Ablation Update and Case Studies. Lawrence Nair, MD, FACC Director of Electrophysiology Presbyterian Heart Group

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1 Ablation Update and Case Studies Lawrence Nair, MD, FACC Director of Electrophysiology Presbyterian Heart Group

2 Disclosures No financial relationships to disclose

3 Objectives At the conclusion of this activity, participants will be able to: 1.Recognize the indications for an ablation. 2. Identify the alternatives, risks and success rate of an ablation procedure. 3. Compare case studies of various arrhythmias, including SVT, atrial flutter and atrial fibrillation.

4 Intracardiac Electrograms

5

6 Indications for Ablation Common Arrhythmias SVT Atrial Flutter Atrial Fibrillation PVCs/Ventricular Tachycardia Risks and Benefits Alternatives Introduction

7 Classifications of Recommendations and Level of Evidence Class I Benefit>>>Risk Treatment should be performed Class IIa Benefit >>Risk Reasonable to Perform Class IIb Benefit >Risk Treatment may Be considered Class III No Benefit, possible harm Level A Multiple randomized clinical trials Recommendation that treatment is effective Recommendation in favor of treatment Some conflicting evidence Recommendation for treatment less well established. Greater conflicting evidence Recommendation that treatment is not useful and may be harmful Level B Single randomized trial or nonrandomized studies Recommendation that treatment is effective Recommendation in favor of treatment Some conflicting evidence Recommendation for treatment less well established. Greater conflicting evidence Recommendation that treatment is not useful and may be harmful Level C Consensus opinion, case studies, standard of care Recommendation that treatment is effective Recommendation in favor of treatment Some conflicting evidence Recommendation for treatment less well established. Greater conflicting evidence Recommendation that treatment is not useful and may be harmful

8 SVT 69 year old man presents to the ED with 90 minutes of palpitations and dizziness. He reports 3 similar episodes over the past two years. These episodes are typically associated with polyuria. Physical exam is notable for cannon a waves in his jugular veins. ECG reveals a narrow complex tachycardia with no evidence of P waves. Vagal maneuvers are ineffective. SVT is terminated with 6 mg of IV adenosine.

9 Narrow QRS Tachycardia No Visible P Waves Yes Yes Regular Tachycardia No Afib or aflutter with variable conduction AVNRT A rate > V rate No RP < PR (P after QRS) Yes No Aflutter or Atrial tach Yes RP < 90 msec Atrial tach, Atypical AVNRT, or PJRT Yes AVNRT No AVRT, Atypical AVNRT, or Atrial tach

10 Ecg

11 AVNRT Mechanism Atrium Fast pathway Ag Slow pathway Left Ventricle Right Ventricle

12 Acute Treatment of AVNRT AVNRT Vagal maneuvers and/or IV adenosine (Class 1) If Ineffective Hemodynamically Stable Yes IV Beta blocker, diltiazem or verapamil (Class IIa) If Ineffective IV amiodarone (Class IIb) No Synchronized Cardioversion (Class I)

13 Management of AVNRT AVNRT Symptomatic Yes No Clinical follow-up (Class IIa) Yes Ablation Candidate Patient prefers ablation No Slow pathway Catheter ablation (Class I) Beta blockers, diltiazem or verapamil (Class 1) Flecainide or Propafenone (Class IIa) Amiodarone, digoxin, dofetilide, or sotalol (Class IIb) If Ineffective

14 AVNRT - Slow pathway Jump 434ms 497ms

15 AVNRT Ablation Proprietary and confidential do not distribute Junctional beats during ablation Sinus

16 SVT 28 year old woman with a history of palpitations since early childhood. Episodes have been increasing in frequency and duration, up to an hour in length. Typical triggers include bending over and laying on her left side. Episodes can be terminated with a Valsalva maneuver. Her aunt has known SVT.

17

18 AVRT Right Atrium Left Atrium AV Node Accessory Pathway Right Ventricle Left Ventricle

19 Acute Treatment of AVRT Orthodromic AVRT Vagal maneuvers Or IV adenosine (Class 1) Hemodynamically stable IV Beta blockers, Diltiazem or Verapamil (Class IIa) Synchronized cardioversion (Class I) If Ineffective

20 Management of AVRT Orthodromic AVRT Yes Pre-excitation on resting ECG No No Yes Yes No Flecainide or propafenone (no structural heart disease) (Class IIa) Dofetilide, sotalol, or amiodarone (Class IIb) Catheter Ablation (Class I) Beta blockers, diltiazem, or verapamil (Class I) Dofetilide, sotalol, digoxin, or amiodarone (Class IIb)

21 WPW Prevalence of manifest accessory pathways 0.1 to 0.3% of the population Ten year risk of sudden cardiac death is 0.15% to 0.24%. Highest risk in the first two decades of life. Low risk profile associated with intermittent loss of pre-excitation on an ECG or ambulatory monitor, or abrupt loss during exercise testing (Class I). EP testing for risk stratification. High risk profile: induced AVRT, AP ERP < 240 ms, R-R interval with induced AF < 250 ms, multiple APs, AVRT triggered AF. Ablation is reasonable with high risk findings or when WPW precludes employment (Class IIa) Observation without treatment (Class IIa)

22 WPW 21 year old male with several year history of rapid palpitations and syncope was diagnosed with WPW one year ago. He declined ablation or medical therapy. Admitted following VF arrest requiring CPR and DC shock for treatment. ECG revealed pre-excitation c/w left lateral accessory pathway location. At EP study three separate pathways were found. Afib with rapid conduction down the AP was easily inducible with R-R interval < 250 ms, as well as ORT. All three pathways underwent successful RF ablation.

23 Ecg

24 Termination of Accessory Pathway during RF ablation Proprietary and confidential do not distribute

25 Termination of Accessory Pathway during RF ablation Proprietary and confidential do not distribute

26 Success and Complication Rates for SVT Ablation Arrhythmia Acute Success Recurrence Rate Complications AVNRT 96-97% 5% Overall 3% PPM 0.7% Groin comp 1-2 % AVRT/AP 93% 8% Overall 2.8% Tamponade 0.4% PPM 0.3% Proprietary and confidential do not distribute

27 Atrial Flutter 56 year old man with a history of HTN, smoking, and COPD complains of 6 weeks of fatigue, exertional intolerance, dyspnea and cough. He was seen in urgent care, diagnosed with bronchitis and treated with a 5 day course of azithromycin. His symptoms persisted and came to his PCP, where and ECG revealed atrial flutter. Exam notable for JVD, a rapid irregular pulse, and bibasilar rales. Echo revealed global hypokinesis with an LVEF of 35%.

28

29 Typical Atrial Flutter Right Atrium AV Node Right Ventricle

30 Management of Atrial Flutter Atrial Flutter Treatment Strategy Rate Control Rhythm Control* Beta-blocker, diltiazem, or verapamil (Class I) Catheter Ablation (Class I) *After adequate anticoagulation or TEE to exclude LAA thrombus Flecainide or propafenone (in the absence of SHD, combine with AV nodal blocking agents) (Class IIb) Sotalol, dofetilide, or amiodarone (Class IIa)

31 Proprietary and confidential do not distribute Mapping Atrial Flutter

32 Atrial Flutter Propagation Map

33 Ablation of the Cavotricuspid Isthmus

34 Termination of Atrial Flutter with RF ablation Proprietary and confidential do not distribute

35 Atrial Fibrillation 68 year old man with obesity, HTN, and sleep apnea notes 6 years of palpitations, lasing up to 12 hours in duration. Event monitor has demonstrated paroxysmal atrial fibrillation. He experiences fatigue and dyspnea during episodes of palpitations. His symptoms have been refractory to metoprolol and flecainide. He has been maintained on chronic anticoagulation with Xarelto.

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37 Atrial Fibrillation Right superior pulmonary vein Left Atrium Left superior pulmonary vein Left inferior pulmonary vein Right inferior pulmonary vein Left Ventricle

38 Atrial Fibrillation Management Atrial Fibrillation No Structural Heart Disease Structural Heart Disease Flecainide Propafenone Dofetilide Dronedarone Sotalol Catheter Ablation* Dofetilide Dronedarone Sotalol CAD Catheter Ablation* Heart Failure Amiodarone Dofetilide Amiodarone Amiodarone * Class I for paroxysmal AF, Class IIa for persistent AF, Class IIb for long-standing persistent AF (refractory or intolerant of at least one Class 1 or Class III AAA)

39 AF Catheter Ablation Recommendations Class I 1. Symptomatic paroxysmal AF refractory or intolerant to at least one class I or class III antiarrhythmic agent. Class IIa 1. Symptomatic persistent AF refractory intolerant to at least one class I or class III antiarrhythmic agent. 2. Symptomatic paroxysmal AF prior to a trial of antiarrhythmic drug therapy. Class IIb 1. Symptomatic longstanding (>12 mo) persistent AF refractory or intolerant to at least one class I or class III antiarrhythmic agent. 2. Symptomatic persistent AF prior to a trial of antiarrhythmic drug therapy. Class III 1. AF catheter ablation should not be performed in patients who cannot be anticoagulated during or after the procedure. 2. AF catheter ablation should not be performed with the sole intent of obviating the need for anticoagulation.

40 3D Reconstructed CT of the Heart

41 AF Ablation via Radiofrequency (RF) LIPV Pre ablation LIPV Post ablation Pulmonary vein potential Proprietary and confidential do not distribute Fairfield V signal Only Fairfield V Isolated LIPV

42 AF Radiofrequency Ablation Pre and Post Pre Ablation Voltage Post ablation Voltage with ablation lesions Proprietary and confidential do not distribute

43 Cryoballoon catheter Cryoballoon

44 Cryoballoon structure Cryoballoon

45 Cryoballoon Deployment Inflation to Occlude PV Ostium

46 Right Superior Pulmonary Vein Cryo AF ablation RSPV With Contrast Cryo Balloon Proprietary and confidential do not distribute

47 Left Superior Pulmonary Vein Cryo AF ablation Proprietary and confidential do not distribute Balloon LSPV

48 Cryo AF Ablation Voltage Map Pre Voltage Post Voltage Pre Ablation Post Ablation Proprietary and confidential do not distribute

49 Cryo AF with Termination During Ablation AF Sinus Proprietary and confidential do not distribute

50 Success and Complication Rates for Aflutter and Afib Arrhythmia Acute Success Recurrence Rates Complications Typical Atrial Flutter 97% 10.6% Overall 2.5% PPM 0.2% Tamponade 0.3% Atrial Fibrillation 70% 33% Overall 4.5% Tamponade 1.3% CVA/TIA 0.94% A-E Fistula 0.04% Death 0.15%

51 Proprietary and confidential do not distribute PVC/Ventricular Tachycardia 28 year old woman with frequent palpitations, dizziness and exertional intolerance Episodes occur throughout the day, most notable at rest and when trying to sleep ECG shows frequent PVCs with a LBBB morphology and inferior axis Holter monitor reveals 33% burden of ventricular ectopy, with short runs of NSVT, up to 5 beats in duration Echo with LVEF 45% and borderline LV enlargement No efficacy with beta-blockers or flecainide, and associated with increasing fatigue

52

53 RVOT/LVOT and Idiopathic Left Ventricular Tachycardia Pulmonary Artery Aorta Right Atrium Left Ventricle Right Ventricle

54 Management of VT in Structurally Normal Hearts Class I Catheter ablation is useful in patients with symptomatic drug-refractory VT, or in patients drug intolerant or who do not desire long-term drug therapy Class II EP testing is reasonable for diagnostic evaluation in patients with palpitations and suspected outflow tract VT Drug therapy with beta-blockers, calcium channel blocker, or type Ic agents can be useful with symptomatic VT. ICD implantation can be considered for sustained VT with drug refractory VT

55 Focal VT Sinus VT Proprietary and confidential do not distribute

56 Focal VT VT, ablation on Termination at 5 seconds Sinus Rhythm Proprietary and confidential do not distribute

57 Success and Complication Rates for PVC/NSVT Ablation Arrhythmia Acute Success Recurrence Rate Complications RVOT 90-95% 5-8% Tamponade 1% LVOT 85-95% 5-10% Coronary artery injury 0.5%, CVA 0.5% ILVT 85-95% 5-10% CVA 0.5%, CHB 0.5-1% Proprietary and confidential do not distribute

58 Summary AVNRT, AVRT, Atrial Flutter and normal heart PVCs/VT can generally be cured with ablation (90% or higher) AF can be effectively controlled by ablation in up to 70% of patients Treatment options are always patient specific

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