Mapping techniques in AFib. Helmut Pürerfellner, MD Public Hospital Elisabethinen Academic Teaching Hospital Linz, Austria

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1 Mapping techniques in AFib Helmut Pürerfellner, MD Public Hospital Elisabethinen Academic Teaching Hospital Linz, Austria

2 critical zone Microreeentrant circuits LOM PV foci Sueda Ann Thorac Surg 1997 Haissaguerre NEJM 1998 Hwang Circulation 2000

3 LA mechanisms of AFib PV triggers/drivers Rotors Ganglionated Plexi (GP) Triggers/drivers from other thoracic veins

4 Ablation strategy Focal (within PV) Segmental ostial Circumferential atrial Additional lines Substrate mapping (CAFE, DF) Ganglionated plexus (GP)

5 Ablation strategy Focal (within PV) Segmental ostial Circumferential atrial Additional lines Substrate mapping (CAFE, DF) Ganglionated plexus (GP)

6 PV Mapping

7 PV-Mapping

8 LSPV and LAA Electrograms

9 LSPV and LAA Electrograms

10 Virtual endoscopic view LAA/LSPV and LIPV

11 RSPV Electrogram

12 RMPV

13 LSPV/LAA Electrogram in AFib

14 LSPV and LAA electrogram during ablation

15 Ablation strategy Focal (within PV) Segmental ostial Circumferential atrial Additional lines Substrate mapping (CAFE, DF) Ganglionated plexus (GP)

16 Wide areas circumferential ablation (WACA) (+ left atrial lines± ostial ablation)

17 SOI vs WACA Oral et al, Circulation 2003; 108: Decrease in local atrial electrogram amplitude >50% or amplitude <0,1mV (voltage abatement) Additional ablation within circumferential lines in 32% Lines not specifically verified for conduction block and PV isolation (PVP still present in 30-60% of PVs assessed) 8mm tip ablation catheter (55 C, 60 W)

18 SOI vs WACA Oral et al, Circulation 2003; 108:

19 WACA Proposed mechanisms: Elimination of triggers and drivers located in PVs Elimination of rotors anchoring at the PV-LA junction Debulking effect Vagal denervation

20 Ablation validation (Pappone)

21 Electrophysiologically guided LA ablation: Double Lasso Technique Ouyang et al, Circulation 2004;110:

22 Double Lasso Technique

23 Double Lasso Technique: Simultaneous isolation of LSPV and LIPV

24 Double Lasso Technique: Sequential isolation of RSPV and RIPV

25 Double Lasso Technique: Dissociated automatic PV activity

26 Double Lasso Technique: PV tachycardia

27 Double Lasso Technique: Clinical results

28 Double Lasso Technique: PV reconnection Redo procedure in 25% of pts with paroxysmal AFib and in 35% of pts with persitent AFib Recovered PV conduction in circumferential lesions in >80% of cases Succssful elimination by segmental RF ablation

29 Clinical impact of PV reconnection

30 Double Lasso technique Proposed mechanisms Ablation including adjacent atrial myocardium Delivery of higher power with more reliable PV disconnection Debulking effect Prevention of focal and macroreentrant atrial arrhythmias

31 Ablation strategy Focal (within PV) Segmental ostial Circumferential atrial Additional lines Substrate mapping (CAFE, DF) Ganglionated plexus (GP)

32 Mitral Isthmus ablation (Jais et al, Circulation 2004;110: )

33 Mitral isthmus ablation

34 Mitral isthmus ablation

35 Mitral isthmus block

36 Mitral isthmus block

37 Atypical perimitral left atrial flutter with Incomplete mitral isthmus block

38 Left atrial activation after mitral isthmus block

39 Clinical results

40 Atypical left atrial flutter circuits following PV isolation

41 LA roofline (Hocini et al, Circulation 2005;112: )

42 LA roofline

43 LA roofline validation

44 Activation Map during LAA pacing

45 Atypical left atrial flutter following PV isolation

46 AFib termination by roofline ablation

47 Mitral isthmus line and roofline validation

48 Success rates with PVI ± roofline

49 Additional lines Proposed mechanisms Prolongation of AFib cycle length Reduced AFib inducibility Elimination of atypical left atrial flutters

50 Catheter Ablation of long-lasting persistent AFib Haissaguerre et al, JCE 2005;16:

51 Catheter Ablation of long-lasting persistent AFib Haissaguerre et al, JCE 2005;16:

52 Catheter Ablation of long-lasting persistent AFib Haissaguerre et al, JCE 2005;16:

53 Catheter Ablation of long-lasting persistent AFib Haissaguerre et al, JCE 2005;16:

54 Catheter Ablation of long-lasting persistent AFib Haissaguerre et al, JCE 2005;16:

55 Catheter Ablation of long-lasting persistent AFib Haissaguerre et al, JCE 2005;16:

56 Catheter Ablation of long-lasting persistent AFib Haissaguerre et al, JCE 2005;16:

57 Termination

58 Clinical outcome

59 Ablation strategy Focal (within PV) Segmental ostial Circumferential atrial Additional lines Substrate mapping (CAFE, DF) Ganglionated plexus (GP)

60 Ideal approach for tailored AFib ablation (Haissaguerre et al)

61 CAFE Areas of fractionationed electrograms Areas with extremely short cycle lengths (<120ms) Endpoint: Elimination of all areas of fractionation, conversion to SR (including ibutilide), noninducibility in pts with paroxysmal AFib

62 Complex fractionated electrograms (CAFE) Nademanee et al, JACC 2004;43:

63 AFib Termination

64 Substrate mapping and ablation: Clinical results

65 Optical and electrogram fractionation Kalifa et al, Circulation 2006;113: Isolated sheep heart preparation (n=8) AF induced by acetylcholine Experimental and compter models of AF to explore mechanism underlying signal fractionation during AF (using endocardial videoimaging and electric mapping) Characterization of DF and a regularity index (ratio of DF to total power)

$fractionation$ Circulation

66 Optical and electrogram fractionation Kalifa et al, Circulation 2006;113:

67 Optical and electrogram fractionation Kalifa et al, Circulation 2006;113: Clinical implications: Relationship between fastest and most fractionated sites Fastest activity is in fact the most regular Most fractionated electrograms recorded in adjacent locations surrounding the AF sources Electrogram fractionation is the result of increased variability in propagation velocity and direction of waves emanating form AF sources Targeting CAFEs may result in isolation of areas harbouring AF sources

68 Future role: CAFE Alternative/adjunct to linear ablation in pts requiring substrate modification No studies formally comparing CAFE with other ablation techniques to date

69 Ablation strategy Focal (within PV) Segmental ostial Circumferential atrial Additional lines Substrate mapping (CAFE, DF) Ganglionated plexus (GP)

70 Programmed electrical nerve stimulation (PENS) and GP ablation Requires high rates and strengths of stimultion (appr times more than PES) Distal tip of map/ablation catheter deivering typically 1200 bpm (20Hz) with a pulse width of 10ms at 5 to 15 V High frequency stimulation (HFS) during SR at GP areas induces AFib (by local release of Acetylcholine) and CAFEs HFS during AFib induces vagal response (AV block and hypotension) within 10 sec Ablation directly over GP area infrequently causes symptoms HFS after ablation fails to reinduce vagal response (eliminates afferent response)

71 HFS

72 GP mapping

73 GP ablation Nakagawa et al, Heart Rhythm 2006

74 GP ablation

75 Future role: unclear GP ablation Adjunct to conventional ablation strategies?

Complications During Cardiovascular Interventions: Management and Prevention

Complications During Cardiovascular Interventions: Management and Prevention Helmut Pürerfellner, MD Public Hospital Elisabethinen Academic Teaching Hospital Linz, Austria Atrial Tachycardia/Atypical left