How to improve procedural outcome of cryoballoon ablation in persistent AF Experience from Redo procedures
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1 How to improve procedural outcome of cryoballoon ablation in persistent AF Experience from Redo procedures Kyoung-Ryul Julian Chun Cardioangiologisches Centrum Bethanien (CCB) Markus Krankenhaus, Med. Klinik III Frankfurt am Main, Germany
2 DISCLOSURES Activity Advisory Board Research Grant Speaker s Honoraria Company Medtronic Biosense Webster CardioFocus Medtronic Biotronik Boston Sci CardioFocus Medtronic
3 Persistent AF-Cryoballoon-Redo procedures CENTRAL QUESTIONS 1. Definition of persistent AF 2. Ablation strategies in persistent AF 3. Status Cryoballoon and PVI 4. Role Cryoballoon in Redo (persistent) AF
4 Persistent AF-Cryoballoon-Redo procedures NEW AF DEFINITIONS Kirchhof et al. European Heart J 2016
5 Persistent AF Ablation HRS/EHRA/ECAS/APHRS/SOLAECE NEW DEFINITION 2017 EARLY PERSISTENT AF Early persistent AF is defined as AF that is sustained beyond 7 days but less than 3 months in duration Calkins H et al. Heart Rhythm 2017
6 AF Mapping, Non PV Trigger PV Trigger across AF Types (n=2168 pts) Santangelii et al. Heart Rhythm Oct 15. pii: S (15)
7 Persistent AF Ablation STAR AF II Verma A et al. N Engl J Med May 7;372(19):
8 Persistent AF Ablation STAR AF II Verma A et al. N Engl J Med May 7;372(19):
9 Persistent AF Ablation STAR AF II, AF TERMINATION NO PREDICTOR Kochhä user et al. Heart Rhythm 2017;14:
10 VHF Ablation: Hochfrequenzstrom oder Ballon? CHASE AF: PVI vs. PVI + step wise (n=153 pts) Vogler J et al. JACC 2015
11 Persistent AF-Cryoballoon-Redo procedures ENDPOINT AF ABLATION 2017 Kirchhof P et al. European Heart J 2016 Calkins H et al. Heart Rhythm. 2017
12 AF Ablation, ESC Guidelines AF RFC Ablation procedures 92% (156/169) pts: recovered PV conduction...!! J Cardiovasc Electrophysiol, 26,pp , April 2015
13 Cyroballoon AF ablation METHODS, 2. Generation CB
14 CCB-EP Frankfurt: CRYOBALLOON
15 VHF Ablation: Hochfrequenzstrom oder Ballon? FRENCH AF: CB vs. RFC Providencia et al. Europace 2016
16 EFFICACY: Durable PVI Permanent PVI 30% 21% 70% 79% Kuck et al 2016, GAP AF Study Reddy et al 2015, SUPIR AF 93 patients 19 patients RFC PVI Remapping 3 months after index procedure CB2 PVI Remapping 3.4 months after index procedure
17 AF REDO FINDINGS GENERTION CB Low rate of PV reconnection Total Parox. AF Pers. AF 91 % 56 % 34 % 0 PV Reconnected 1 PV Reconnected 2 PV Reconnected 3 PV Reconnected 4 PV Reconnected Frankfurt
18 REDO FINDINGS GENERTION CB Durable PVI rate (%) (n=91pts, 357 PVs) RIPV RSPV RCV LIPV LSPV LCPV Overall Total PV PV Iso PV Reconection % Iso RIPV RSPV LIPV LSPV LCPV Overall Frankfurt
19 REDO FINDINGS GENERTION CB, persistent AF 100 Durable PVI rate (%) in persistent AF (n=34 pts) RIPV RSPV RCV LIPV LSPV LCPV Overall Frankfurt
20 Persistent AF-Cryoballoon-Redo procedures Atrial Fibrillation = Atrial Fibrillation???
21 SCAR AF - Role of AF Substrate LA Fibrosis Marrouche NF et al. JAMA 2014
22 SCAR AF - Role of AF Substrate LA Fibrosis Marrouche NF et al. JAMA 2014
23 SCAR AF - Role of AF Substrate LA Fibrosis Marrouche NF et al. JAMA 2014
24 SCAR AF - Role of AF Substrate Low Voltage Zone (LVZ): bipolar mV Transitional Zone (TZ): bipolar mV SR Abnormal Electrogram (SR-AE) >300 points LA map Gang Yang et al., Circulation AEP 2016
25 SCAR AF - Role of AF Substrate Gang Yang et al., Circulation AEP 2016
26 SCAR AF - Role of AF Substrate Step wise vs. Substrate Ablation 69.8% 51.3% Gang Yang et al., Circulation AEP 2016
27 Persistent AF Ablation Bordignon S et al. DGK 2017
28 Persistent AF Ablation METHODS SCAR AF Study (PAF + persistent AF) Patient in SR Carto bipolar map Patient in AF 2 CV attempts, if no SR: exclusion Time to LAA in SR AF Cycle length in 4 PVs, LAA + CS Seite 29
29 Persistent AF Ablation PATIENTS Bordignon S et al. DGK 2017
30 Persistent AF Ablation RESULTS PRIMARY ENDPOINT Bordignon S et al. DGK 2017
31 Persistent AF Ablation PVI: No Substrate vs. Substrate Bordignon S et al. DGK 2017
32 AF Substrate SMART Lines... Bordignon et al. DGK HT 2015
33 Persistent AF Ablation SUGGESTION PV Isolation Responder vs. PV Isolation Non-Responder
34 Cryoballoon AF Persistent AF (n=100pts) Koektuerk B et al., Circulation AEP 2015
35 Laser Balloon or Radiofrequency Ablation for Persistent Atrial Fibrillation Boris Schmidt a, MD, Peter Neuzil b, MD, Armin Luik c, MD, Joaquin Osca Asensi d, MD, Jan Wilko Schrickel e, MD, Thomas Deneke f, MD, Stefano Bordignon a, MD, Jan Petru b, MD, Matthias Merkel c, MD, Lucie Sediva b, PhD, Annemarie Klostermann a, Laura Perrotta a, MD, Oscar Cano d, MD and KR Julian Chun a, MD a Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; b Na Homolce Hospital, Prague, Czech Republic; c Stä dtisches Klinikum, Karlsruhe, Germany; d Hospital Universitari i Politè cnic la Fe, Valencia, Spain; e University Hospital, Bonn, Germany; f Herzzentrum, Bad Neustadt, Germany
36 LASER VERSUS RF IN PERS AF RESULTS STUDY FLOW Enrolled and Randomized (n = 152) R LB (n = 75) RF (n = 77) - 1 screening failure (PAF) - 1 withdrew consent - 2 screening failures (1 AT, 1 anatomic reasons) - 3 withdrew consent Successful PVI (n = 73) Successful PVI (n = 72) 12 Month follow-up completed (n=68) 12 Month follow-up completed (n=66) Schmidt B et al., KRJ Chun LBCT DGK 2017
37 LASER VERSUS RF IN PERS AF RESULTS PRIMARY ENDPOINT Schmidt B et al., KRJ Chun LBCT DGK 2017
38 Persistent AF Ablation Di Biase et al. Circulation Jul 13;122(2):
39 Di Biase L et al. JACC 2016
40 Persistent AF-Cryoballoon-Redo procedures LAA Isolation in PVI Non Responder BASELINE CHARACTERISTICS Male 14/20(70%) Age (years) 68±10 Diagnosis - PAF - Pers AF 5/20 (25%) 14/20 (70%) 1/20 (5%) - AT from LAA History of AF (years) 3.4±3.,3 Arterial hypertension 16/20(80%) Diabetes mellitus 2/20(10%) History of stroke/tia 3/20(15%) NYHA >I 2/20(10%) Coronary artery disease 7/20(35%) LA diameter (mm) 44±7 Left ventricular (EF) 62±5 Procedure number 2.6±1.,3 Bordignon S. et al., Chun KRJ submitted
41 Persistent AF-Cryoballoon-Redo procedures LAA Isolation in PVI Non Responder Bordignon S. et al., Chun KRJ submitted
42 Persistent AF-Cryoballoon-Redo procedures LAA Isolation in PVI Non Responder LAAI - PROCEDURAL DATA Procedure Time (min) 67±33 Fluoroscopy Time (min) 9,0±6,2 LAA Spike Visualization 20/20 (100%) LAA Real Time Isolation - sustained LAAI - non sustained LAAI 16/20 (80%) 11/16 (69%) 5/16 (31%) LAA Time to sustained block (s) 94±57 LAA Temperature at time to sustained block ( C) -44±7 LAA Time to non-sustained block (s) 142±64 LAA Temperature at time to non-sustained block ( C) -48±3 LAA total freeze applications (n) 2.0±1.6 LAA bonus applications (n) 8/20 (40%) LAA mean occlusion grade 3.,9±0,.2 LAA mean minimal temperature ( C) -50,0±54,7 LAA mean freeze duration (s) 214±37 Bordignon S. et al., Chun KRJ submitted
43 Bordignon S. et al. Europace Vienna 2017
44 Persistent AF-Cryoballoon-Redo procedures LAA ISOLATION PATIENTS Bordignon S. et al. Europace Vienna 2017
45 Persistent AF-Cryoballoon-Redo procedures COMPLICATIONS Bordignon S. et al. Europace Vienna 2017
46 Persistent AF-Cryoballoon-Redo procedures LAA ISOLATION IMPROVES RHYTHM OUTCOME Bordignon S. et al. Europace Vienna 2017
47 Persistent AF-Cryoballoon-Redo procedures CONCLUSIONS PVs are critical sites in persistent AF High rate of permanent PVI (1. procedure) After durable PVI: Substrate modification (EP endpoint) Cryoballoon LAA isolation feasible Durable LAA isolation linked to sinus rhythm The role of LAA merits investigation
48 TEAM FFM Thanks for your attention!
49 SCAR AF - Role of AF Substrate Jadidi et al. Localized Reentry with Activity >70% AF Cycle Length at Low Voltage Area Voltage <0.5mV in AF Regional Activity >70% AF Cycle Length AF Termination CL=155ms 120ms 0.5mV Fig. S1
50 Selective Voltage guided Ablation of persistent AF Jadidi A. et al. CircEP 2016
51 Persistent AF Ablation RESULTS PRIMARY ENDPOINT Jadidi A. et al. CircEP 2016
52 Persistent AF Ablation STAR AF II, AF TERMINATION NO PREDICTOR Kochhä user et al. Heart Rhythm 2017;14:
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