Bipolar Radiofrequency Energy

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1 Bipolar Radiofrequency Energy Ralph J. Damiano, Jr., MD Evarts A. Graham Professor of Surgery Chief, Division of Cardiothoracic Surgery Barnes-Jewish Hospital Washington University School of Medicine St. Louis, MO USA AATS STARS Meeting Miami, FL USA November 17, 2017

2 DISCLOSURE Speaker for AtriCure, Edwards Lifesciences, LivaNova Consultant for Medtronic Research and educational grants over the last 2 years: AtriCure Edwards

3 Surgical AF Ablation: The most important goal for an ablation device Create conduction block. To do this you must consistently create transmural and continuous lesions. Our laboratory and others have shown that gaps as small as 1 mm can conduct NSR and AF impulses. Heart Rhythm 2008;5(9):

4 Epicardial Surgical Ablation: What are we trying to do? fat 0-10 mm muscle mm blood 37 o C Cabrera et el: European Heart Journal (2008) 29,

5 Unipolar Irrigated Suction-assisted RF Device Lesion Depth vs. Thickness Depth (mm) Only 18% of lesions were transmural! 60 Seconds 90 Seconds 120 Seconds Transmural Line Thickness (mm) Damiano et al. Heart Rhythm 2009;6:S41-46

6 Mode of RF Energy Application: Sensitivity to Convective Cooling Unipolar Surface Bipolar Transmural Bipolar fat fat fat muscle muscle muscle blood blood blood -

7 Epicardial Bipolar Ablation Device

8 AtriCure Coolrail: Chronic Study CoolRail Chronic Lesion Depth vs. Tissue Thickness Lesion Depth cross sections 77% transmural Average Depth 3.7 ± 1.5 mm By mapping, none of the 12 linear lesions created demonstrated conduction block at 30 days! Tissue Thickness Lee et al. J Thorac Cardiovasc Surg 2012

9 BIPOLAR RADIOFREQUENCY ABLATION Atricure Bipolar Device Medtronic Bipolar Device

10 Bipolar RF Device

11 Bipolar RF Energy + + MaxTemp ( o C) Most ablation by resistive heating. Minimal effects of convective cooling mm Distance from Electrode Laterally (mm)

12 Bipolar RF Ablation Tissue Conductance Siemens Seconds

13 Irrigated RF Bipolar Clamps Tissue heating Irrigation (facilitates energy flow) Heating driven deeper into the tissue as irrigation reduces surface impedance Lower impedance reduces microbubble formation Allows tissue heating to fully penetrate the tissue

14 Transmurality Detection: Cardioblate Bipolar Algorithm The algorithm customizes energy delivery based on the thickness of the tissue. Impedance (Z) Power (W) Ablation Duration (t)

15 Surgical Ablation for AF: Advantages of Bipolar RF Ablation Reliable transmural lesions 100% transmurality Prasad et al. J Thorac Cardiovasc Surg 2002;124:708 Prasad et al. Ann Thorac Surg 2003; 76:836 Gaynor et al. Ann Thorac Surg 2004; 78:1671 Melby et al. J Thorac Cardiovasc Surg 2006;132:853 Voeller et al. Innovations 2011;6:17 Short ablation times seconds to circumferentially isolate PVs Focused delivery of energy prevents collateral damage

16 Bipolar RF Ablation Ablate without unclamping until ablation time is less than 10 seconds 2-3 ablations for each lesion Tissue Conductance Siemens Seconds

17 Technical Tips with Bipolar RF Ablation Fully mobilize the pulmonary veins Do not bunch tissue in the clamp perform individual PV isolation if needed Ablation duration and energy delivery is controlled by an algorithm based on conductance between the electrodes avoid artificially decreasing conductance (i.e. air, fat, char)

18 Bipolar RF Ablation Shortcomings Requires clamping - need to fold or penetrate target tissue On the arrested heart, unable to complete lesions at the right and left atrial isthmus. Limited to PVI only on the beating heart You can not perform a Maze procedure with bipolar clamps only!!

19 Cryoablation Devices 2-3 cm long, reusable probes 10 cm long disposable probes Lee, et al Innovations 2010;5:

20 Bipolar RF Ablation: Conclusions Atrial wall thickness is variable and architecture is complex with free running pectinate muscles and epicardial fat of varying thickness. These factors, combined with the heat sink effect has limited ablation efficacy. Bipolar RF ablation has been the most efficacious in the experimental laboratory, and has been the only energy source we have tested with 100% reliability.

21 Thank you for your attention!

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