Download Cardiac Resynchronization Therapy for HF

Atrial Fibrillation Ablation:
My personal experience 2000-2008
Helmut Pürerfellner
MD, Assoc. Prof.
Division of Cardiology
St.Elisabeth´s Sisters
Hospital
Academic Teaching
Center
Linz/Austria
Rationale for Catheter ablation of AFib:
Poor drug efficacy
Pulmonary vein potentials (PVP)
Right atrium
Superior
caval Vein
Left atrium
Septum
17
31
Pulmonary Veins
Fossa
ovalis
6
Inferior
caval vein
Coronary
Sinus
11
… critical zone
Microreeentrant
circuits
Sueda
Ann Thorac Surg 1997
LOM
Haissaguerre
NEJM 1998
PV foci
Hwang
Circulation 2000
Ablation of AFib Techniques
Trigger approach:
Substrate approach:
• Focal (within PV)
• Circumferential atrial
• Segmental ostial
• Additional lines (roof, mitral
isthmus)
• Substrate mapping (CAFE,
DF)
• Ganglionated plexus (GP)
• Tailored approach
PV-Angiographie (LIPV)
Lasso Catheter
Deflectable Tip
(B curve)
Atraumatic tip
Different loop
diameters available
Micro-catheter loop
featuring 10
electrodes (3F)
Ablation LIPV
PV-Diskonnektion
… critical zone
Microreeentrant
circuits
Sueda
Ann Thorac Surg 1997
LOM
Haissaguerre
NEJM 1998
PV foci
Hwang
Circulation 2000
Ablation of AFib Techniques
Trigger approach:
Substrate approach:
• Focal (within PV)
• Circumferential atrial
• Segmental ostial
• Additional lines (roof, mitral
isthmus)
• Substrate mapping (CAFE,
DF)
• Ganglionated plexus (GP)
• Tailored approach
PV-Antrum (CT/ICE)
Wide areas circumferential ablation (WACA)
(+ left atrial lines± ostial ablation)
SOI vs WACA
Oral et al, Circulation 2003; 108:2355-60
• Decrease in local atrial
electrogram amplitude >50%
or amplitude <0,1mV
(voltage abatement)
• Additional ablation within
circumferential lines in 32%
SOI vs WACA
Oral et al, Circulation 2003; 108:2355-60
Success rates (extraostial)
Complication rates (extraostial)
AFib-Ablation Elisabethinen Hospital Linz
2001-2005
• Period 01/2001 – 05/2005
• N=200 Pat.
• Age 53±10 a
• 82%m, 18%f
Arrhythmia
• Paroxysmal: n=162 (81%)
• Persistent: n=32 (16%)
• Permanent: n=5 (2,5%)
Procedures
•
N=276
•
Procedures:
1. Lasso (segmental ostial)
2. Pappone (circumferential)
3. Combi (circumferentiell + ostial)
4. Mixed
Follow up
• Fu after 1 month (clinical examination, 24h-HolterEKG, QOL)
• In hospital Fu at 3, 6 und 24 months (clinical
examination, Holter/Monitor, Echo, stress test,
Spiral-CT, TEE, QOL; Lung scan and MRI as
needed)
Classification of success
• Complete :
0 recurrences, 0 drug
• Partial:
0 recurrences, + drug
• failure:
+ recurrences, + drug
• Clinical response: complete + partial success
Success/patient
AFib paroxysmal
JICE 2007
Study design
• 40 consecutive patients (56.4 ± 9.6 y; 36 male)
Multislice computed tomography imaging
• 16-slice MSCT
• Non ionic contrast agent
• Caudocranial scanning
• Exspiratory breath-hold
• Barium contrast (esophagus)
Electroanatomic mapping
• 4-mm irregated tip
quadripolar catheter
• Contact mapping of
LA and PVs
• EAM and MSCT
displayed next to
each other
Allignment of MSCT and EAM
• Landmark registration
• Visual allignment
• Surface registration
AF ablation procedure
• Circumferential
approach
(Pappone C et al., Circulation
2000;102(21):2562-4)
• PV-Isolation
(Haissaguerre M et al., N Engl
J Med 1998;339:659–65)
• Additional lines
Accuracy (position error)
4
3
2
1
Mean = 1.6mm
Mean = 2.3mm
0
PRE
POST
> No difference between SR and AF.
> Independent of number of points.
Studies
Position error:
2.3 ± 0.4 mm
(J Cardiovasc Electrophysiol, Vol. 17, pp. 341-348, April 2006)
Our results:
1,6 ± 1,2 mm (pre)
2,3 ± 1,8 mm (post)
Position error:
2.1 ± 0.2 mm
(Heart Rhythm 2005;2:1076 –1081)
Conclusion
• Integration of MSCT scanning into 3D EAM is
feasible and accurate.
• Cardiac rhythm during procedure has no influence
on the precision of fusion.
• Matching accuracy
ablations.
decreases
after
multiple
• Combining EAM and imaging methods might
provide easier, faster and more reliable ablation
procedures in AF.
INTRODUCTION
Does MSCT integration into 3D EAM …
• …lower complication rate of RF ablation?
• …improve of clinical outcome?
• …enhance procedural efficacy?
– Procedural duration
– Radiation times
METHODS
• 161 consecutive patients (134 male)
• Mean age 55.5 ± 9.5 y
• Multi-drug-resistant AF (2.4±1.1 failed AAD)
• Serial MSCT before and 3 months after ablation
• 24-hour Holter and patients questionnaire at 3
months after procedure
CartoXPTM vs. CartoMergeTM
CARTO
XP:
79 pts.
CARTO
Merge:
82 pts.
BASELINE CHARACTERISTICS
RESULTS - SAFETY
Zero PV stenosis in the
CartoMERGE group
Procedure-related Complications
9
versus
Severe adverse events in
total considerably reduced
(8 vs. 2; p=0.043).
Number of Patients
Five in the conventional
group (p=0.021).
8
7
6
Phrenic Nerve Injury
5
Pericardial Effusion
4
TIA/Cerebral Infarction
3
PV-Stenosis
2
1
0
XP
Merge
Procedure Type
RESULTS - OUTCOME
Verfahrensart
60
XP
Merge
Overall success after
50
3 months:
- CARTO XP 71%
Percent
- CARTOMerge 87.5%
40
30
p = 0.019.
20
Martinek et al, PACE 2007
10
0
failure
full success
success on drugs
Outcome
nach
Monaten
Outcome
at 33 months
RESULTS - EFFICACY
CONCLUSION
MSCT image integration into 3D EAM …
… significantly improves safety …
… significantly enhances success …
of WACA with confirmed PV isolation and
additional lines.
Image Integration
AFib Ablation Lesion Sets
Are you sure you know what you are
doing ?
Journal of Cardiovasc Electrophysiol 2007
Catheter Ablation of AF 2008 –
Open issues
• AF as first-line treatment (RAAFT, CACAF, APAF)
• Persistent/long standing persistent AF („chronic AF“)
• Energy Source/Catheter design
• Remote navigation
• Vs AAA (CABANA), vs A+P (PABA-CHF)
• AF and CHF
• Mortality (CASTLE-AF)
• Cost-effectiveness