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Circumferential Electroanatomical Ablation around PV Ostia • 3D-electroanatomic maps (CARTO™ System) showing pre- and post-ablation electrical activity • Endpoint is complete electrical isolation of left atrium Pre-ablation Post-ablation Point by point RF lesions Delayed activation reproduced with permission, Pappone C, et al. Circulation (2001) 104: 2539 CARTOMERGE™ Image Integration Software Module Combines 3D-electroanatomic mapping with CT or MR images by the following steps: 1. Import pre-acquired MRI or CT scan images from radiology scanners and workstations 2. Process the MRI or CT images on the CARTO™ XP in order to select the chambers of interest 3. Register the selected chamber in order to “merge” the processed image with electroanatomical map from CARTO™ XP CARTOMERGE™ Image Integration Software Module – Very precise guidance – Visualization of anatomic variations – Identification of different cardiac structures and chambers of interest AP view PA view PV Antrum Isolation Guided by CARTOMERGE™ Image Integration Software Module RUPV LUPV RMPV LA AC RLPV LLPV Courtesy of Professor Antonio Raviele, Mestre, Italy Endocardial Section Before and After RF Ablation - LPV LUPV LUPV LAp LAp LLPV LLPV Identification of the left mitral appendage ridge Courtesy of Professor Antonio Raviele, Mestre, Italy Endocardial Section Before and After RF Ablation - RPV RUPV RUPV RLPV RMPV RLPV RMPV Courtesy of Professor Antonio Raviele, Mestre, Italy Navigation Directly Within the CT/MRI Image using CARTOMERGE™ Image Integration Software Module Superimposed Anatomical CT Information and CARTO™ System Electroanatomical Map 3. Technological Aspects Cardiac Imaging Techniques Cardiac Imaging Techniques • Fluoroscopy • Angiography • Intracardiac echography • Cardiac spiral CT • Cardiac MRI 3. Technological Aspects Cardiac Imaging Techniques – fluoroscopy and angiography Catheter Visualization under Fluoroscopic Guidance Right upper PV RA catheters Transseptal sheath Catheter Visualization under Fluoroscopic Guidance Ablation catheter LAO LASSO® RAO Angiographic Visualization of LUPV reproduced with permission, Haïssaguerre M, et al. N Engl J Med (1998) 339: 659 3. Technological Aspects Cardiac Imaging Techniques – Intracardiac Echocardiography (ICE) Intracardiac Echocardiography (ICE) • Visualization of – Transseptal puncture – PV anatomy – Ostium diameter – Circular mapping catheter • Monitoring of ablation – Energy delivery – Tissue catheter interface – Thrombus/char formation • PV Doppler flow to assess for narrowing Transseptal Puncture Visualized by ICE Courtesy of Professor Antonio Raviele, Mestre, Italy ICE: PV Anatomy Location of left upper and lower PVs LA LLPV LLPV LUPV LUPV Courtesy of Professor Antonio Raviele, Mestre, Italy ICE: PV Anatomy Visualization of PV anatomy: left common ostium Courtesy of Professor Antonio Raviele, Mestre, Italy ICE: PV Anatomy Visualization of PV anatomy: right pulmonary veins RSPV RIPV Courtesy of Professor Antonio Raviele, Mestre, Italy ICE: PV Anatomy Visualization of PV anatomy: RSPV, LSPV and LA Posterior wall Courtesy of Professor Antonio Raviele, Mestre, Italy Correlation between ICE and Spiral CT Carena between left PVs LASSO® ICE Spiral CT Courtesy of Professor Antonio Raviele, Mestre, Italy PV Anatomy and Circular Mapping Catheter Positioning PV Ostium: Correlation Angiography-ICE in 19/125 PV (15%) LASSO® LASSO® Marrouche NF, et al. Circulation (2003) 107: 2710 Monitoring of RF Energy Delivery RF energy titration Scattered microbubbles Brisk shower of microbubbles Courtesy of Professor Antonio Raviele, Mestre, Italy Visualization of Endothelial and Subendothelial Injury Courtesy of Professor Antonio Raviele, Mestre, Italy Early Detection of Complications Monitoring of thrombus/char formation Soft thrombus on transseptal sheath Courtesy of Professor Antonio Raviele, Mestre, Italy Esophagus Location as imaged by ICE Esophageal contrast Courtesy of Professor Antonio Raviele, Mestre, Italy 3. Technological Aspects Cardiac Imaging Techniques – CT and MRI Cardiac CT Imaging – Epicardial and Endocardial Views Cardiac CT and MRI Imaging – Epicardial Views 3. Technological Aspects Future Technologies The EP Lab of the Future CARTO™ RMT System • Integrated system incorporating the Niobe™ steering system with the CARTOTM XP Navigation System • Magnetic remote control technology • Operator located away from X-ray exposure, not requiring lead vests Niobe® is a trademark of Stereotaxis, Inc Magnetic Remote Controlled Ablation • Niobe-Artis™ – Magnetic remote control navigation – CARTO™ RMT System (Magnetic Compatible CARTO™ XP System) – Operates in the Niobe-Artis environment in stowed or active positions – Ability to use standard NAVISTAR® Catheters The third-party trademarks used herein are trademarks of their respective owners Summary • Catheter ablation for AFib has undergone significant methodological and technical revolution since its initial appearance two decades ago • Discovery that PVs are a major source of ectopic triggers was pivotal in determining efficacy of procedure • Significant technological advances in catheters and imaging are further improving the efficiency of catheter ablation • 3D reconstructions of actual left atrial PV anatomy using CT, MRI, or intracardiac echography enables ever more accurate placement of lesions 4. Success Rates with Catheter Ablation Clinical Outcomes with Catheter Ablation 1. Meta-analyses, worldwide survey, results from pioneering centres 2. Comparative studies: • Non-randomized and randomized controlled trials Success Rates with Catheter Ablation 1. Meta-analyses, worldwide survey, results from pioneering centres Meta-analysis of Catheter Ablation Studies (I) Patients Paroxysmal AF SHD Linear 443 75% 26% 33% 55% Focal 508 81% 35% 54% 71% 2,187 83% 36% 62% 75% Circumferential (all) 15,455 68% 37% 64% 74% Circumferential (LACA, WACA) 2,449 65% 37% 59% 72% Circumferential (PVAI) 11,132 68% 42% 67% 76% 559 51% 49% 75% 87% 23,626 61% 55% 63% 75% Ablation method Isolation Substrate ablation (CFAE) TOTAL 6-month cure 6-months OK Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the absence of AAD. OK means improvement (fewer episodes, no episodes with previously ineffective AAD). SHD indicates structural heart disease. Fisher JD, et al. PACE (2006) 29: 523 Meta-analysis of Catheter Ablation Studies (II) Condition / Type of AFib Patients Paroxysmal AFib SHD 1,026 86% 3% 81% 72% 350 29% 100% 74% 79% Paroxysmal AFib 3,880 100% 23% 64% 73% Persistent – Permanent AFib 3,741 0% 82% 66% 74% No structural HD Structural HD 6-month cure 6-months OK Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the absence of AAD. OK means improvement (fewer episodes, no episodes with previously ineffective AAD). SHD indicates structural heart disease. Fisher JD, et al. PACE (2006) 29: 523 Worldwide Survey on Efficacy and Safety of Catheter Ablation for AFib Worldwide Survey on the Methods, Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation Cappato, R, Calkins, H, Chen, S-A, et al. Circulation (2005) 111: 1100 • Types of AFib treated by catheter ablation – Paroxysmal AFib - 100% of centers – Persistent AFib - 53% of centers – Permanent AFib - 20% of centers Worldwide Survey on Efficacy and Safety of Catheter Ablation for AFib • Total success rate: 76% • Of 8745 patients: – 27.3% required 1 procedure – 52.0% asymptomatic without drugs – 23.9% asymptomatic with an AAD within <1 yr • Highly variable outcome between centres Cappato R, et al. Circulation (2005) 111: 1100 Results from Pioneering Centres • Total success rate: 75-88% SHD, % Tool(s) AF Free (Off drugs), Follow-up, End point % d Study Year Ouyang et al 2004 41 63 ± 9 100 NA CARTO PV Isolation 76 178 Haïssaguerre et al 2004 70 53 ± 8 NA 43 Fluoro PV Isolation 79 210 Mansour et al 2004 40 55 ± 10 80 13 CARTO PV Isolation 75 330 Marrouche et al 2003 259 54 ± 11 51 21 ICE PV Isolation 87 347 Oral et al 2003 40 3 CARTO EGM Reduction 88 365 Pappone et al 2003 589 6 CARTO EGM Reduction 79 861 Total Follow-up Age, y Parox, % 1039 54 ± 11 100 65 ± 9 69 81.0 Verma A & Natale A Circulation (2005) 112: 1214 Success Rates with Catheter Ablation 2. Comparative studies: Non-randomized, controlled trials Non-Randomized Trials Mortality, Morbidity, and Quality of Life after Circumferential Pulmonary Vein Ablation for Atrial Fibrillation Fibrillation Outcomes from a Controlled Nonrandomized Long-term Study Pappone, C, Rosanio, S, Augello, G, et al. J Am Coll Cardiol (2003) 42: 185 • 1,171 consecutive patients with symptomatic AFib enrolled between 1998 and 2001 • 589 ablated patients were compared with 582 who received antiarrhythmic medications for SR control Improved Survival with Catheter Ablation vs Drug Treatment Ablation Group Medical Group Survival probability (%) 100 90 Expected Observed 80 70 60 One-sample log-rank test Obs=36, Exp=31, Z=0.597, p=0.55 0 0 180 360 540 720 900 Days of follow-up One-sample log-rank test Obs=79, Exp=341, Z=7.07, p<0.001 1080 0 180 360 540 720 900 1080 Days of follow-up Pappone C, et al. J Am Coll Cardiol (2003) 42: 185 More AFib-Free Patients with Catheter Ablation vs Drug Treatment AFib-free survival probability (%) 100 80 60 40 Ablation Group Medical Group 20 0 0 100 200 300 Follow-up (days) No. at risk Ablation 589 507 479 379 282 217 135 Medical 582 456 354 277 207 141 97 Pappone C, et al. J Am Coll Cardiol (2003) 42: 185 Catheter Ablation has a Beneficial Effect on Cardiac Function Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure Hsu, L-F, Jaïs, P, Sanders, P, et al. N Engl J Med (2004) 351: 2373 • Evaluation of left ventricular function and dimensions, symptom score, exercise capacity, and quality of life in 58 consecutive patients with congestive heart failure (CHF) who were undergoing catheter ablation for AFib versus 58 patients without CHF who were undergoing ablation Significantly Improved Cardiac Function, Symptoms, Exercise Capacity, and QoL p<0.001 60 p<0.001 p<0.001 p<0.001 40 20 40 LV fractional shortening (%) LV ejection fraction (%) 80 0 1 3 6 20 10 12 0 1 3 6 12 60 p=0.001 70 p=0.03 p=0.02 p=0.001 60 50 40 0 1 3 Month 6 12 LV end-systolic diameter (%) 80 LV end-diastolic diameter (mm) 30 p<0.001 p<0.001 p<0.001 0 0 0 p<0.001 p<0.001 p<0.001 p=0.001 p=0.001 50 40 30 0 0 1 3 6 12 Month Hsu LF, et al. N Engl J Med (2004) 351: 2373 Success Rates with Catheter Ablation 2. Comparative studies: Randomized controlled trials Recent Randomized Clinical Trials of Catheter Ablation RF ablation vs AAD as first-line treatment for AFib • Wazni OM et al. JAMA (2005) 293: 2634-2640 Catheter ablation in drug-refractory AFib • Stabile G et al. Eur Heart J (2006) 27: 216-221 Circumferential PV ablation for chronic AFib • Oral H et al. N Engl J Med (2006) 354: 934-941 Randomized Clinical Trial of RF Ablation vs Antiarrhythmic Drugs Radiofrequency Ablation vs Antiarrhythmic Drugs as First-line Treatment of Symptomatic Atrial Fibrillation A Randomized Trial Wazni, OM, Marrouche, NF, Martin, DO, et al. JAMA (2005) 293: 2634 • Multicentre, prospective, randomized study of 70 patients with monthly symptomatic AFib episodes for at least 3 months not treated with AADs • Patients were randomized to receive either PVI using RF ablation (n=33) or AAD treatment (n=37), with 1-year follow-up Pulmonary Vein Isolation Considered as First-line Treatment of Symptomatic AFib 233 Patients Screened 163 Excluded 132 Did not meet criteria 31 Refused 70 Randomized 33 Assigned to receive PV isolation 37 Assigned to receive AADs 1 Lost to follow-up 2 Lost to follow-up 32 included in primary analysis 35 included in primary analysis Wazni OM, et al. JAMA (2005) 293: 2634 Baseline Characteristics Characteristics Age, mean (SD), y Pulmonary Vein Isolation Group (n=33) Antiarrhythmic Drug Group (n=37) 53 (8) 54 (8) 4.1 (0.8) 4.2 (0.7) 5 (2.0) 5 (2.5) 32 (97) 35 (95) 1 (3) 2 (5) Structural heart disease and hypertension 8 (25) 10 (28) Left ventricular ejection fraction, mean (SD),% 53 (5) 54 (6) Use of β-blocker therapy 19 (57) 23 (62) Left atrial size, mean (SD), cm Duration of atrial fibrillation, mean (SD), months Atrial fibrillation Paroxysmal Persistent *Data are presented as No. (%) unless otherwise specified Wazni OM, et al. JAMA (2005) 293: 2634 One-Year Follow-up Results by Treatment Group No. (%) of Patients Characteristics Symptomatic atrial fibrillation recurrence Pulmonary Vein Isolation Group (n=32) Antiarrhythmic Drug Group (n=35) p value 4 (13) 22 (63) <0.001 3 (9) 19 (54) <0.001 0 0 NA 2 (6.3) 1 (2.9) 0.60 0 3 (8.6) 0.20 Mild 1 (3) 0 0.50 Moderate 1 (3) 0 0.50 0 0 NA Hospitalization Thromboembolic events* Bleeding Bradycardia Pulmonary vein stenosis† Severe NA = not applicable. *Defined as transient ischemic events, stroke, deep vein thrombosis, or pulmonary embolism. †Mild pulmonary vein stenosis is defined as less than 50%; moderate, 50% to 70%; and severe, more than 70%. Wazni OM, et al. JAMA (2005) 293: 2634 Kaplan-Meier Curve of AFib-Free Survival AFib.free survival 1.0 0.8 0.6 0.4 PVI Group Antiarrhythmic Drug Group 0.2 0 0 100 200 300 Follow-up (days) No. at risk PVI Group 32 28 28 28 28 28 28 Antiarrhythmic Drug Group 35 343 23 19 13 13 13 Wazni OM, et al. JAMA (2005) 293: 2634 AFib Event Recordings Pulmonary Vein Isolation (n=4) Antiarrhythmic Drugs (n=4) Study Initiation Study Completion Study Initiation Study Completion Corrected difference in mean change (95% CI) 13 (6) 1 (2) 12 (7) 6 (4) -6 (-13 to 1) 0.05 Duration of episodes, mean (SD), s 480 (30) 15 (12) 520 (40) 45 (15) 10 (-7 to 27) 0.63 Ventricular rate, mean (SD), beats/min 138 (26) 126 (18) 126 (35) 92 (21) 22 (16 to 28) 0.001 0 2 0 16 No. of episodes, mean (SD) Time patients are in asymptomatic episodes of AF, % p value AF = atrial fibrillation; CI = confidence interval Wazni OM, et al. JAMA (2005) 293: 2634 Quality of Life Assessment Pulmonary Vein Isolation Group (n=32) Antiarrhythmic Drug Group (n=35) Baseline Follow-up Baseline Follow-up Corrected difference in mean change at 6 mo (95% CI) General health 57 (2) 9 (1) 57 (2) 68 (2) 11 (8 to 14) <0.001 Physical functioning 71 (3) 97 (3) 69 (2) 75 (7.5) 20 (13.2 to 24.2) 0.001 Role physical 73 (5) 71 (2) 51 (5) 53 (3) 14.9 (9.9 to 19.9) 0.047 Bodily pain 71 (3) 97 (1) 70 (3) 90 (3) 6 (1.5 to 9.5) 0.004 Mental health 65 (4) 65 (2) 64 (2) 68 (3) -4 (-3.5 to -7.5) 0.62 Social functioning 78 (3) 93 (3) 76 (3) 82 (2) 9 (7.5 to 11.5) 0.004 Role emotional 70 (1) 76 (1) 70 (1) 75 (1) 1 (−4.0 to 4.3) 0.90 Vitality 52 (4) 65 (1) 51 (1) 60 (2) 4 (1.7 to 5.7) 0.21 Short-Form 36 Subscale p value CI = confidence interval. *Quality of life was assessed using the Medical Outcomes Study 36-item Short-Form health survey (Short-Form 36) and was measured at enrollment and 6-month follow-up visit. Wazni OM, et al. JAMA (2005) 293: 2634 Randomized Clinical Trial of Catheter Ablation in Drug-Refractory AFib Catheter Ablation Treatment in Patients with Drug-refractory Atrial Fibrillation: a Prospective, Multi-centre, Randomized, Controlled Study (Catheter Ablation For The Cure Of Atrial Fibrillation Study) Stabile, G, Bertaglia, E, Senatore, G, et al. J Eur Heart J (2006) 27: 216 • Multicentre, prospective, controlled, randomized trial to investigate the adjunctive role of ablation to AAD therapy in preventing AFib relapses in patients with paroxysmal or persistent AFib in whom AADs had already failed. Catheter Ablation vs. AADs Alone in Drug-refractory AFib Prospective, multicentre, randomized, controlled trial Patients with AFib (n=137) AADs plus catheter ablation (n=68) AADs alone (n=69) 12 months 91.3% at least one arrhythmia occurrence 44.1% at least one arrhythmia occurrence Stabile G, et al. Eur Heart J (2006) 27: 216 Ablation Combined with AADs is Superior to AADs alone in Preventing AFib Recurrences 1 year follow up Ablation Group Medical Group AFib-free survival (%) 100 80 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Months Stabile G, et al. Eur Heart J (2006) 27: 216 Randomized Clinical Trial of Circumferential PV Ablation for Chronic AFib Circumferential Pulmonary-Vein Ablation for Chronic Atrial Fibrillation Oral, H, Pappone, C, Chugh, A, et al. N Engl J Med (2006) 354: 9 • Randomized, controlled study investigating efficacy of circumferential pulmonary vein ablation in maintaining sinus rhythm in patients with chronic AFib Randomized Controlled Trial of Amiodarone + Cardioversion + Catheter Ablation Long-term SR maintained in most patients with chronic AFib after PV ablation Patients with chronic AFib (n=146) Amiodarone & cardioversion plus PV ablation (n=77) Amiodarone & cardioversion (n=69) 12 months 3% AFib-free without AADs 74% AFib-free without AADs Oral H, et al. N Engl J Med (2006) 354: 9 Patient Characteristics Control (n=69) Circumferential pulmonary-vein ablation (n=77) 58 ± 8 55 ± 9* 62 67 7 10 4±4 5±4 Left atrial diameter (mm) 45 ± 5 45 ± 6 Left ventricular ejection fraction (%) 56 ± 7 55 ± 7 Structural heart disease (no. of patients) 6 6 - nonischemic cardiomyopathy 1 2 - coronary artery disease 4 3 - valvular heart disease 0 1 - congenital heart disease 1 0 No. of previously ineffective anti-arrhythmic drugs 2.1 ± 1.2 2.0 ± 1.2 No. of prior cardioversions 1.7 ± 1.0 2.2 ± 1.7 Characteristic Age (yr) Sex (no. of patients) - Male - Female Duration of atrial fibrillation (yr) Plus-minus value are means ± SD; *p=0.03. Oral H, et al. N Engl J Med (2006) 354:9 Sinus Rhythm Maintained in Majority of Patients Undergoing PV Ablation for Chronic AFib 100 Circumferential pulmonary-vein ablation Control Sinus rhythm (%) 80 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 Months Oral H, et al. N Engl J Med (2006) 354: 9 Summary of Published RCTs to date Type of AFib Ablation group Wazni et al. 2005 Symptomatic Stabile et al. 2006 Oral et al. 2006 Author Afib-free at 1 year Comparator n Ablation Comparator PV isolation AADs 70 87% 37% Drugrefractory Ablation + AADs AADs 137 56% 9% Chronic Ablation + amiodarone Amiodarone 147 78% 4% RCTs Presented as Abstract Type of AFib Ablation group Pappone et al. 2006 Paroxysmal Jais et al. 2006 Paroxysmal Author Afib-free at 1 year Comparator n Ablation Comparator Circumferential PV ablation AADs 198 84% 24% Ostial PV isolation AADs 112 75% 7% 4. Success Rates with Catheter Ablation Early Recurrence After Ablation Early Recurrence after Ablation • AFib episodes that occur early (ERAF) after ablation and do not persist beyond the initial weeks after the procedure are common and have been reported in 35-46% of patients with paroxysmal and persistent AFib Early Recurrences Post-Ablation • 35% within the first 15 days Cumulative percent of patients with recurrent AFib (%) 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 Time to 1st episode of AFib (days) Oral H, et al. J Am Coll Cardiol (2002) 40: 100 Catheter Ablation is Successful in the Long Term No ERAF ERAF Freedom from Recurrent AFib 1.0 0.8 0.6 0.4 0.2 0 0 2 4 6 8 10 12 Months after PV isolation Oral H, et al. J Am Coll Cardiol (2002) 40: 100 Clinical Significance of Early Recurrences of Atrial Fibrillation or Atrial Flutter after Pulmonary Vein Antrum and Superior Vena Cava Isolations Sakis Themistoclakis, Robert A. Schweikert, Walid I. Saliba, Jennifer E. Cummings, Aldo Bonso, Antonio Rossillo, Oussama Wazni, William A. Belden, Michelle Williams-Andrews, Dhanumjaya Lakkireddy, Antonio Raviele, Andrea Natale Division of Cardiology, Umberto I Hospital, MestreVenice, Italy Cleveland Clinic Foundation, Cleveland, OH American College of Cardiology 55th Annual Scientific Session, Atlanta, March 11-14, 2006 Predictors of Early Recurrence of AF/AFL Patient population: 1272/1495 pts ERAF NO ERAF Unadjusted OR P N = 497 N = 775 (95% CI) Age (y), mean (SD) 56.6 (10.8) 55.5 (11.1) 1.009 (0.998-1.019) 0.080 Gender, male, n (%) 394 (79.27) 589 (78.32) 0.933 (0.706-1.232) 0.626 Paroxysmal, n (%) 233 (46.88) 463 (59.74) Reference Persistent, n (%) 86 (17.30) 117 (15.09) 1.493 (1.075 – 2.075) 0.017 Permanent, n (%) 178 (35.81) 195 (25.16) 1.842 (1.419 – 2.391) < 0.001 Duration (y), mean (SD) 7.45 (6.47) 6.28 (5.31) 1.034 (1.011-1.058) 0.004 LA size, mean (SD) 4.42 (0.93) 4.42 (2.61) 1.001 (0.941- 1.065) 0.957 LVEF, mean (SD) 53.48 (8.43) 53.82 (8.58) 0.995 (0.981-1.009) 0.518 AF type American College of Cardiology 55th Annual Scientific Session, Atlanta, March 11-14, 2006 Long-term Outcome in Patients with and without ERAF/AFL Population: 1495 pts with follow up of 22±9.8 months 100 Arrhythmia free off AAD Late recurrences p<0.00001 87 80 (%) 60 52 48 40 20 0 13 ERAF/AFL No ERAF/AFL American College of Cardiology 55th Annual Scientific Session, Atlanta, March 11-14, 2006 Predictors of Late Recurrences in Patients with ERAF Patient population: 497 pts AF Rec No AF Rec Unadjusted OR P N = 228 N = 269 (95% CI) Age (y), mean (SD) 56.18 (10.7) 57.05 (10.88) 0.992 (0.976 – 1.009) 0.379 Gender, male, n (%) 179 (78.51) 216 (80.30) 0.896 (0.579 – 1.386) 0.623 Paroxysmal, n (%) 89 (39.03) 144 (53.53) Reference Persistent, n (%) 44 (19.30) 42 (15.61) 1.661 (0.997 – 2.769) 0.052 Permanent, n (%) 95 (41.67) 83 (30.86) 1.841 (1.233 – 2.748) 0.003 AF duration (y), mean (SD) 7.75 (6.38) 7.20 (6.54) 1.013 (0.980 – 1.046) 0.428 LA size, mean (SD) 4.58 (0.78) 4.29 (1.02) 1.458 (1.117 – 1.902) 0.005 53 (8.61) 53.89 (8.28) 0.987 (0.965 – 1.924) 0.266 AF type LVEF, mean (SD) American College of Cardiology 55th Annual Scientific Session, Atlanta, March 11-14, 2006 Clinical Implications of Early Recurrence after Ablation • Early recurrences of AFib are more frequent in patients with: – Persistent and permanent AFib – Longer history of AFib • ERAF do not necessarily predict the failure of the procedure • ERAF may be a transient phenomenon and often patients with ERAF have no further AFib during longterm follow up • Temporary AAD therapy may be more appropriate than an early repeat ablation procedure Mechanisms of AFib Recurrences after Ablation Presumed mechanism of ERAF • Transient stimulatory effect of RF (inflammatory response, abnormal acetylcholine release after damage of vagal nerve fibres ) • Delayed therapeutic effect of RF (growth of RF lesion) Oral H, et al. J Am Coll Cardiol (2002) 40: 100 Pappone C, et al. Circulation (2004) 109: 327 Delayed Cure Despite Early Recurrence After PV Isolation for AFib Delayed cure: early recurrence(s) of AFib with subsequent absence of AF beyond 3 months Acute cure (n=24) Delayed cure (n=10) Failure (n=16) Time frame Pre 3 mo Pre 3 mo Pre 3 mo Left atrial size (mm) 38 ± 2 37 ± 2 45 ± 4 42 ± 3* 46 ± 3 46 ± 3 105 ± 11 106 ± 15 137 ± 22 120 ± 26* 122 ± 17 128 ± 23 38 ± 10 33 ± 15 74 ± 26 56 ± 20* 68 ± 20 66 ± 25 P-wave duration (ms) P-wave dispersion (ms) *p<0.05 compared with preprocedure value. O’Donnell D, et al. Am J Cardiol (2003) 91: 83 Asymptomatic Recurrences after Ablation • A number of reports have suggested that current monitoring/evaluation methods after catheter ablation may overestimate success due to the presence of undetected asymptomatic recurrences • Trans-telephonic ECG monitoring has been shown to be effective in detecting AFib relapses: – Trans-telephonic ECG success rate: 72% – Standard ECG and 24-hour Holter recording success rate: 86% Neumann T, et al. Europace (2006) 8: 495 Senatore G, et al. J Am Coll Cardiol (2005) 45: 873 Hindricks G, et al. Circulation (2005) 112: 307 5. Complication Rates Meta-analyses, worldwide survey, results from pioneering centres Meta-analysis of Complications from Catheter Ablation Studies Proc Time* Repeat proc PV stenosis CVA TIA Other Linear 289 43% 0.3% 0.6% 0% 7.5% Focal 302 34% 0.6% 0% 0.2% 5.5% Isolation 278 21% 4.5% 1.1% 0.2% 1.7% Circumferential (all) 201 24% 1.2% 0.8% 0.4% 5.8% Circumferential (LACA, WACA) 174 9% 0.4% 0.3% 0.6% 8.9% Circumferential (PVAI) 209 26% 1.7% 1.1% 0.4% 16.8% Substrate ablation (CFAE) 194 22% 0% 0.2% 0% 1.2% TOTAL 212 25% 1.5% 0.7% 0.5% 5.2% Ablation method *Procedure time (min) Fisher JD, et al. PACE (2006) 29: 523 Meta-analysis of 7 Series Major complications with pulmonary vein ablation in 1049 patients (7 series) n=29 3.0 Occurrence (%) 2.5 2.0 1.5 n=13 1.0 0.5 0 n=8 n=5 Air emboli n=4 n=3 n=3 n=1 Tamponade Bradycardia CVA TIA Phrenic nerve PV stenosis PV dissect Packer DL, et al. J Cardiovasc Electrophysiol (2003) 14: S296 Worldwide Survey of Complications Reported in Catheter Ablation Studies Major complications Complication type Patients (n) Patients (%) 4 0.05 107 1.22 Sepsis, abscesses, or endocarditis 1 0.01 Pneumothorax 2 0.02 Hemothorax 14 0.16 Permanent diaphragmatic paralysis 10 0.11 Femoral pseudoaneurysm 47 0.53 Arterovenous fistulae 37 0.42 Valve damage 1 0.01 Aortic dissection 3 0.03 For all types of procedures (n=8745 patients) Periprocedural death Tamponade Cappato R, et al. Circulation (2005) 111: 1100 Worldwide Survey of Complications Reported in Catheter Ablation Studies Patients (n) Patients (%) For procedures involving left atrial ablation (n=7154 patients) Stroke 20 0.28 Transient ischaemic attack 47 0.66 - Acute 23 0.32 - Chronic 94 1.31 2 0.03 15 0.21 3 0.04 41 057 51 0.71 524 5.9 PV stenosis (No. with >50% stenosis) PV stenosis (No. with closure) - Acute - Chronic PV stenosis (Patients with symptoms) - Acute - Chronic PV stenosis (Patients undergoing intervention) - Percutaneous - Surgical Total Cappato R, et al. Circulation (2005) 111: 1100 Complications Reported by Leading Centres Major complications with pulmonary vein ablation in 1039 patients (6 series) Events (n) Rate (%) Range in studies (%) Transient ischaemic attack 4 0.4 0-3 Permanent stroke 1 0.1 0-1 Severe PV stenosis (>70%, symptomatic) 3 0.3 0-3 13 1.3 0-5 Tamponade / perforation 5 0.5 0-3 Severe vascular access complication 3 0.3 0-4 Complication Moderate PV stenosis (40-70%, asymptomatic) Verma A & Natale A Circulation (2005) 112: 1214 Cardiac Tamponade Cardiac Tamponade • 15/632 (2.4%) perforations requiring pericardiocentesis – Left atrium – 60% – Right atrium - 6.7% – Right ventricle - 33.3% • 2 patients required surgical closure • CONCLUSION: The incidence of perforation during ablation of the left atrium is low. Most perforations occur in the left atrium; however, few require surgical closure. Although less than with uncomplicated procedures, the majority of patients with complete ablations achieve long-term elimination of AFib. Bunch TJ, et al. J Cardiovasc Electrophysiol (2005) 16: 1172 Cardiac Tamponade • 348 consecutive AFib catheter ablations over 1 year (PVI plus linear lesion at mitral isthmus in 73% and tricuspid isthmus in 76%) – Tamponade occurred in 10 of the patients (2.9%) during the creation of linear ablation lesions • 398 consecutive AFib catheter ablations in the following year with RF power for linear lesions limited to < 42W – Tamponade occurred in 4 patients (1%) during the creation of linear ablation lesions Hsu LF, et al. PACE (2005) 28: S106 Thromboembolic Complications Thromboembolic Complications Cardiovascular Complication Associated with Pulmonary Vein Ablation Kok, LC, Mangrum, JM, Haines, DE, et al. J Cardiovasc Electrophysiol (2002) 13: 764 • 56 patients undergoing RF ablation for a focal source of AFib • Cerebrovascular event occurred in 3/56 (5%) • 2 with prior history of TIA Thromboembolic Complications • LA thrombus formation identified using ICE • Observed in 24/232 (10.3%) • Patients with LA thrombus: – Increased LA diameter (4.8 vs 4.5 cm) – Spontaneous echo contrast (67% vs 3%) – History of persistent AFib (29% vs 6%) • No patient (0%) with LA thrombus suffered a clinical thromboembolic complication Ren J-F, et al. J Am Coll Cardiol (2004) 43: 1861 Thromboembolic Complications Embolic events and char formation during pulmonary vein isolation in patients with atrial fibrillation: impact of different anticoagulation regimens and importance of intracardiac echo imaging Wazni, OM, Rossillo, A, Marrouche, NF, et al. J Cardiovasc Electrophysiol (2005) 16: 576 • 785 patients undergoing catheter-based PVI for treatment of drug refractory, symptomatic AFib Thromboembolic Complications Distribution of embolic events according to the anticoagulation protocol 10 Stroke/TIA 8 Patients (%) p=0.01 6 p=0.4 p=0.34 4 2 0 ACT 250-300 (194 pts) ACT 300-350+ INTEGRILIN ACT 350-400 (411 pts) (180 pts) Wazni OM, et al. J Cardiovasc Electrophysiol (2005) 16: 576 Thromboembolic Complications Bleeding complications Hematoma Pericardial effusion Tamponade ACT = 250-300 1 1 1 ACT = 300-350 + Epti 2 1 1 ACT = 350-400 2 0 0 ACT = activated clotting time; Epti = eptifibatide. Wazni OM, et al. J Cardiovasc Electrophysiol (2005) 16: 576 Thromboembolic Complications Distribution of embolic events according to the energy delivery strategy 8 Stroke/TIA Patients (%) 6 p=0.2 p=0.029 4 2 0 Ultrasound (33 pts) Temperature control (482 pts) ICE + Bubbles (270 pts) Wazni OM, et al. J Cardiovasc Electrophysiol (2005) 16: 576 Thromboembolic Complications • More aggressive anticoagulation with heparin reduced peri-procedural embolic events • The use of platelet inhibition does not have incremental beneficial effect • None of the anticoagulation protocols abolished char formation Wazni OM, et al. J Cardiovasc Electrophysiol (2005) 16: 576 Thromboembolic Complications • A high flow perfusion rate through sheaths (80 ml/h) and a higher concentration of heparin for the transseptal sheath (1000 units/cc) before deployment reduce the risk of thrombus formation and thromboembolic complications Cauchemez B, et al. J Cardiovasc Electrophysiol (2004) 15: 276 Maleki K, et al. J Cardiovasc Electrophysiol (2005) 16: 561 Pulmonary Vein Stenosis Pulmonary Vein Stenosis Pulmonary Vein Stenosis after Catheter Ablation of Atrial Fibrillation Robbins, IM, Colvin, EV, Doyle, TP, et al. Circulation (1998) 98: 1769 • First report in 1998 Pulmonary Vein Stenosis • Balloon inflation in ostium of left superior PV. Note severe stenosis at junction of PV with LA, as demonstrated by waist on 12-mm-diameter balloon. Robbins IM, et al. Circulation (1998) 98: 1769 Reported Frequency of PV Stenosis Linear ablation • Reported rates of between 2-7% Focal or segmental AF ablation • Gerstenfeld and coworkers reported an 8.3% occurrence of clinically relevant PV stenosis in an early series of 40 patients undergoing focal AFib ablation • Haïssaguerre et al reported a 5% occurrence rate but have recently suggested a decrease to 1% overall with additional experience in ablation • Pappone et al. reported a 1% PV stenosis rate with ablation limited to atrial tissue outside the PV orifice Packer D, et al. Circulation (2005) 111: 546 Reported Frequency of PV Stenosis • The prevalence of PV stenosis has decreased through a range of factors, including (1) abandonment of in-vein ablation at the site of the AFib focus (2) limiting ablation at or outside the orifice of the vessel (3) the use of ICE to guide catheter placement and monitor energy delivery (4) a reduction in target ablation temperature and the amounts of energy deliveries (5) increased operator experience Packer D, et al. Circulation (2005) 111: 546 Frequency of Severe Pulmonary Vein Stenosis Pulmonary Vein Stenosis after Radiofrequency Ablation of Atrial Fibrillation Functional Characterization, Evolution, and Influence of the Ablation Strategy Saad, EB, Rossillo, A, Saad, CP, et al. Circulation (2003) 108: 3102 • PV isolation performed in 608 patients • Electroanatomic approach used in 71 and circular mapping in 537 (distal isolation, 25; ostial isolation based on PV angiography, 102; guided by intracardiac echocardiography, 140; with energy delivery based on visualization of microbubbles, 270 • Severe (70%) narrowing detected in 21 patients (3.4%) Frequency of Severe Pulmonary Vein Stenosis Distribution of severe PV stenosis according to ablation strategy used to isolate PVs p=0.835 25 p=0.02 CARTO™ Circular mapping 20 20 15.5 (%) 15 p=0.029 10 5 2.9 1.4 0 Carto (n=71) Distal isolation Proximal Angio (n=25) (n=102) ICE (n=140) 0 ICE with Bubbles (n=270) Saad EB, et al. Circulation (2003) 108: 3102 Frequency of Severe Pulmonary Vein Stenosis • Real-time imaging is valuable in preventing severe PV stenosis • Continuous visualization associated with energy titration based on the generation of microbubbles contributes to successful proximal isolation of PVs • The incidence of severe PV stenosis seems to be declining with better imaging techniques to ensure ostial isolation and to guide power titration Saad EB, et al. Circulation (2003) 108: 3102 Pulmonary Vein Stenosis Presentation Clinical presentation and CT findings in patients with severe PV stenosis n (%) Patients 21 Clinical presentation - cough 8 (38.1) - dyspnea 11 (52.4) - pleuritic chest pain 6 (28.6) - hemoptysis 5 (23.8) - asymptomatic 8 (38.1) Spiral CT, >70% PV stenosis, No. occluded - LSPV 14 (6) - LIPV 15 (7) - RSPV 4 (1) - RIPV 3 (1) LS = left superior; LI = left inferior; RS = right superior; RI = right inferior. Saad EB, et al. Ann Intern Med (2003) 138: 634 Avoiding PV Stenosis in Patients Undergoing Ablation • Performing PVI on the atrial side, far away from PV ostium (more than 1.5 mm) as in the circumferential or antral approach, has dramatically reduced the incidence of severe PV stenosis (from less than 1% to 0%) Management of PV Stenosis Clinical Presentation, Investigation, and Management of Pulmonary Vein Stenosis Complicating Ablation for Atrial Fibrillation Packer, DL, Keelan, P, Munger, TM, et al. Circulation (2005) 111: 546 • Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AFib Evolution of PV Narrowing • No patients with normal spiral CT at 3 months had stenosis at 6-12m CTS • Progression from mild or moderate to severe stenosis was observed in 3/74 patients (4%) • One of which occurred within 3 months of ablation. 2 patients had progression between 3-6 month followup Saad EB, et al. Circulation (2003) 108: 3102 Treatment of Pulmonary Vein Stenosis Transcatheter Angioplasty for Acquired Pulmonary Vein Stenosis after Radiofrequency Ablation Quershi, AM, Prieto, L, Latson, LA, et al. Circulation (2003) 108: 1336 • Retrospective review of data from 19 patients with pulmonary vein stenosis who underwent catheterization and angiography Qureshi AM, et al. Circulation (2003) 108: 1336 Treatment of Pulmonary Vein Stenosis • Balloon stent angioplasty Qureshi AM, et al. Circulation (2003) 108: 1336 Pre-existing PV Stenosis in Patients Undergoing Ablation • Details of congenital PV stenosis in 178 patients before ablation • Five PVs in 5 patients (2.8%) showed at least 50% stenosis before ablation. Two types of pre-existing PV stenosis: – Type I - external compression of PV by the descending aorta, observed in LIPV – Type II - focal narrowing of PV, observed in RSPV • Detection of this condition by 3D CT or MRA before catheter ablation can provide information for planning of ablation strategy and prevent misdiagnosis of ablation-related PV stenosis Wongcharoen W, et al. J Cardiovasc Electrophysiol (2003) 17: 423 Atrio-esophageal Fistula Atrio-esophageal Fistula – First Reported Case • First reported case • RF catheter ablation in a 72-year-old man • PV isolation using an 8-mm-tip electrode (60 W or 55 °C) guided by a 25-mm circular catheter • Patient presented with seizures on day 22 of follow- up followed by hematemesis due to left atrialesophageal fistula Scanavacca MI, et al. J Cardiovasc Electrophysiol (2004) 15: 960 CT Analysis of the LA and Esophagus • Implications for catheter ablation • Topographic anatomy of the esophagus and the posterior LA visualised using helical CT scan of the chest with 3D reconstruction – The esophagus and posterior LA wall are in close contact over a large area that may often lie within the – There is marked variation in the anatomic relationship of the esophagus and the posterior LA – Both the esophageal and atrial walls are quite thin. However, a layer of adipose tissue may serve to insulate the esophagus from thermal injury, explaining why atrioesophageal fistulas are rare Lemola K, et al. Circulation (2004) 110: 3655 CT Analysis of the LA and Esophagus • Fat layer (FL) visible in image on left Lemola K, et al. Circulation (2004) 110: 3655 CT Analysis of the LA and Esophagus • Relationship of esophagus to posterior LA wall on 3D CT images. • A. Positioned very close to ostia of left-sided; oblique course from left to right as it travels caudally B; closer to right-sided PVs than leftsided PVs C. • D. Sagittal section. Esophagus wraps around posterior left atrium along its entire length (D) Lemola K, et al. Circulation (2004) 110: 3655 Atrio-esophageal Fistula: Additional Cases • 2 cases reported in 4360 patients treated in two centres - incidence of 0.05% • Patients developed symptoms compatible with endocarditis 3 to 5 days after ablation • Both suffered multiple gaseous and/or septic embolic events causing cerebral and myocardial damage • One patient survived after emergency cardiac and esophageal surgery Pappone C, et al. Circulation (2004) 109: 2724 Characteristics of 9 Reported Cases Description of an additional 9 cases Characteristics of patients Male sex Mean time to presentation (d) Deaths (n/n) Presenting symptoms Sepsis Neurologic symptoms MI or ischaemia Overt GI bleeding Diagnosis by CT Diagnosis confirmed by autopsy Diagnosis only by autopsy n=4 12.3 9/9 9/9 8/9 2/9 3/9 3/4 9/9 6/9 Cummings JE, et al. Ann Intern Med (2006) 144: 572 Characteristics of 9 Reported Cases Relationship between atrio-esophageal fistula and volume of centre Case-patient Annual reported volume of AFib ablation cases (#/y) 1 2 3 4 5 6 7 8 9 <100 >300 100-150 <100 >300 200-250 >300 <100 100-150 Cummings JE, et al. Ann Intern Med (2006) 144: 572 Real-time Monitoring of Luminal Esophageal Temperature • 3 patients undergoing catheter ablation during real- time monitoring of luminal esophageal temperature • Enhances recognition of esophageal heating and adds useful information beyond that provided by fluoroscopic assessment of esophageal position Perzanowski C, et al. J Cardiovasc Electrophysiol (2006) 17: 166 Phrenic Nerve Injury Frequency of Phrenic Nerve Injury • 18 cases out of 3755 procedures (0.48%) – 16 right PNI during ablation of right superior PV (12) or SVC disconnection (3) – 2 left PNI during ablation of LA appendage Sacher F, et al. J Am Coll Cardiol (2006) 47: 2498 Symptoms and Diagnosis of Phrenic Nerve Injury • Immediate features: 9 patients diagnosed acutely with: – Dyspnea – Cough – Hiccup – and/or sudden diaphragmatic elevation • Diagnosis after ablation: dyspnea in 7; radiography in 2 • Four asymptomatic • Complete or partial recovery in the majority Sacher F, et al. J Am Coll Cardiol (2006) 47: 2498 Post Atrial Ablation Left Atrial Tachycardia / Flutter Post Atrial Ablation Left Atrial Tachycardia / Flutter • 10% of cases observed during procedure • Time to appearance: mean 2-3 months post ablation – Range 1.2-24% of cases – Mean 10% (251/2718) Raviele A, et al. J Cardiovasc Electrophysiol (2006) 16: 298 Post Atrial Ablation Left Atrial Tachycardia/Flutter Author Patients LAT/FL Time to LAT/FL (months) Kanagataran 2001 71 14 (20%) NR Villacastin 2003 30 2 (6.6%) 2 Oral 2003 80 1 (1.2%) NR Ernst 2003 88 6 (7.0%) NR Gerstenfeld 2004 341 10 (3.4%) 5.7+2.8** Mesas 2004 276 13 (4.7%) 2.6+1.6** Pappone 2004 560 39 (7.0%)* 2.4/2.9 Jaïs 2004 100 12 (12%) NR Oral 2004 100 21 (21%) NR Ouyang 2005 100 21 (21%) 0.21 Cummings 2005 737 23 (3.1%) NR Chugh 2005 349 85 (24%) >3-4 Hocini 2005 20 4 (20%) >13 *28 (10%) in patients undergoing CPVA; 11 (3.9%) in patients undergoing CPVA + linear lesions ** Time to LAT/FL ablation Raviele A, et al. J Cardiovasc Electrophysiol (2006) 16: 298 Mechanisms of Post Atrial Ablation LAT/FL Principal mechanisms • Macro-reentry in 76% • More rarely, ectopic focus • Underlying cause thought to be due to interruptions in the lesion lines • Often requires a second ablation procedure to eliminate the arrhythmia Raviele A, et al. J Cardiovasc Electrophysiol (2006) 16: 298 Mechanisms of Post Atrial Ablation LAT/FL Role of linear lesions in reducing LAT/FL • Some authors have proposed to perform empirical linear lesions in addition to PVI at the level of the mitral isthmus, poster wall and roof of left atrium to prevent the occurrence of this pro-arrhythmic complication Italian Guidelines on Management of Atrial Fibrillation GIAC (2006) 9: 1 Mechanisms of Post Atrial Ablation LAT / FL Role of linear lesions in reducing LAT/FL Pappone et al 2004 • CPVA only 10% • CPVA plus linear lines 3.9% Pappone C, et al. Circulation (2004) 110: 3036 Mechanisms of Post Atrial Ablation LAT / FL Role of linear lesions in reducing LAT/FL • However, the real value of such lesions is still the object of debate and according to other authors such lesions may be pro-arrhythmic rather than anti-arrhythmic, especially if conduction block is not confirmed at the end of the procedure • Additional linear lesions 14-21% Jaïs P, et al. Circulation (2004) 110: 2996 6. Cost effectiveness Catheter Ablation May Be More Costeffective than Pharmacological Therapy After 5 years, the cost of RF ablation was below that of medical management and further diverged thereafter 118 patients with symptomatic, drug-refractory AFib 1.52 ± 0.71 ablation procedures 32 weeks Pharmacological treatment Catheter ablation €1590/year €4715 followed by €445/year Weerasooriya R, et al. PACE (2003) 26: 292 Differences in Hospital Visits and Costs with and without Catheter Ablation Although the initial cost of ablation is high, after ablation, utilization of healthcare resources is significantly reduced No ablation Catheter ablation Clinical visits per year 7.4 (2.5) 1.1 (0.6) Emergency room visits per year 1.7 (0.9) 0.03 (0.17) Hospitalization days per year 1.6 (0.8) 0 (0) $1920 (889) $87 (68) Healthcare costs per year Goldberg A, et al. J Interv Card Electrophysiol (2003) 8: 59 Catheter Ablation Cost-Effective in Patients at High Risk of Stroke Model to compare the cost-effectiveness of left atrial catheter ablation (LACA), amiodarone, and rate control therapy in the management of AFib The use of LACA may be cost-effective in patients with AFib at moderate risk for stroke This model did not find it to be cost-effective in low-risk patients. Conclusions Cost-effective in patients at moderate or high risk of stroke Chan DP, et al. J Am Coll Cardiol (2006) 47: 2513 7. Indications Suitability Criteria for Catheter Ablation • General referral criteria for catheter ablation – patients with paroxysmal or persistent AFib – refractory to pharmaceutical intervention – left atrium size less than 5.0 cm – absence of severe structural heart disease – younger patients • General criteria of unsuitability for catheter ablation – upper limit of left atrial size between 5.5 and 6.0 cm – lower limit of LVEF between 30% and 35% – prior heart surgery – older patients with permanent AFib Guidelines for Catheter Ablation Class I Paroxysmal/persistent AFib non-elderly patients refractory to pharmacological therapy severe symptoms that significantly affect QoL Class IIa Chronic AFib non-elderly patients refractory to pharmacological therapy severe symptoms that significantly affect QoL Paroxysmal/persistent/chronic AFib arrhythmia causing significant deterioration of cardiac function refractory to pharmacological therapy Italian Guidelines on Management of Atrial Fibrillation GIAC (2006) 9: 1 Guidelines for Catheter Ablation Class IIb Paroxysmal/persistent AFib elderly patients refractory to pharmacological therapy severe symptoms that significantly affect QoL Other patients that are: informed about risk/benefits of procedure choose procedure for personal reasons Italian Guidelines on Management of Atrial Fibrillation GIAC (2006) 9: 1 Current ACC/AHA/ESC Guidelines Recurrent Paroxysmal AF Minimal or no symptoms Disabling symptoms in AF Anticoagulation and rate control as needed Anticoagulation and rate control as needed No drug for prevention of AF AAD therapy AF ablation if AAD treatment fails ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation J Am Coll Cardiol (2006) 48: 854 Current ACC/AHA/ESC Guidelines Maintenance of Sinus Rhythm No (or minimal) heart disease Hypertension Flecainide Propafenone Sotalol Amiodarone Doeftilide Substantial LVH Catheter ablation No Yes Flecainide Propafenone Sotalol Amiodarone Amiodarone Dofetilide Catheter ablation Coronary artery disease Heart failure Dofetilide Sotalol Amiodarone Doeftilide Amiodarone Catheter ablation Catheter ablation Catheter ablation ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation J Am Coll Cardiol (2006) 48: 854 Recent Commentary Why Ablation for AFib might be Considered FirstLine Therapy for Some Patients “Current therapies, especially AAM, not only are ineffective but also pose a threat to patient QoL and even longevity. In the hands of experienced operators, AF ablation is an effective, safe, and established treatment for AF that offers an excellent chance for a lasting cure … unlike other therapies, ablation tackles AF at its electrophysiological origin.” Verma A & Natale A Circulation (2005) 112: 1214 Summary of catheter ablation • High success rate • Improves survival, cardiac function and freedom from recurrence • New data from RCTs confirm benefits • Safe, with a risk comparable to other low-risk, routine interventions • Cost effective compared to standard pharmacological therapy, at least in patients at moderate thromboembolic risk