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AF ablation with 3D mapping: our technique and results. Dr Dhiraj Gupta MRCP MD DM Liverpool Heart and Chest Hospital. Northern UK AF experts Best Practice meeting Langdale Hotel, Cumbria 5 Feb 2010. Schema. Our approach to AF ablation at LHCH Our reasons for each step

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af ablation with 3d mapping our technique and results
AF ablation with 3D mapping: our technique and results
  • Dr Dhiraj Gupta MRCP MD DM
  • Liverpool Heart and Chest Hospital

Northern UK AF experts Best Practice meeting

Langdale Hotel, Cumbria 5 Feb 2010

schema
Schema

Our approach to AF ablation at LHCH

Our reasons for each step

Our in-lab and follow-up results

our approach in a nutshell
Our approach in a nutshell
  • PVAI with Wide area circumferential ablation
  • CT image integration using CARTO
  • Individualised lesion set prescription
  • Aim to ablate out of AF, ideally to SR
  • Procedure duration limit of 5 hours
ct image registration
CT image registration
  • Critical part of the process
  • 2 steps
    • Single point Landmark registration
    • Surface Registration with Fast Anatomical Mapping
  • Takes 5-10 minutes
why the individualised approach
Why the individualised approach?
  • Heterogeneity amongst AF population
  • Trigger removal vs Substrate Modification
  • Aim to achieve high single procedure success rates
    • Incremental risk with multiple procedures
    • That’s what the patient wants
    • That’s what the health economists want!
patient selection criteria
Patient selection criteria
  • Patients not offered Catheter ablation if
    • Very long standing Persistent AF (>3 years)
    • Very large LA (>5.5 cm)
    • Morbid Obesity (BMI >40), Sleep Apnea
    • Significant RA dilatation (>LA)
  • Patients not offered first redo at least for 6 months
  • Not offered Second redo if still in PsAF
not all af patients are the same
Not all AF patients are the same
  • True PAF
    • Short lived episodes, short history, normal sized LA
  • Sustained PAF: 2 or more of the following
    • AF episodes>24 hours, History of AF > 5 years, LA size >4.5 cm, Age >65 years, Documented flutter, High AF burden (most days)
  • Persistent AF
  • Long standing Persistent AF (>12 months)
minimum rf lesion set
Minimum RF Lesion set
  • True PAF
    • PVAI using WACA
  • Sustained PAF
    • + LA roof line + RA flutter line
  • Persistent AF
    • + LA floor line + Mitral isthmus line
  • Long standing Persistent AF
    • + Epicardial CS ablation+ CAFÉ ablation
surgical maze for permanent af

Still the Gold standard in terms of results

  • 96% free of AF at 5 years*
Surgical Maze for ‘Permanent AF’

* SM Prasad et al, J Thorac Cardiovasc Surg 2003; 126: 1822-27

why ct image integration
Why CT image integration?
  • Forewarned is forearmed: PV anatomical variations
    • Common Left Pulmonary Vein
    • Additional pulmonary vein(s)
  • Important anatomical information
    • thickness of the LAA ridge, intervenous carina
    • extent of the PV antra
    • length of the mitral isthmus
why ct image integration20
Why CT image integration?
  • Dramatically reduces procedural fluoro times:
    • <10 minutes for PAF cases
    • 10-20 minutes for PsAF cases
    • Decreases fatigue
  • Removes ‘the fear of the unknown’…..
  • Demystifies AF ablation for the nurses/ radiographers!
why carto rather than esi
Why CARTO rather than ESI?
  • Unmatched catheter stability
    • no catheter ‘dive’ with onset of RF delivery
    • Allows linear lesions
  • No need for stable intracardiac reference
  • Ability to perform activation mapping if needed
  • Great CT image integration software
advances with carto 3
Advances with CARTO-3
  • Hybrid of impedance and magnetic catheter location
  • Ability to see all catheters
  • Ability to create fast anatomical maps
    • Makes CT image integration easier
  • More streamlined patient set-up
why waca
Why WACA?
  • PV ostial/ antral triggers
  • Substrate modification by Atrial debulking
  • Less risk of PV stenosis
  • Quicker than segmental PVI
  • Easy to anchor linear lesions on either side
  • ‘Et tu, Bordeaux?!’
why our rf settings
Why our RF settings?
  • Continuous RF: 35 W, 50°C, 10 ml/ min flow
    • Quicker signal obliteration than 30/25 W
    • Short procedure time (20-30’ per WACA)
    • Prevents peri-lesion edema (?  reconnection risk)
  • RF controlled by Foot pedal
    • Frees up a cardiac physiologist
    • Imposes discipline on use of X-ray pedal!
slide27

Our results

131 consecutive pts. between Jan 08-July 09

individualised ablation strategy
Individualised ablation strategy
  • True PAF (n=45)
    • PVAI using WACA
  • Sustained PAF (n=31)
    • + LA roof line+ RA flutter line
  • Ps AF (n=22)
    • + LA floor line+ Mitral isthmus line
  • Long standing Ps AF (n=33)
    • + Epicardial CS ablation+ CAFÉ ablation
in lab results
In-lab results
  • All patients received prescribed minimum lesion set
  • Mean Procedure time 173 min (98-300)
  • Fluoroscopy times
    • Mean 26.5 min (13-58) (as pre-CARTO 3 era)
    • Now with CARTO-3 (n=36): Mean 14 min (6-21)
  • Complications
    • 1 tamponade (PVI group), 1 AV fistula
our follow up strategy
Our follow-up strategy
  • Antiarrhythmic drug therapy for 2-3 months
  • Early post-op arrhythmias
    • DC CV if sustained and poorly tolerated (n=1)
  • No redo ablation procedure for at least 6 months
  • Mean follow up 11.3 months (6-24)
our clinical results
Our Clinical Results
  • Definition of Procedural Success:
    • No symptoms beyond 3 months, AND
    • Absence of AF/AT on 24 hour Holter at 6 mo
  • Single procedure success rates at 6 months
    • PAF 84%
    • PsAF 86%
    • Sustained PAF 77% (p=0.05)
    • Long standing PsAF 64% (p<0.001)
conclusions
Conclusions
  • Single procedure success should be the goal
  • Most patients need substrate modification in addition to trigger removal
  • This needs application of linear lesions
  • 3D mapping guided ablation the gold standard
www heartrhythmspecialist co uk
www.heartrhythmspecialist.co.uk

Acknowledgements to Dr Richard Schilling, my mentor and guide

Thank You