Cardiovascular Surgery and Electrophysiology: Where are the opportunities for a Combined Interdisciplinary approach in Atrial Fibrillation?

Transcription

1 Cardiovascular Surgery and Electrophysiology: Where are the opportunities for a Combined Interdisciplinary approach in Atrial Fibrillation? Felix Yang, MD, FACC, FHRS, CCDS Associate Director, Cardiac Electrophysiology Department of Cardiology Maimonides Medical Center 11/2018 Philadelphia

2 Relevant Disclosures Consulting fees from Atricure, Biosense Webster, Boston Scientific, Abbott

3 Paroxysmal AF Success Rates PVI plus more extensive ablation ~70-80% PVI alone ~70% Success

4 Catheter Ablation oflong-standing Persistent Atrial Fibrillation 5-Year Outcomes of the Hamburg Sequential Ablation Strategy Roland Richard Tilz, MD, Andreas Rillig, MD, Anna-Maria Thum, Anita Arya, MD, Peter Wohlmuth, Andreas Metzner, MD, Shibu Mathew, MD, Yasuhiro Yoshiga, MD, Erik Wissner, MD, Karl- Heinz Kuck, MD, Feifan Ouyang, MD Hamburg, Germany First ablation Last ablation JACC Vol. 60, No. 19, 2012

5 Catheter Ablation oflong-standing Persistent Atrial Fibrillation 5-Year Outcomes of the Hamburg Sequential Ablation Strategy Roland Richard Tilz, MD, Andreas Rillig, MD, Anna-Maria Thum, Anita Arya, MD, Peter Wohlmuth, Andreas Metzner, MD, Shibu Mathew, MD, Yasuhiro Yoshiga, MD, Erik Wissner, MD, Karl- Heinz Kuck, MD, Feifan Ouyang, MD Hamburg, Germany Multiple procedure success AF <2 yrs AF > 2 yrs Journal of the American College of Cardiology Vol. 60, No. 19, 2012

6 Limitations of Catheter Ablation Beyond PVI Need to Address Chronic Progressive Disease High Late Recurrence Rate (VLR) in Successfully ablated patients (e.g. SR off 1 year). Persistent patients recur at a much higher rate than paroxysmal. Patients with multiple risk factors also have a much higher recurrence rate. Parox Persistent PAF, no HTN HTN or Persistent HTN & persistent 10 yrs Steinberg JS. Very long-term outcome after initially successful catheter ablation of atrial fibrillation. Heart Rhythm2014;11:

7 Approaches to Catheter Ablation for Persistent Atrial Fibrillation Atul Verma, M.D. et al for the STAR AF II Investigators Single procedure success N Engl J Med 2015; 372:

8 What is the best method to deal with persistent atrial fibrillation?

9 Clinical factors associated with limited efficacy of AF ablation Long standing persistent AF AF ablation can also be offered to those with persistent and long standing persistent AF but the expected efficacy is less. Sleep apnea Increased left atrial size (> 5.5 cm) Increased age (> 70 yrs) Severe obesity Frequently the factors that limit use of standard catheter ablation most often occur in patients who need the ablation the most HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation. Calkins H et al. Heart Rhythm 2007; 4(6):

10 Methodologies of AF ablation A: The circumferential ablation lesions that are created in a circumferential fashion around the right and the left PVs. The primary endpoint of this ablation strategy is the electrical isolation of the PV musculature. B: Some of the most common sites of linear ablation lesions. These include a roof line connecting the lesions encircling the left and/or right PVs, a mitral isthmus line connecting the mitral valve and the lesion encircling the left PVs at the level of the left inferior PV, and an anterior linear lesion connecting either the roof line or the left or right circumferential lesion to the mitral annulus anteriorly. A linear lesion created at the cavotricuspid isthmus is also shown. C: Also shows additional linear ablation lesions between the superior and inferior PVs resulting in a figure of 8 lesion set as well as a posterior inferior line allowing for electrical isolation of the posterior left atrial wall. An encircling lesion of the superior vena cava (SVC) directed at electrical isolation of the SVC is also shown. D: Some of the most common sites of ablation lesions when complex fractionated electrograms are targeted (these sites are also close to the autonomic GP).

11 The problem is that much substrate exists on the posterior wall Importance of the Posterior Wall Substrate

12 Common regions of fibrosis Adapted from Cochet et al. J Cardiovasc Electrophysiol 2015; 26: 489.

13 Schematic of Progressive Atrial Remodeling Panel A: Schematic of progressive atrial remodeling. Pericardial reflections (green lines), their attachments to the posterior left atrium, and their relation to proposed high stress regions. Panel B: Ganglionated plexi (yellow) and epicardial fat (green). Left superior ganglionated plexi (LSGP), left inferior ganglionated plexi (LIGP), right anterior ganglionated plexi (RAGP), right inferior ganglionated plexi (RIGP), aortocaval ganglionated plexi (ACGP) There are also additional factors that contribute to the AF substrate

14 The Risks of Posterior But how can we safely treat this substrate? wall collateral injury

15 Convergent vs Thoracoscopic AF Ablation Lesion Set Panel A: Schematic of the Convergent procedure lesion pattern relative to the high stress regions. Panel B: Thoracoscopic hybrid AF ablation lesion set. Hybrid AF ablation utilizing a thoracoscopic approach commonly involves pulmonary vein isolation, a roof line, posterior box line, exclusion of the left atrial appendage (blue lines). Endocardial ablation is performed to confirm bidirectional block across the lines and create a cavotricuspid isthmus line (red dotted line). Additional ablation may be performed to create an intercaval line, mitral line, and at ganglionated plexi.

16 How is convergent AF ablation performed?

17 EPi-Sense System Tips & Techniques EPi-Sense Coagulation Device Preshape device distal end so deflects along pericardium to reach roof pericardial reflections Connect device vacuum connection to -400 to -450 suction Always turn vacuum off when moving device Place device above cannula guidewire to separate device from pericardium Always ensure arrows and dots extending from heel of electrode are facing epicardium Make sure saline is flowing from unpressurized bag of saline prior to initiation of RF energy delivery Vacuum openings Dots identify direction of heating Ablation coil electrode Arrows identify direction of heating Sensing electrodes

18 Advantages of the Convergent Approach Endocardial Ablation of Reflections Eliminates Dissections Ablating Posterior Left Atrium No Dissecting of Reflections Ablating Reflections Ablating Reflections to Complete Isolation of PVs

19 EPi-Sense Directs Heating into Epicardial Surface Protects Collateral Anatomy by Cooling Device Temperature (C) Endocardial vs Epicardial Ablation Heating Profile Temperature Reached Along Pericardium [Myocardial Wall Thickness: mm] Catheter Ablation - 25Watts Max Tip Pressure 15g Catheter Ablation - 35Watts Max Tip Pressure 15g Catheter Ablation - 45Watts Max Tip Pressure 15g Epicardial Ablation - ncontact 30Watts Collateral Heating, EPi-Sense Device Time (sec)

20 EPi-Sense Guides Epicardial Ablation Electrogram Sensing & Pacing Benefits Confirm target anatomy to ablate Atrium vs Ventricle vs Pericardium LAA vs Anterior Left Atrium Confirm lesion completeness Visualize drop in electrogram signal Pacing to confirm inability to capture Ensures posterior left atrium is ablated No electrograms or inability to capture Map posterior under endoscopic vision Evaluation of Lesion Completeness Pre ncontact Ablation Post ncontact Ablation

21 Electrophysiology portion of Convergent AF ablation

22 Efficacy of Convergent epicardial AF ablation. Confirmation of dense scar using endocardial electroanatomic mapping Batul, S, Plawes, Z, Kupferstein, E, Israel Jacobowitz, IJ, Yang, F, Greenberg, Y. Maimonides Medical Center Age Lesions La size 4.77 LA volume carto BMI 33+6 Dense Superior Scar 45.7% Dense Inferior Scar 52.5% Overall Dense Scar 47.68%

23 The Effect of Hybrid Ablation for AF on Left Atrial Function Patel, JA, John, J, Greene, M, Chen, O, Greenberg, Y, Jacobowitz, IJ, Yang, F, Sadiq, A, Saxena, A. Maimonides Medical Center Pre and post-procedural echocardiograms of patients who underwent the Convergent AF ablation were evaluated for parameters of LA size and function using a rhythm independent Left Atrial Function Index. 30 patients who underwent the Convergent AF ablation, 19 patients had pre and post-procedural echocardiograms where LAFI was calculated. LA ESV Mean LAFI Pre-procedure ml pre-procedure 0.11 Post-procedure 92.2 ml post-procedure 0.13 p=0.048, 95% CI: p=0.93, 95% CI:

24 Maimonides Persistent AF: A Difficult Substrate Mean age 62 Mean BMI 35.3 ~90% HTN ~30% Diabetic ~25% CAD Mean CHADS 2.44 Mean LA Size 4.6cm Mean LVEF 52% Mean Time from First AF Dx 6.1 yrs 18/100 with prior ablation We had a much sicker population Than STAR AF 2!

25

26 93% 83% 85% 73% 82% 77% OPEN CHEST COX IV OPEN CHEST COX IV OPEN CHEST COX IV OPEN CHEST COX IV ~50-60% ~52% ~35% OPEN CHEST COX IV ~50% OPEN CHEST COX IV ~25-30% ~40% ~20-25% STAR year; Freedom From AF +/- AA Ganesan et al year; Arrhythmia Free +/- AA; JAHA 2013 year; Lawrence, Damiano et al; Annals of Cardiothoracic Surgery, Jan 2014 Arrhythmia Free +/- AA Hamburg Gaita et year; AF Free on year; AA); Europace Arrhythmia Free 3/2018 +/- AA Hamburg Gaita et year; AF Free on year; AA); Europace Arrhythmia Free 3/2018 +/- AA

27

28

29 The LAA

30 Watchman/Lariat Good data for Watchman for stroke prevention but doesn t provide electrical isolation Lariat electrically isolates the LAA but more challenging to place

31 Incidence of device related thrombus in patients with LAA imaging was 7.2%/year

32 27% of repeat ablation procedures had LAA firing

33 Freedom From AF at 12 months 76% 56% 56% 28% WITH LAA ISOLATION WITHOUT LAA ISOLATION single procedure repeat procedure

34

35 Atriclip : LAA Closure Pro2 ProV

36 LAA Closure with Atriclip

37

38

39

40

41 Additional reasons to Close the Appendage

42

43 LAA Neurohormal interactions ANP is secreted by myocytes throughout the atria, with the LAA/RAA accounting for 30% of sources More ANP storage granules in RAA>LAA LAA is innervated by parasympathetic and sympathetic fibers (but not as densely as the LA posterior wall or pulmonary veins)

44 Significant findings: Persistent decline in epinephrine, norepinephrine, renin, and aldosterone lasting at least 3 months with Lariat device Sustained and significant decrease in systolic and diastolic pressures of 15% and 12% Possible mechanisms: Natriuretic peptide pathway (mostly short term effects) Neurally mediated pathway Possibly by interruption or modification of neural reflexes by destruction of afferent fibers within the LAA or injury to peri-laa ganglionated plexi during Lariat ligation

45 29 patients Combined Convergent with Atriclip Early experience at Maimonides Age 61.5± 7.4yrs Male 72% BMI 34.2 CHADS 2 -VA 2 Sc 2.2 ± 1.1 Post procedure TEE performed in 12 patients RESULTS After 3 month blanking period only 1 patient on sotalol for VT. 1 patient died 9 months post procedure due to MI 5/29 discontinued a/c due to low CHADS-VASc score or increased bleeding risk Zero strokes / TIA Mean f/u time 10.4 months Freedom from Arrhythmia 97% 89% AF/AT free ± AA AF/AT free off AA Freedom from Arrhythmia

46 Updated Results 100 Convergent + LAA AtriClip Closure 51 Patients % 84% Average Age = Female/35 Male % Freedom from AF off AA Freedom from ATA off AA % on AA at last follow-up 49 average burns / patient Mean follow up time: 499 days 7/8 recurrences were AF 1/8 Atrial Tachycardia

47