Role of LAA isolation in AF cure
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1 MAM 2017, Zurich Role of LAA isolation in AF cure Sakis Themistoclakis, MD Director, Unit of Electrophysiology and Cardiac Pacing Department of Cardiothoracic & Vascular Medicine Ospedale dell Angelo, Mestre-Venice, Italy 1
2 CONFLICTS OF INTEREST TO DISCLOSE Consultant: Biosense Webster, Daiichi Sankyo, Pfizer/BMS Research Grant: Bayer Pharma: X-VERT Trial (Local PI) Biosense Webster: OAT Study (Steering Committee) BMS/Pfizer: AEGEAN Trial (Local PI) Daiichi Sankyo: ENSURE AF Trial (National PI, Steering Committee) Boheringher Ingelheim: RE-CIRCUIT Trial (National PI) AF-NET, BMS/Pfizer: AXAFA Trial (National PI, Steering Committee) Speaker Honoraria: Bayer Pharma, Boheringher Ingelheim, Daiichi Sankyo, Pfizer/BMS
3 Circumferential Ablation With Pulmonary Vein Isolation in Long standing persistent atrial fibrillation Cheema et al. Am J Cardiol 2007;99:
4 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Heart Rhythm 2007;4:816-61
5 Ablation strategy according to the type of atrial fibrillation Themistoclakis et al. J Cardiovasc Electrophysiol 2014; 25:
6 Approaches to Catheter Ablation for Persistent Atrial Fibrillation: STAR AF II TRIAL Success rate after 1 st ablation procedure, with or w/out AAD: PVI: 41% PVI + CFAE: 51% PVI + lines: 54% Verma et al. N Engl J Med 2015;372:
7 2016 ESC Guidelines for the management of atrial fibrillation Freedom from recurrence of AF or atrial arrhythmias, in patients with persistent or long-standing persistent AF Kirchhof P et al. Eur Heart J Aug 27
8 ESC 2016 AF management guidelines Catheter ablation: Kirchhof P et al. Eur Heart J Aug 27
9 Extra PV ostia foci triggering AF Extra PV triggers: % Extra PV Foci Chen et al. Circulation 1999; Tsai CF et al. Circulation 2000; Hwang C et al. Circulation 2000; Tai CT et al. PACE 2000; Katritsis D et al JCE 2001; Lin WS et al. Circulation. 2003; Nademanee K et al. JACC 2004; Elayi CS et al. Heart Rhythm 2006
10 Heart Rhythm 2015;12:
11 Heart Rhythm 2015;12:
12 Disconnection of the LA Appendage for Elimination of AT from the LAA: Foci Maintaining AF LAA Apex Takahashi et al. J Cardiovasc Electrophysiol 2005;16:917-9
13 Disconnection of the LA Appendage for Elimination of Dissociated rhythm in the LAA: Foci Maintaining AF Takahashi et al. J Cardiovasc Electrophysiol 2005;16:917-9
14 Localized reentry within the left atrial appendage: arrhythmogenic role in patients undergoing ablation of persistent atrial fibrillation LAA tachycardia: 15/74 pts (19%) Hocini et al. Heart Rhythm 2011;8:
15 Localized reentry within the left atrial appendage: arrhythmogenic role in patients undergoing ablation of persistent atrial fibrillation Follow-up of 18±7 months: Sinus rhythm off antiarrhythmic drugs 13/15 (87%) patients Hocini et al. Heart Rhythm 2011;8:
16 EVIDENCE of the LAA as a TRIGGER for AF/AT
17 Left Atrial Appendage An Underrecognized Trigger Site of Atrial Fibrillation Baseline characteristics of patients with LAA firings: LAA Firing: 266/987 pts (27%) LAA as only trigger: 86/987 pts (8.7%) Paroxysmal AF: 5/86 (6%) Non Paroxysmal AF: 81/86 (94%) Di Biase et al. Circulation. 2010;122:109-18
18 Circulation. 2010;122:109-18
19 LAA Isolation
20 LAA Isolation
21 LAA Isolation CM Catheter at LAA ostium: Baseline LAA isolation
22 J Am Coll Cardiol. 2016;68:
23 After First Procedure off AADs After multiple Procedure 76% p= % 28% p= % Di Biase et al. J Am Coll Cardiol. 2016;68:
24 Di Biase et al. J Am Coll Cardiol. 2016;68:
25 1 LAA thrombus (patient was receiving OAC with subtherapeutic INR) and 1 case of LAA spontaneous echocardiographic contrast (INR 2.24 on warfarin) were detected in the empirical electrical left atrial appendage isolation group Di Biase et al. J Am Coll Cardiol. 2016;68:
26 No stroke or transient ischemic attack was reported with empirical electrical left atrial appendage isolation (group 1), whereas 4 (4.5%) patients had stroke after standard ablation (group 2) (p=0.12) Di Biase et al. J Am Coll Cardiol. 2016;68:
27 BELIEF Trial The results of this randomized study show that both after a single and redo procedures in patients with long standing persistent AF, the EMPIRICAL ISOLATION of the LAA improve the long-term freedom from atrial arrhythmias without increasing complications. Di Biase et al. J Am Coll Cardiol. 2016;68:
28 Relative contribution of different ablation targets in the AF disease continuum Non-PV Triggers Non-PV Triggers Other Non-PV Triggers Substrate? PV Triggers LAA LAA PV Triggers PV Triggers Paroxysmal Persistent Long-standing persistent
29 Ospedale Dell Angelo
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