Atrial Fibrillation Ablation:Atrial Fibrillation Ablation:My personal experience 2000-2008My personal experience 2000-2008

Helmut Pürerfellner MD, Helmut Pürerfellner MD, Assoc. Prof.Assoc. Prof.

Division of CardiologyDivision of Cardiology

St.Elisabeth´s Sisters St.Elisabeth´s Sisters HospitalHospital

Academic Teaching CenterAcademic Teaching Center

Linz/AustriaLinz/Austria

Rationale for Catheter ablation of AFib:Rationale for Catheter ablation of AFib:Poor drug efficacyPoor drug efficacy

Pulmonary vein potentials (PVP)Pulmonary vein potentials (PVP)

Right atrium Left atrium

17 31

116

Superiorcaval Vein

Inferior caval vein

Fossaovalis

CoronarySinus

Pulmonary Veins

Septum

… critical zone

Sueda Sueda Ann Thorac Surg 1997Ann Thorac Surg 1997

Microreeentrant Microreeentrant circuitscircuits

HaissaguerreHaissaguerreNEJM 1998NEJM 1998

PV fociPV foci

LOMLOM

HwangHwangCirculation 2000Circulation 2000

Ablation of AFib - Ablation of AFib - TechniquesTechniques

Trigger approach:Trigger approach:

• Focal (within PV)Focal (within PV)

• Segmental ostialSegmental ostial

• Tailored approach Tailored approach

Substrate approach:Substrate approach:

• Circumferential atrialCircumferential atrial

• Additional lines (roof, mitral Additional lines (roof, mitral isthmus) isthmus)

• Substrate mapping (CAFE, Substrate mapping (CAFE, DF)DF)

• Ganglionated plexus (GP)Ganglionated plexus (GP)

PV-Angiographie (LIPV)PV-Angiographie (LIPV)

Lasso CatheterLasso Catheter

Atraumatic tip

Different loop diameters available

Micro-catheter loop featuring 10

electrodes (3F)

Deflectable Tip (B curve)

Ablation LIPVAblation LIPV

PV-DiskonnektionPV-Diskonnektion

… critical zone

Sueda Sueda Ann Thorac Surg 1997Ann Thorac Surg 1997

Microreeentrant Microreeentrant circuitscircuits

HaissaguerreHaissaguerreNEJM 1998NEJM 1998

PV fociPV foci

LOMLOM

HwangHwangCirculation 2000Circulation 2000

Ablation of AFib - Ablation of AFib - Techniques Techniques

Trigger approach:Trigger approach:

• Focal (within PV)Focal (within PV)

• Segmental ostialSegmental ostial

• Tailored approach Tailored approach

Substrate approach:Substrate approach:

• Circumferential atrialCircumferential atrial

• Additional lines (roof, mitral Additional lines (roof, mitral isthmus) isthmus)

• Substrate mapping (CAFE, Substrate mapping (CAFE, DF)DF)

• Ganglionated plexus (GP)Ganglionated plexus (GP)

PV-Antrum (CT/ICE)PV-Antrum (CT/ICE)

Wide areas circumferential ablation (WACA) Wide areas circumferential ablation (WACA) (+ left atrial lines(+ left atrial lines± ostial ablation± ostial ablation) )

SOI vs WACASOI vs WACAOral et al, Circulation 2003; 108:2355-60Oral et al, Circulation 2003; 108:2355-60

• Decrease in local atrial Decrease in local atrial electrogram amplitude electrogram amplitude >50% or amplitude <0,1mV >50% or amplitude <0,1mV (voltage abatement)(voltage abatement)

• Additional ablation within Additional ablation within circumferential lines in 32%circumferential lines in 32%

SOI vs WACA SOI vs WACA Oral et al, Circulation 2003; 108:2355-60Oral et al, Circulation 2003; 108:2355-60

Success rates (extraostial)Success rates (extraostial)

Complication rates (extraostial)Complication rates (extraostial)

AFib-Ablation Elisabethinen Hospital Linz AFib-Ablation Elisabethinen Hospital Linz 2001-20052001-2005

• Period 01/2001 – 05/2005Period 01/2001 – 05/2005

• N=200 Pat.N=200 Pat.

• Age 53Age 53±10 a ±10 a

• 82%m, 18%f82%m, 18%f

Arrhythmia Arrhythmia

• Paroxysmal: n=162 (81%)Paroxysmal: n=162 (81%)

• Persistent: n=32 (16%)Persistent: n=32 (16%)

• Permanent: n=5 (2,5%)Permanent: n=5 (2,5%)

ProceduresProcedures

• N=276N=276

• Procedures: Procedures:

1.1. Lasso (segmental ostial)Lasso (segmental ostial)

2.2. Pappone (circumferential)Pappone (circumferential)

3.3. Combi (circumferentiell Combi (circumferentiell + ostial)+ ostial)

4.4. Mixed Mixed

Follow upFollow up

• Fu after 1 month (clinical examination, 24h-Holter-Fu after 1 month (clinical examination, 24h-Holter-EKG, QOL) EKG, QOL)

• In hospital Fu at 3, 6 und 24 months (clinical In hospital Fu at 3, 6 und 24 months (clinical examination, Holter/Monitor, Echo, stress test, examination, Holter/Monitor, Echo, stress test, Spiral-CT, TEE, QOL; Lung scan and MRI as Spiral-CT, TEE, QOL; Lung scan and MRI as needed)needed)

Classification of successClassification of success

• Complete : 0 recurrences, 0 drugComplete : 0 recurrences, 0 drug

• Partial: Partial: 0 recurrences, + drug 0 recurrences, + drug

• failure:failure: + recurrences, + drug + recurrences, + drug

• Clinical response: complete + partial successClinical response: complete + partial success

Success/patient Success/patient

AFib paroxysmalAFib paroxysmal

JICE 2007

Study designStudy design

• 40 consecutive patients (40 consecutive patients (56.4 ± 9.6 y; 36 male)56.4 ± 9.6 y; 36 male)

Multislice computed tomography imagingMultislice computed tomography imaging

• 16-slice MSCT16-slice MSCT

• Non ionic contrast agentNon ionic contrast agent

• Caudocranial scanningCaudocranial scanning

• Exspiratory breath-holdExspiratory breath-hold

• Barium contrast (esophagus)Barium contrast (esophagus)

Electroanatomic mappingElectroanatomic mapping

• 4-mm irregated tip 4-mm irregated tip quadripolar catheterquadripolar catheter

• Contact mapping of Contact mapping of LA and PVsLA and PVs

• EAM and MSCT EAM and MSCT displayed next to displayed next to each other each other

Allignment of MSCT and EAMAllignment of MSCT and EAM

• Landmark registrationLandmark registration

• Visual allignmentVisual allignment

• Surface registrationSurface registration

AF ablation procedureAF ablation procedure

• Circumferential Circumferential approachapproach

(Pappone C et al., (Pappone C et al., Circulation 2000;102(21):2562-4))

• PV-IsolationPV-Isolation

(Haissaguerre M et al., (Haissaguerre M et al., N Engl J Med 1998;339:659–65))

• Additional linesAdditional lines

Accuracy Accuracy (position error)(position error)

POSTPRE

4

3

2

1

0

Mean = 1.6mm

Mean = 2.3mm

> No difference between SR and AF.

> Independent of number of points.

StudiesStudies

(J Cardiovasc Electrophysiol, Vol. 17, pp. 341-348, April 2006)

Position error: 2.3 ± 0.4 mm

(Heart Rhythm 2005;2:1076 –1081)

Position error: 2.1 ± 0.2 mm

Our results:

1,6 ± 1,2 mm (pre)

2,3 ± 1,8 mm (post)

ConclusionConclusion

• Integration of MSCT scanning into 3D EAM is Integration of MSCT scanning into 3D EAM is feasible and accurate.feasible and accurate.

• Cardiac rhythm during procedure has no influence Cardiac rhythm during procedure has no influence on the precision of fusion.on the precision of fusion.

• Matching accuracy decreases after multiple Matching accuracy decreases after multiple ablations.ablations.

• Combining EAM and imaging methods might Combining EAM and imaging methods might provide easier, faster and more reliable ablation provide easier, faster and more reliable ablation procedures in AF.procedures in AF.

INTRODUCTIONINTRODUCTION

Does MSCT integration into 3D EAM …Does MSCT integration into 3D EAM …

• ……lower complication rate of RF ablation?lower complication rate of RF ablation?

• ……improve of clinical outcome?improve of clinical outcome?

• ……enhance procedural efficacy?enhance procedural efficacy?

– Procedural durationProcedural duration

– Radiation timesRadiation times

METHODSMETHODS

• 161 consecutive patients (134 male)161 consecutive patients (134 male)

• Mean age 55.5 ± 9.5 yMean age 55.5 ± 9.5 y

• Multi-drug-resistant AF (2.4±1.1 failed AAD)Multi-drug-resistant AF (2.4±1.1 failed AAD)

• Serial MSCT before and 3 months after ablationSerial MSCT before and 3 months after ablation

• 24-hour Holter and patients questionnaire at 3 24-hour Holter and patients questionnaire at 3 months after proceduremonths after procedure

CartoXPCartoXPTMTM vs. CartoMerge vs. CartoMergeTMTM

CARTO XP:

79 pts.

CARTO Merge:

82 pts.

BASELINE CHARACTERISTICSBASELINE CHARACTERISTICS

RESULTS - SAFETYRESULTS - SAFETY

ZeroZero PV stenosis in the PV stenosis in the CartoMERGE group CartoMERGE group

versusversus

FiveFive in the conventional in the conventional group (p=0.021).group (p=0.021).

Severe adverse events in Severe adverse events in total considerably reduced total considerably reduced (8 vs. 2; p=0.043). (8 vs. 2; p=0.043).

Procedure-related Complications

0

1

2

3

4

5

6

7

8

9

XP MergeProcedure Type

Num

ber o

f Pat

ient

s Phrenic Nerve Injury

Pericardial Effusion

TIA/Cerebral Infarction

PV-Stenosis

RESULTS - OUTCOMERESULTS - OUTCOME

failure full success success on drugs

Outcome nach 3 Monaten

0

10

20

30

40

50

60

Pe

rce

nt

Verfahrensart

XP

Merge

Outcome at 3 months

Overall success afterOverall success after

3 months:3 months:

- CARTO XP 71%- CARTO XP 71%

- CARTOMerge 87.5%- CARTOMerge 87.5%

p = 0.019.p = 0.019.

Martinek et al, PACE 2007

RESULTS - EFFICACYRESULTS - EFFICACY

CONCLUSIONCONCLUSION

MSCT image integration into 3D EAM …MSCT image integration into 3D EAM …

… … significantly improves safety …significantly improves safety …

… … significantly enhances success …significantly enhances success …

of WACA with confirmed PV isolation and of WACA with confirmed PV isolation and additional lines.additional lines.

Image IntegrationImage Integration

AFib Ablation Lesion SetsAFib Ablation Lesion Sets

Are you sure you know what you are Are you sure you know what you are doing ?doing ?

Journal of Cardiovasc Electrophysiol 2007Journal of Cardiovasc Electrophysiol 2007

Catheter Ablation of AF 2008 – Catheter Ablation of AF 2008 – Open issuesOpen issues

• AF as first-line treatment (RAAFT, CACAF, APAF)AF as first-line treatment (RAAFT, CACAF, APAF)

• Persistent/long standing persistent AF („chronic AF“)Persistent/long standing persistent AF („chronic AF“)

• Energy Source/Catheter designEnergy Source/Catheter design

• Remote navigationRemote navigation

• Vs AAA (CABANA), vs A+P (PABA-CHF)Vs AAA (CABANA), vs A+P (PABA-CHF)

• AF and CHFAF and CHF

• Mortality (CASTLE-AF)Mortality (CASTLE-AF)

• Cost-effectivenessCost-effectiveness