensing provides a highly accurate means to titrate RF ablation lesion depth and may provide clinically valuable information regarding the efficacy of RF ablation lesions. (electrical coupling index, EnSite) Holmes D, et al.J Cardiovasc Electrophysiol. 2010(29):1540-8167. ④Real-time lesion assessment using high-frequency ultrasound integrated into an ablation catheter is feasible and allows differentiation between true necrosis and hemorrhage. Wright M, et al. Real-time lesion assessment using a novel combined ultrasound and RF ablation catheter. Heart Rhythm. 2011;8(2):304-312.

  17. Reasons of Recurrence After AFib Ablation--Impact of Ablation procedure end-point (4) PATIENT FLOW CHART 85% 49% 95% 52% 69% 15% O'Neill MD, et al. Long-term follow-up of persistent AF ablation using termination as a procedural endpoint. Eur Heart J. 2009;30(9):1105-1112.

  18. Tachycardia Transition During Ablation of PsAF. JCE. Arantes L & Haïssaguerre M et al. Nov 29 2010(29). Cavotricuspid isthmus AT Left isthmus AT Left isthmus AT Cavotricuspid isthmus AT Focal AT on the septum AT Macroreentry AT-LA roof 356 235 Transition to a second AT occurs frequently in the ablation of AT in PsAF patients. This transition occurs most commonly abruptly within the range of a single CL of the original AT (79.4%). This is best explained by a continuation of AT that was "present" simultaneously with the pre-transition tachycardia, being "entrained" (for a reentrant tachycardia) or "overdriven" for an automatic focal tachycardia. Transition was followed by a macro-reentrant AT related to MA/TA in 26% and followed by focal or roof related macroreentry AT in 74%.

  19. AFL2 AFL1 AFL3

  20. 陈 ，M，54岁，房颤持续近1年 心超：LA 33mm，EF 58% AP Failed 3 Shocks: 300J-360J-360J

  21. LL AP Mapping of AT

  22. Periodogram of AFib recorded in the CS at baseline (A), 3 minutes prior to conversion (B), and the frequency of AT (C). At baseline, the dominant frequency (DF) of AF is 6.60 Hz (A). Ablation of CFAEs results in a decrease in DF of AFib; however, there is no change in the frequency of the spectral component (B, arrow). After termination of AFib to AT, the frequency of AT (4.84 Hz) is similar to the frequency of the spectral component identified in the periodogram of AF (C). The mechanism of AT was mitral isthmus– dependent flutter in this example. Yoshida K, et al. Relationship between the spectral characteristics of AF and AT that occur after catheter ablation of AF. Heart Rhythm. 2009;6(1):11-17.

  23. Baseline Elimination of spectral components of AF by targeted linear ablation suggests that spectral components may indicate site-specific ATs that coexist with AF despite a lower frequency than the DF of AF Yokokawa M, et al. Effect of linear ablation on spectral components of AF. Heart Rhythm. 2010;7(12):1732-1737. Antral PVI Linear ablation Effect of antral PVI and linear ablation on the prevalence of spectral components in the left atrium, coronary sinus, and right atrium.

  24. Reasons of Recurrence After AFib Ablation--Impact of the patient’s characteristics (5) • ① Type of Afib1,2,5，duration of permanent AFib7 • ② LA volume（145ml）2,3,6, LA strain4, fibrillatory wave amplitude on surface ECG7,8 • Bhargava M, et al. Impact of AF type and repeat catheter ablation on long-term freedom from AF: Results of multicenter study. Heart Rhythm. 2009;9:9. • Abecasis J, et al. LA volume calculated by multi-detector CT may predict successful PVI in catheter ablation of AF. Europace. 2009;23:23. • Hof I, et al. Does LA volume and PV anatomy predict the outcome of AF ablation? JCE. 2009;20(9):1005-1010. • Hwang HJ, et al. LA strain as predictor of successful outcomes in catheter ablation for AF. J Interv Card Electrophysiol. 2009;16:16. • Bhargava M, et al. Impact of type of AFib and repeat catheter ablation on long-term freedom from AFib: Results of multicenter study. Heart Rhythm. Jun 9 2009;9:9. • McCready JW, et al. Predictors of recurrence following radiofrequency ablation for PsAF. Europace. 2011;13(3):355-361. • Matsuo S, et al. Predictors of catheter ablation outcome for PsAF. JACC.2009;54(9):788-795. • Nault I, et al. Clinical value of fibrillatory wave amplitude on surface ECG in patients with PsAF. J Interv Card Electrophysiol. 2009;30:30.

  25. Reasons of Recurrence After AFib Ablation--Impact of the patient’s characteristics (5) • Pre-procedural elevated levels of NT-proBNP1, Endothelin-12, Interleukin-63, hCRP4 and conventional markers of the inflammatory cascade such as WBC count, as well as hypertension and increased BMI were significantly associated with AFib recurrence3,5. • Hwang HJ, et al. Incremental predictive value of pre-procedural NT-proBNP for short-term recurrence in AF ablation. Clin Res Cardiol. 2009;19:19. • Nakazawa Y, et al. Endothelin-1 as a predictor of AFib recurrence after PVI. Heart Rhythm. 2009;6(6):725-730. • Henningsen KM, et al. Prognostic impact of hs-CRP and IL-6 in patients undergoing RFCA for AFib. Scand Cardiovasc J. 2008;31:1-7. • Kurotobi T, et al. A pre-existent elevated C-reactive protein is associated with the recurrence of atrial tachyarrhythmias after catheter ablation in patients with AF. Europace. 2010;12(9):1213-1218. • Letsas KP, et al. Pre-ablative predictors of atrial fibrillation recurrence following pulmonary vein isolation: the potential role of inflammation. Europace. 2009;11(2):158-163.

  26. 3D Delayed Enhancement MRI Oakes RS, et al. Detection and quantification of LA structural remodeling with delayed-enhancement MRI in patients with AF. Circulation. 2009; 119(13):1758-1767 Staging of AF by DE-MRI

  27. DE-MRI based Staging of AF Stage 1 (Mild enhancement) Stage 2 (Moderate enhancement) Stage 3 (Extensive enhancement) Oakes RS, et al. Detection and quantification of LA structural remodeling with delayed-enhancement MRI in patients with AF. Circulation. 2009;119(13):1758-1767

  28. Relationship of Pre-ablation Delayed Enhancement (Disease Stage) and Procedural Outcome Stage 2 Stage 3 Oakes RS, et al. Detection and quantification of LA structural remodeling with delayed-enhancement MRI in patients with AF. Circulation. 2009;119(13):1758-1767

  29. Staging AF by DE-MRI Stage 1 Stage 2 Persistent 43% Permanent 7% Persistent 57% Permanent 7% Paroxysmal 49% Paroxysmal 36% Stage 3 Permanent 14% Paroxysmal 9% Persistent 77% Oakes RS, et al. Circulation. 2009;119(13):1758-1767

  30. 如何提高慢性房颤导管消融治疗的成功率 Reasons of Recurrence After AFib Ablation 选择合适的房颤消融患者； 优化消融方法、技术和手术终点； 对于复发患者根据具体情况选择再次消融、药物或其它治疗 Recurrence of AFib may related to: Mechanisms of AFib Ablation approaches and techniques Procedure end-points Characteristics of patients with AFib

  31. Thanks!

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