1995 Our First AF Ablation. Atrial Tachycardias During and After Atrial Fibrillation Ablation. Left Atrial Flutter. 13 Hours Later 9/25/2009

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1 1995 Our First AF Ablation Atrial Tachycardias During and After Atrial Fibrillation Ablation G. Neal Kay MD University of Alabama at Birmingham Right Anterior Oblique Left Anterior Oblique Left Atrial Flutter I AVF V1 13 Hours Later HRA p HRA d CS p CS m CS d 1

Atrial Tachycardias After AF Ablation Are relatively uncommon (1-2% of pts) when only ostial PVI is performed Are very common (10-30%) when WACA, Linear ablation, or CFAE approaches are used Are

Transition of AFl Multiple ATs are Common Mapping ATs Where to Start? First, ask yourself what are the possible mechanisms?

2 Atrial Tachycardias After AF Ablation Are relatively uncommon (1-2% of pts) when only ostial PVI is performed Are very common (10-30%) when WACA, Linear ablation, or CFAE approaches are used Are expected (>50%) when the goal of ablation is to terminate persistent AF Mechanism is macroreentry in 75% and focal mechanism in 25% Ablation of Persistent PV & LA AF ablation may be Extensive Transition of AFl Multiple ATs are Common Mapping ATs Where to Start? First, ask yourself what are the possible mechanisms? Macroreentry Microreentry Focal source Second, look at the CS electrograms Are they quite regular or is there irregularity? Are they sequential in a consistent direction? Third, entrain the RA and LA Fourth, map a few widely separated points in the chamber of interest 2

3 First Step Is it Right or Left Atrial? Rapid pacing from the Right Atrial Tricuspid Annulus and Coronary Sinus Is the tachycardia entrained? Where is the earliest return cycle? Is the PPI close to the tachycardia CL? Is the PPI constant at a given site? Atrial Flutter of 2 Types Yamada T, et al. JCVEP 2008;19:219. 3

Transient Entrainment from RA 2 nd Step Is it Reentry

Can the entire CL be accounted for in a single chamber?

RA Halo AVF I V1 LLRA p LLRA d RAA p RAA d CS p CS m CS

4 Transient Entrainment from RA 2 nd Step Is it Reentry or Focal Source? Is classic entrainment demonstrated? Is the tachycardia regular or not? Is the PPI constant at a site? Can the entire CL be accounted for in a single chamber? Yamada T, et al. JCVEP 2008;19:219. RA Halo AVF I V1 LLRA p LLRA d RAA p RAA d CS p CS m CS d 19/20 17/18 15/16 13/14 11/12 9/10 7/8 5/6 3/4 1/2 Classic Entrainment proves reentry Irregularity Suggests a Focal Source 4

5 Organization of AF with Ablation Is it Macroreentry or a Focal Source? RA Septal Focus Left Atrium 122 ms Tachycardia CL 290 ms 5

6 Variable PPI Predicts Focal Source PPI (Longest Shortest) Macroreentry Focal Source 2 Patterns of Localized Sources Haissaguerre M. Circulation 2006;113:616 Focal Atrial Tachycardia Centrifugal Pattern Microreentrant Pattern Tachycardia CL 245 ms LA Activation 98 ms 58% 42% 6

7 Focal Reentry Entire CL accounted for in a small region PV Tachycardia Sinus Tachycardia 7

8 P-Wave Morphology A discrete P-wave with Isoelectric Segment Suggests a Focal Source Teh, A, et al. JCVEP 2009;20:

Non-Coronary Cusp Atrial Tach Right Coronary Cusp Left Coronary Cusp NCC RCC RCC Non Coronary Cusp

Cavotricuspid Isthmus dependent Mitral Annulus Roof Dependent PV Encircling Lesion Gaps

or out CTI dependent AFL) Map and entrain prox CS, distal CS, Anterior MA (rule in or out MV annulus

9 Non-Coronary Cusp Atrial Tach Right Coronary Cusp Left Coronary Cusp NCC RCC RCC Non Coronary Cusp What are the Possible Macroreentrant Circuits? Cavotricuspid Isthmus dependent Mitral Annulus Roof Dependent PV Encircling Lesion Gaps Macroreentrant Strategy Sequential CS activation Entrain from Lateral RA tricuspid annulus (rule in or out CTI dependent AFL) Map and entrain prox CS, distal CS, Anterior MA (rule in or out MV annulus AFL) Simultaneous CS activation Map and entrain high and low points on Anterior and Posterior LA walls Opposite cranial-caudal directions suggests LA roof dependent AFL 9

10 CircumAnnular LA Flutter 10

11 Mitral Isthmus Dependent Macroreentry Veenhuyzen G, et al. JCVEP 2009;20:949 Veenhuyzen G, et al. JCVEP 2009;20:949 Roof Left Atrium Tachycardia CL 280 ms LA activation 277 ms 11

12 Roof Left Atrium Bachmann s Bundle Roof Left Atrium Roof Left Atrium 240ms ms ms 12

13 Roof Dependent Macroreentry Roof Dependent AFL Jais P, et al JCVEP 2009;20:480. Anterior LA High to Low Posterior LA Low to High Yamada T, et al. JCVEP 2008;19:219. Ablation of Roof Dependent AFL PV Reentry Entire CL recorded in small region Jais P, et al JCVEP 2009;20:

14 Macroreentry Through WACA Gaps Satomi K, et al. Heart Rhythm 2008;5:43 Macroreentry Through WACA Gaps Entrainment Satomi K, et al. Heart Rhythm 2008;5:43 Satomi K, et al. Heart Rhythm 2008;5:43 14

15 Location of Gaps Ablation at Entrance or Exit Satomi K, et al. Heart Rhythm 2008;5:43 Satomi K, et al. Heart Rhythm 2008;5:43 ASD Repair Scar Flutter Left Lung Transplant Macroreentrant Tachycardia Right Anterior Oblique Left Anterior Oblique 15

16 Potential Reentrant Circuits Halo - Left Pulmonary Veins Right Anterior Oblique Left Anterior Oblique I AVF V1 HBE p HBE d CS p CS m CS d Start of Ablation Line Ablation Line End of Ablation Line 16

17 I AVF V1 Deductive Mapping Strategy for ATs Step 1 CL Irregularity >15% HBE p <15% HBE d CS p Step 2 Activation Map & PPI Consistent with: Mitral annulus CTI Roof Reentry No Step 3 Identify Focal Source CS m CS d Yes Linear Ablation PPI Activation Map Jais P, et al JCVEP 2009;20:480. Ablation of Drivers Ablation of 1 st Driver Drivers after Maze Operation Termination of AF N=27 2nd AF Driver N=6 Conversion to AFL N=5 56 yr old man CABG and mini-maze 1 yr previously Induced 2 nd Driver N=2 Ablation of 2nd Driver N=8 WACA ablation 4 mos ago Recurrent AF Termination of AF N=5 3rd AF Driver N=3 Ablation Terminated AF N=3 Haissaguerre M. Circulation 2006;113:616 17

18 Posterior Right Atrial Focal Driver 18

Left Atrial Focal Driver 2 nd Tachycardia Induced Is Post Ablation AT an

Group I 33 pts with Persistent AF who converted to AT during ablation of AF CS and

to AT, and after conversion to AT Group II 20 consecutive pts undergoing ablation

19 Left Atrial Focal Driver 2 nd Tachycardia Induced Is Post Ablation AT an Underlying Driver or Iatrogenic? Group I 33 pts with Persistent AF who converted to AT during ablation of AF CS and Surface V1 EGMs recorded for 60 sec before ablation, for 3 min prior to conversion to AT, and after conversion to AT Group II 20 consecutive pts undergoing ablation of AT mos after AF ablation All had AF terminated by DCCV during index AF ablation procedure Yoshida K, et al. Heart Rhythm 2009;6:11 19

Baseline CS FFT 52% of Group I 20% of Group II Ablation of AF Decreases DF of AF But Not the AT Component CS FFT 3 min prior to Termination to AT (or DCCV) 79% of Group I 50% of Group II Yoshida K,

20 Baseline CS FFT 52% of Group I 20% of Group II Ablation of AF Decreases DF of AF But Not the AT Component CS FFT 3 min prior to Termination to AT (or DCCV) 79% of Group I 50% of Group II Yoshida K, et al. Heart Rhythm 2009;6:11 CS FFT immediately after Termination to AT Yoshida K, et al. Heart Rhythm 2009;6:11 Correlation of DF in AT to DF in AF Group I Correlation of DF in AT to DF in AF Group II Yoshida K, et al. Heart Rhythm 2009;6:11 Yoshida K, et al. Heart Rhythm 2009;6:11 20

21 Significance of AT after Atrial Fibrillation Ablation If AT is uncovered during AF ablation, the mechanism is usually a preexisting driver If AT occurs late after AF ablation, the mechanism is usually iatrogenic creation of lines with gaps Atrial Tachycardias after AF Ablation May Be Macroreentrant CTI Mitral Annular Roof LA Focal Mechanisms Microreentry (continuous, fractionated EGMs) Focal source (discrete EGMs with centrifugal activation) 21

How to Distinguish Focal Atrial Tachycardia from Small Circuits and Reentry

How to Distinguish Focal Atrial Tachycardia from Small Circuits and Reentry Pierre Jaïs; Bordeaux, France IHU LIRYC ANR-10-IAHU-04 Equipex MUSIC imaging platform ANR-11-EQPX-0030 Eutraf HEALTH-F2-2010-261057