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What is it?
Who is it for?
How good is it?
Arrhythmia Alliance Regional Update Oct 2010
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EP SpR
Ian Lines
AF AblationPlymouth
David Tomlinson
Guy Haywood
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Haïssaguerre M et al NEJM 1998 339:659-666
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TRIGGER
ROTORS
Jaliffe J. Cardiovasc Res (2002) 54 (2): 204-216
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PARASYMPATHETIC GANGLIA
Courtesy of Professor Antonio Raviele, Mestre, Italy
PO, S. S., NAKAGAWA, H. and JACKMAN, W. M. (2009), Localization of Left Atrial Ganglionated Plexi in Patients with Atrial Fibrillation. Journal of Cardiovascular Electrophysiology, 20: 1186–1189
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Focal activation Multiple Wavelets
PVs
LA
IVC IVC
RA
SVC SVC
PVs
LA
RA
Adapted from ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation J Am Coll Cardiol (2006) 48: 854
Initiated by focal triggers and maintained by substrate mediated factors that become more prevalent as AFib progresses
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Kato T, et al. Circ J (2004) 68: 568
Transformation of paroxysmal AFib to persistent AFib:5.5% patients per year
Ratio in s
inus r
hyth
m
0
1.0
0.8
0.6
0.4
0.2
Follow-up (years)
0 30
Without structural heart disease
With structural heart disease
252015105
Paroxysmal AF onset
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Resulting Prevalence –Presentation of AFib in EuroHeart Survey
40
30
10
0Paroxysmal AFib
% p
atients
Persistent AFib Permanent AFib
20
50
60
36
2836
EuroHeart Survey 2005
5,333 patients enrolled with AFib on ECG or Holterrecording during the qualifying admission/consultation, or in the preceding 12 months
Nieuwlaat R, et al. Eur Heart J (2005) 26: 2422
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Percutaneous Intra-operative
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Pulmonary Vein Isolation
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Arctic Front®
CARTO
CARTOMERGE
T-VAC™
Selective venography
Percutaneous AF Ablation TechniquesUsed in Plymouth
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Electrical Isolation of a Pulmonary Vein
Atrial p waveStill enteringPulmonary V
Pulmonary V‘Fenced off’from rest of Atrium
When isolatedP waves can’t get inPV triggers can’t get out
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Isolated Pulmonary Vein Potential
A trigger fires in the pulmonary veinbut does not get out in to the atriumand Sinus Rhythm continues undisturbed
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Randomised controlled trial over one year- 70 patients / AF frequency > 3 mths / no previous AA drugs
- PVI ablation(s) (n = 33) versus AA drugs (n = 37)
End-points: PVI AADs p
Recurrence of AF (>1) 13% 63% < 0.00
Hospitalisations 9% 54% < 0.001
Quality of life (6 mths) better worse
Quantifying the effectiveness of AF Ablation
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Efficacy of catheter ablation in patients with AF
Calkins H et al. Circ Arrhythm Electrophysiol 2009;2:349-
361
Copyright © American Heart Association
Treatment of atrial fibrillation with antiarrhythmicdrugs or radiofrequency ablation: two systematic literature reviews and meta-analyses
International
success rate from
single procedure =
72% (freedom from AF on or
off drugs)
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72 Patients
Minimum 6 month Follow-Up Data on 31
CLASS 1 2 3 4 % SUCCESS
PAF 18 10 4 3 1 78%
PeAF 13 6 3 1 3 69%
TOTAL 31 16 7 4 4 73%
Single operator data – GAH
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1995-2002 (N = 8,745) Patient N %Death 4 0.05
Tamponade 107 1.22
Stroke 47 0.66
PV Stenosis (symptomatic) 41 0.57
Permanent diaphragmatic paralysis
10 0.11
International data - 2010 updateOverall – serious complication rate 4.5%Death 0.15%
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Point by point ablation (up to 2009) – no
deaths, no long term adverse outcomes, no
tamponade, no strokes with detectable long
term disability
Duty Cycled RF (from 2009) - Complications: 1 patient with seizures following barbiturate withdrawal post procedure – full recovery, Tamponade 0, Stroke 0, Death 0
Comparison complication rates for AF management on long term antiarrhythmic drugsMajor complications 30%, Death 2.8%
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10
8
6
4
2
0
Prevale
nce (
%)
50-59 60-69 70-79 80-89
12
8.8
4.8
1.80.5
Wolf PA, et al. Stroke (1991) 22: 983
Framingham study
Torbay dataClin Med 2009; 3: 219-23
Age distribution of patients
with Atrial Fibrillation
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• Linear RF Ablation Catheter• 6 Platinum electrodes• Deflectable curve
In Vitro testing of linear ablation lesion
TVAC
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•Targeting of Complex Fractionated Atrial Electrograms in addition to WACA & linear lesions
Tsai W J Card Electrophysiol 2010: 21-6
TVAC
Hunter R et al. Heart 2010; 96:1372-8
74% PVI + CFAEs v. 45% PVI only @ 1 year Verma STAR-AF EHJ 2010; 31: 1344-56
With substrate modification
Without substrate modification
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80% PAF asymptomatic 69% Persistent AF asymptomatic 23% Persistent AF no better 25% “Re-do rate” No long-term procedural complications:
One severe contrast reaction before resulting in cardiac arrest and admission to ITU for 24 hours
Two groin haematoma One pericardial effusion – no drainage required Un-explained general weakness with full recovery - ?
related to GA
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Ablation Frontiers2009
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0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 proj
No
. o
f P
roc
ed
ure
s
Year
AF Ablations Plymouth
DRT
GAH
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After correction for co-morbiditiesestimated 1.5 fold excess mortalityattributable to AF
Prognostic Impact
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589 ablated vs 582 AAD for rhythm control
Non-randomised Pappone C, JACC 2003
CABANA study – randomized mortality trialDue to start reporting 2012 – full results 2015Non randomised report AHA 2011 –Stroke reduction with AF Ablation
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AV node Ablation
Ablate and Pace - Palliative
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Ablate and Pace OutcomesWood MA Meta analysis Circulation 2000 101 1138-44
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Reviewed AF prevention Trials including DAPPAF, ASPECT, OASES, ADOPT, ATTEST
Conclusion: ‘ At present, permanent pacing to prevent AF is not indicated’
Role of Permanent Pacing to PreventAtrial Fibrillation (AHA Advisory Statement)Circulation 2005; 111:240-243
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UltraCinch
UltraWand
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European Society ofCardiology Guidelines2010 Camm J et al.
European Heart Journal(2010) 31, 2369–2429www.escardio.org
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Symptomatic Paroxysmal or Pesistent AF
Failure to respond to one or more antiarrhythmicdrugs (Flecainide, Sotalol, Propafenone, Amiodarone, Disopyramide, Dronedarone)
Absence of severe co-morbidities or significant structural heart disease
Age < 70
LA diameter < 55 mm
AF duration < 5 years
Oral H, Morady F. Heart Rhythm 2006; 3: 615-618
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• Atrial fibrillation ablation is an established technique with overall effectiveness in PAF of approximately 80%
• Efficacy is lower the longer the duration of persistent AF but in selected cases is 65 – 75%
• New technologies are developing and showing promise
• The technique should be reserved for patients with drug refractory symptoms sufficiently severe to adversely affect quality of life