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Atrial Fibrillation Ablation

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

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  1. Atrial Fibrillation Ablation Cardiology Symposium December 6, 2004 Paul R. Steiner, M.D. Cardiac Electrophysiology

  2. 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

  3. 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

  4. Treatment History: Rate control strategy: • Digoxin • β – blockers • CCBs Rhythm control strategy: • Propafenone (Rhythmol) • Flecainide What next?

  5. 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

  6. 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.

  7. 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.

  8. Left Atrium, Posterior Wall Variable Anatomy(Common) SVC RAA LAA RSPV LSPV RIPV LIPV IVC Nathan, Circ Res, 1969?

  9. Left Atrium, Posterior Wall

  10. Atrial FibrillationInitiation Mechanism – PV Triggers

  11. Left Atrium, Posterior Wall Pulmonary Vein Isolation Nathan, Circ Res, 1969?

  12. 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.

  13. T8 Axial View Aorta Esophagus Left PVs Right PVs LeftVentricle Courtesy of M. Ramsey, PhD, CEO CardioCommand

  14. 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

  15. Left Atrium (LA) andPulmonary Vein Anatomy Esophagus Left PVs Right PVs LA Roof LA Appendage 3-D CT Reconstruction(Extreme PA Cranial View)

  16. 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)

  17. Side-by-Side GeometryRF catheter pointing away from esophagus ESI Nav-X 3-D Geometry 3-D CT via CardEP

  18. Pulmonary Vein IsolationSegmental Approach Going… Going… Gone ! Haïssaguerre, M. et al., Circulation. 2000;102:2463–2465.

  19. 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

  20. 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)

  21. Left Atrial Mapping and Catheter AblationVisualization : Intracardiac Ultrasound Optimizing Catheter Placement at PV Os

  22. Caution STOP ! Marrouche N and Natale A. Electromedica 70 (2002) no. 1

  23. PV Isolation by RF Lesion Before …

  24. Electronically Isolated PV After …

  25. 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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