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Stepwise 消融术式结合病例选择的个体化消融

1864. Stepwise 消融术式结合病例选择的个体化消融. Liu Shaowen, MD. PhD. Shanghai First People’s Hospital Shanghai Jiao Tong University. Long-Term Follow-up for SR Maintenance Following Ablation of AF. 1. 2. 3. 4. 5. PAF PsAF. 1. Ouyang F, et al. Circulation 2010;122:2368–2377.

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Stepwise 消融术式结合病例选择的个体化消融

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  1. 1864 Stepwise消融术式结合病例选择的个体化消融 Liu Shaowen, MD. PhD. Shanghai First People’s Hospital Shanghai Jiao Tong University

  2. Long-Term Follow-up for SR Maintenance Following Ablation of AF 1 2 3 4 5 PAF PsAF 1. Ouyang F, et al. Circulation 2010;122:2368–2377. 2. Medi C, et al. J Cardiovasc Electrophysiol 2011;22:137–141. 3. Weerasooriya R, et al. J Am Coll Cardiol 2011;57:160–166. 4. Sorgente A, et al. Am J Cardiol 2012;109:1179–1186. 5. Tilz RR, et al. J Am Coll Cardiol 2012;60:1921–1929. 20%-49% SR after 1 ablation 39%-79.5% SR after multiple ablations 2

  3. Reasons of Recurrence After AFib Ablation --Mechanisms of AFib 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. --Ouyang F, et al. Recovered PV conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the PVs: lessons from double Lasso technique. Circulation. Jan 18 2005;111(2):127-135. --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.

  4. Shanghai First People’s Hospital, Jiao Tong University Individualized CPVA Line RL LL Sup PA Songwen Chen and Shaowen Liu . Spatial torsion of the PVs. J Interv Card Electrophysiol. 2013; 37(1):35-40

  5. Tube PV PV Antrum Reasons of Recurrence After AFib Ablation --Related to Ablation Approaches Becker A et al. JCE 2001

  6. RSPV RSPV LSPV LSPV LSPV LAA LAA LAA RPV LIPV LIPV RIPV RIPV 房颤合并主动脉瘤样扩张 Anatomic Variability

  7. CARTOMERGE in the Ablation of Afib Huge PV Antrum PVI+Roof Line+ CFAE Abl+CD

  8. LSPV RSPV LIPV RIPV LSPV RSPV LIPV RIPV Ablation of Afib using 3D mapping system integrated with CT image Anatomic Variability

  9. Ablation of Afib using 3D mapping system integrated with CT image Individualized CPVA Line

  10. Recovery of PV conduction Durable isolation of the PVs The Role of Adenosine Following PVI--复发率减少约25% McLellan AJ, et al. A Systematic Review. JCE. 2013;24(7):742-51. The effect of waiting time--30-60 mins Yamane T, et al. Circulation: Arrhythmia and Electrophysiology. 2011;4(5):601-608. LA-PV双向传导阻滞提高成功率（90.9%--76.8%--70.5%） Songwen Chen and Shaowen Liu, et al. PACE. 2012; 35(5): 524–531. Benefit of PVI Guided by Loss of Pace Capture on the Ablation Line. (83%--52%, p=0.001) Steven D, et al. J Am Coll Cardiol. 2013;62(1):44-50. Acute electrical isolation is a necessary but insufficient endpoint: The importance of closing the visual gap Miller MA, et al. Europace 2012;14(5):653-660. Prolonged ablation on critical segments of PV ostia in PAF (HR 2.6, p=0.001) Kriatselis C, et al. Pacing Clin Electrophysiol. 2014;37(5):603-9.

  11. 慢性房颤的消融-附加线、CAFE 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？! 二尖瓣狭部消融线--- 增加二尖瓣狭部消融线可以明显提高肺静脉电隔离治疗慢性持续性房颤的有效性（36% VS.74%，P<0.01）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. 左房顶部消融线--- 随访16个月,慢性持续性房颤单纯PVI组只有20%的患者仍维持窦性心律，而左房线性消融组69%为窦性心律(P=0.0001) --Willems S, et al. Substrate modification combined with PVI improves outcome of catheter ablation in patients with persistent AF: 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. 11

  12. Shanghai First People’s Hospital, Jiao Tong University 慢性房颤的消融-CAFE CFAE ablation provided only benefit for persistent AF 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.

  13. Shanghai First People’s Hospital, Jiao Tong University Mechanisms of CFAE 根据目前判断标准确定的CFAEs特异性差!！ The majority of CFAEs reflect far-field signals, AF 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. CS CFAEs are common in controls with induced AF. No difference in the DF during AF was seen. 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. Functional nature of electrogram fractionation demonstrated by LA high-density mapping. Jadidi AS, et al. Circ Arrhythm Electrophysiol. 2012;5(1):32-42.

  14. Shanghai First People’s Hospital, Jiao Tong University Mechanisms of CFAE Epicardial adipose tissue-based defragmentation approach to PSAF PVAI plus EAT-based ablation efficiently eliminates high-frequency sources/ CFE and yields relatively high success (During 16-month follow-up, freedom from AF on AADs: 78% vs 60%, P<0.05). Nakahara S, et al. Heart Rhythm. 2014 May 2.

  15. Limited Versus Extensive Atrial Substrate Modification After CPVI in Nonparoxysmal Atrial Fibrillation --A Prospective and Randomized study (continuous complex fractionated atrial electrogram, CFAE: <60 ms) versus extensive (continuous CFAE plus variable CFAE: <120 ms) Lin YJ, et al. J Cardiovasc Electrophysiol. 2014 Mar 13.

  16. Autonomic denervation added to PVI for PAF ---a randomized clinical trial（3） (74%) (56%) (48%) Katritsis DG, et al. J Am Coll Cardiol. 2013;62(24):2318-25.

  17. Individualized Circumferential PV Ablation Line PA RL RAO PA RAO RL

  18. 房颤导管消融--技术策略与终点 ----慢性房颤的消融 PATIENT FLOW CHART 在持续性房颤中，术中通过消融终止房颤与房颤导管消融的成功率无关！ Elayi CS, et al. Atrial fibrillation termination as a procedural endpoint during ablation in long-standing persistent atrial fibrillation. Heart Rhythm, 2010,7:1261. 85% 49% 95% 70.6% 14.4% 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.

  19. Genqing Zhou, … and Shaowen Liu. JCE. 2013;24(10):1192. p < 0.001 术后8例患者在随访期间(3-24个月）仅有1次房颤/房扑/房速发作，均按复发计算 Shanghai First People Hospital, Jiao Tong University

  20. Genqing Zhou, … and Shaowen Liu. JCE. 2013;24(10):1192. AF>SR AF>AT>SR AF>AT>X AF>X 75% 67.7% 48% 29% Shanghai First People Hospital, Jiao Tong University

  21. Reasons of Recurrence After AFib Ablation--Impact of Ablation procedure end-point Faustino M, et al.Heart Rhythm. 2014 May 23.

  22. Mechanisms of AFib Reasons of Recurrence After AFib Ablation 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

  23. Ablation of FIRM reduces late recurrence of AF compared with trigger ablation alone 1.20.4 procedures 70.4% 36.9% Narayan SM, et al. J Am Coll Cardiol. 2014 May 6;63(17):1761-8.

  24. Body Surface Localization of Left and Right Atrial High Frequency Rotors in AF Pts A Clinical-Computational Study：Phase analysis of surface potential signals after HDF-filtering during AF shows reentrant drivers localized to either the LA or RA, helping in localizing ablation targets Rodrigo M,et al. Heart Rhythm. 2014 May 17.

  25. RSD in addition to PVI in Pts with Refractory Symptomatic AF and Resistant Hypertension RSD reduces SBP and DBP in pts with drug-resistant hypertension and reduces AF recurrences when combined with PVI Restoring NSR in pts with AF and HTN resulted in a sustained decrease in DBP and MBP Ramirez A, et al. The effects of radio-frequency ablation on blood pressure control in pts with AF and hypertension. J Interv Card Electrophysiol. 2012;35(3):285-291. Sanders NA, et al. Restoring sinus rhythm results in blood pressure reduction in pts with PsAF and a history of hypertension. J Cardiovasc Electrophysiol. 2012;23(7):722-726. In pts with sleep apnea syndrome and AF, restoring SR by RFCA leaded to a decrease in apnea-hypopnea index Naruse Y, et al. Radiofrequency catheter ablation of PsAF decreases a sleep-disordered breathing parameter during a short follow-up period. Circ J. 2012;76(9):2096-2103. Maintenance of sinus rhythm after DCC may have a favorable effect on the SQ of patients with AF. Kayrak M, et al. Self-Reported Sleep Quality of Pts with AF and the Effects of Cardioversion on Sleep Quality. Pacing Clin Electrophysiol.2013 Feb 25. n=14, 69% n=13, 29% Pokushalov E, et al. J Am Coll Cardiol 2012; 60(13): 1163-1170. 27

  26. 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 Improving the Outcome of Catheter Ablation in AF Afib pathophysiology Within or out of the PVs Lines, CFAE or FIRM GP or RSD 28

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

  28. LL AP Mapping of AT

  29. Periodogram of AF 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 AF; however, there is no change in the frequency of the spectral component (B, arrow). After termination of AF 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.

  30. 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.

  31. Distinctive patterns of dominant frequency trajectory behavior in drug-refractory persistent AF Characterization of spatiotemporal instability Identification and tracking of the center of gravity (CG) of the highest DF cloud for a specific time (A). Three types of behavior: localized (B), cyclical (C), and chaotic (D). Salinet JL, et al. J Cardiovasc Electrophysiol. 2014;25(4):371-9.

  32. 压力导管（SmartTouch）消融初步经验

  33. Stepwise术式的个体化消融 Wide area durable CPVI Linear ablation Limited CFAE Ablation Ablation end-points Out of procedure... Characteristics of patients with AFib

  34. Shanghai Evening

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