Download ABLACION POR RADIOFRECUENCIA DE LA

RADIOFREQUENCY ABLATION
OF FIBRILLATION: What
clinicians should know.
DR CARLOS LABADET
Electrophysiology Sector
Dr. Cosme Argerich Hospital
WHAT ARRHYTHMIAS ARE
CURED?
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Wolff-Parkinson-White syndrome
Supraventricular paroxysmal tachycardia
Atrial flutter
Atrioventricular node
Atrial tachycardias
SUCCESS 90 - 100 %
ADVANCEMENTS IN ABLATION
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ATRIAL FIBRILLATION
VENTRICULAR TACHYCARDIAS
VENTRICULAR EXTRASYSTOLE
ATYPICAL ATRIAL FLUTTERS
Sucess…~
70%
ATRIAL FIBRILLATION
Problems
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Increase in mortality!
Embolism and stroke
Hospitalization
CHF: lack of atrial systole
Cardiomyopathy by tachycardia
• Left atrial (LA) dilatation by AF
• Chronic anticoagulation
• Chronic symptoms of AF (palpitations, fatigue,
etc.)
HOW TO AVOID THIS WITH AN “ANTIARRHYTHMIC”
DRUG??
Degenerative
Age
Increase of LA
diseases
LV systolic
dysfunction
Tachycardia begets
more tachycardia
Obesity
ATRIAL
FIBRILLATION
Atrial fibrosis
LV diastolic
dysfunction
HTN
Inflammation
Toxic
Metabolic syndrome
Genetic
Diabetes
Sleep apnea
Pericardial fat
Endocrinological disorders
Respiratory
disorders
Spanish Registry of Ablation 2007
Rev Esp Cardiol 2008;61:1287
Male, 26 years old, he consults due to palpitations
Male, 40 years old,
no heart disease, palpitations
5h
ORAL PROPAFENONE 450 mg
AF: WHAT IS THE MECHANISM
• AF is started by focused triggers, 95% in
the pulmonary veins (PV)
• AF is perpetuated by multiple
microreentries or “rotors”
• Dominant rotors locate in the PV-LA
junction
• Vagal impulse can trigger and maintain AF.
There are vagal ganglionic areas in the
PV-LA junction.
MECHANISM OF AF AND OBJECTIVES
OF ABLATION
Anatomia
e Histologia
de venas
pulmonares
Anatomy
and histology
of pulmonary
veins
LSVP
Myocardial bands
LA
FOCUSED TRIGGERS IN PULMONARY VEINS
Haissaguerre et al. Circulation 1997;95:1120
TECHNIQUE OF ELECTRIC DISCONNECTION
OF PULMONARY VEINS
LSPV
LIPV
CIRCUNFERENTIAL ISOLATION
RSPV
LSPV
RIPV
LIPV
ANTRUM
PRE-RF LSPV
VP
S
POST-RF LSPV
PRE
ABLATION
POST
ABLATION
120 mseg
DESCONEXION ELECTRICA VP-AI
A
V
A
V
A
V
A
V
REGISTRO DE VENAS PULMONARES
FA
Ablación unión VP-AI
A
A
A
A
PULMONARY VEIN ABLATION –
Potential mechanisms
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PV and foci isolation
Removal of focused triggers
Modification of substrate
Autonomic denervation (vagal plexi)
AF ABLATION IN REFERENCE
CENTERS
RESULTS
ABLATION OF
AF RECURRENCE
Pappone et al J Am Coll Cardiol 2003;42:185–97)
70% success
50% 2nd RFA
2-3% complic.
NEJM 2004;351:2373
(AFFIRM type) >65 y.o.+ HTN-Diab-CHF-ACV-LVEF<40%
EF>40 SR
EF<40 SR
EF>40 AF
EF<40 AF
STROKE /YEAR: SINUS RHYTHM
AF
Nademanee JACC 08,50:843
0.4%
2%
European
Guidelines
of Cardiology 2010
AF ABLATION IN
THE REAL
WORLD
COMPLICATIONS
Circulation 2005;111:1100
• 162 centers with 45,115
procedures in 32,569
pts.(1995-2006) Mortality at
30 days = 0.98/1,000 pts.
SPANISH REGISTRY OF ABLATION 2007
1,624 accessory pathways: mortality =
1/1000
2,065 nodal reentry: mortality = 0.5/1000
JACC 2009;53:1798
Spanish Registry of Ablation 2007
Complications
Rev Esp Cardiol 2008;61:1287
CURRENT INDICATIONS OF AF
ABLATION
Post-AF ablation – immediate
control
• Remain with anticoagulation for 1-3
months
• During first 72 hs pericarditis may appear
(fever, precordial pain, effusion, evaluate
by echo)
• PAF commonly appears as an effect of rF
• Discharge at 24-48 h
• Maintain antiarrhythmic agents during the
first 1 to 3 months
Post-AF ablation
Long term
• Patients may present left AF or AFl during the
first 3 months, not associated to subsequent
recurrene.
• The most severe complication: atrioesophageal
fistula (0.01%). It appears between the first and
second week: fever, bacteriemia, leukocytosis,
epigastric pain, neurological
focus=hospitalization=NMR or CT=NONendoscopic surgery or contrast study.
Post-AF ablation
Long term
• PV stenosis: around 1%: between the 2nd
and 5th months: dyspnea, cough,
hemoptysis, chest pain
• Severe stenosis of a vein or multiple veins
• Angioplasty with stent
3-D navigation system of AF ablation
LA
USEFULNESS OF 3-D NAVIGATORS
VPSI
VPSD
LAA
VPII
Catéter circular
Catéter de ablación
AF ablation: Who are the main
candidates?
• PAROXYSMAL or PERSISTENT AF <1
year, symptomatic, recurrent with drugs.
• Age <65 years old
• Minimal or no heart disease
• Left atrium <50 mm
CONCLUSIONS
• The patients with paroxysmal forms of AF and
with minimal heart disease obtain the greatest
results with radiofrequency ablation.
• Those wiht persistent forms greater than 1 year
or permanent, require more prolonged
procedures and frequently require a second
ablation.
CONCLUSIONS
• Although the information comes from
observational studies, those with AF + left
ventricular dysfunction present an
improvement in ejection fraction
• Currently, studies on heart failure and
ventricular impairment are being
developed to assess this phenomenon.
Thank you for your
attention!!