ABLATION TECHNIQUES FOR ATRIAL FIBRILLATION
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1 ABLATION TECHNIQUES FOR ATRIAL FIBRILLATION Demosthenes G. Katritsis, MD, PhD(Lon), FRCP Athens Euroclinic
2 Ablation for AF Cox JL, et al. Surgery for atrial fibrillation. Semin Thorac Cardiovasc Surg. 1989;1: Swartz JF, et al. Circulation 1994; 90:I-335 AHA Sessions 1994 Katritsis D, et al. Linear left atrial ablation for the treatment of atrial fibrillation. Eur Heart J 1996; Suppl:I- 45 ESC 1996
3 AF ABLATION Athens Euroclinic CS/LA (ligament of Marshall) PV disconnection Circumferential ablation (CARTO) Non-inducibility Ganglionated Plexi Ablation Combined Techniques
4 Ablation for AF Complication rates following PV and circumferential ablation Complication Rate (%) Worldwide Survey Reynolds et al. HRS 07 Circulation 2005; 111: 1199 HCA Casemix Database 51 Hosps, 2028 pts Death Stroke Transient ischemic attack 0.66 Tamponade PV stenosis Oesophageal damage? Thirty-two deaths (0.98 per 1,000 patients) were reported during 45,115 procedures in 32,569 patients. Cappato et al. JACC 2009;53:
5 Ablation for Paroxysmal AF PV Isolation With Circumferential Ablation Circumferential PV ablation even when performed with a clear end-point of delivering coalescent lesions that produce a voltage reduction to <0.1 mv and delayed local conduction (>30 ms) between contiguous points across the line, cannot achieve complete electrical isolation of PVs in 25 to 45% of patients. Hocini et al. Eur Heart J. 2005;26: Ouyang et al. Circulation. 2004;110: Pappone et al. Circulation. 2001;104: When such clear end-points are not necessarily achieved, complete isolation of all PVs is present in less than 20% of patients, and does not predict freedom from AF in the long-term. Lemola et al. J Am Coll Cardiol. 2005;46: Kottkamp et al. J Am Coll Cardiol. 2004;44:
6 Ablation for AF Katritsis, Ellenbogen, Camm. Europace. 2004;6: I HRA His CS pace L 1-2 L 3-4 L 5-6 L 7-8 L 9-10 Pre-ablation Post-ablation F-U
7 Ablation for AF AF recurrence is associated with PV-LA conduction recurrence Ouyang et al. Circulation. 2005;111: Cappato et al. 2003;108: Hocini et al. Eur Heart J. 2005;26: PV isolation may not be necessary for a successful clinical outcome Cappato et al. Circulation. 2003;108: Stabile et al. Circulation. 2003;108: Lemola et al. Heart Rhythm. 2004;1: (up to 98% recurrence). Katritsis et al. Europace 2004;6: Lemola K, et al. J Am Coll Cardiol. 2005;46: van Brakel et al. Eur Heart J. 2005;26: Pratola et al. Circulation 2008; 117:136
8 PV-LA junction reentry Multi-electrode basket catheter Kumagai et al. JACC 2004; 43:2281 Ablation for AF Antral Ablation Antral isolation
9 Ablation for AF Substrate Mapping (Fractionated potentials) Nademanee JACC 2004; 43:2044 CFAE 121 pts, 1 yr F-U, 76% Success at 1st attempt
10 Ablation for AF CFAEs and GP Katritsis et al. Europace 2009;11:
11 Ablation for AF Katritsis et al. J Cardiovasc Electrophysiol 2001;12:750-8.
12 Ablation for AF Sympathetic Denervation Ligament of Marshall Ablation Katritsis et al. J Cardiovasc Electrophysiol 2001;12:750-8.
13 Ablation for AF Vagal denervation Partial vagal denervation prevents AF Scherlag. JICE 2005; 13 (S1): 37 Scanavacca. Circulation 2006; 114:876 Schauerte. Circulation 2000; 102:2774 Lemola. Circulation 2008; 117:470 Partial vagal denervation (fat pad) increases or does not affect vulnerability to AF Hirose. JCE 2002; 13:1272 Oh. HeartRhythm 2006; 3:701
14 Ablation for AF Anatomic Ganglionic Plexi Ablation: 19 pts with PAF Katritsis et al. Am J Cardiol 2008;102:330 Left Superior GP Right Anterior GP Left and Right Inferiorr GP
15 Ablation for AF Anatomic Ganglionic Plexi Ablation for Parasympathetic Denervation Katritsis et al. Am J Cardiol 2008;102: pts with CP anatomic ablation compared to 19 age- and sex-matched controls with circumferential ablation
16 Ablation for AF
17 AF ABLATION Athens Euroclinic State Research Institute of Circulation Pathology, Novosibirsk Pokushalov and Katritsis. EUROPACE (In press) Extensive GP ablation (Reveal) Pts No F-U (months) AF-free 56 (PAF) 6 73 % 19 (Persistent AF) 6 68%
18 AF ABLATION Selective vs Anatomic GP Ablation A Randomised Comparison (80 pts) Pokushalev and Katritsis. HeartRhythm 2009;6:
19 RSPV SLGP RSPV LSPV SLGP LIPV LSGP RIPV LIPV ILGP LSGP IRGP RIPV ILGP IRGP RSPV LIGP ARGP CruxGP IRGP IRGP RSPV ARGP SLGP LSPV RIPV IRGP RIPV ARGP
20 PVAC AF ABLATION PVAC
21 LSPV RSPV LIPV RIPV
22 LSPV RSPV RIPV LIPV
23 LSPV RSPV RIPV LIPV
24 LSPV RSPV RIPV LIPV
25 LSPV RSPV RIPV LIPV
26 LSPV RSPV RIPV LIPV
27 LSPV RSPV RIPV LIPV
28 LSPV RSPV RIPV LIPV
29 RSPV Ablation for AF LSPV The Euroclinic Experience: 27 PAF pts PV isolation and GP ablation Katritsis et al. Europace (In press) RIPV LIPV
30 AF ABLATION Athens Euroclinic PVAC+GP Pts No F-U (months) AF-free LA flutter (90%) 2
31 AF ABLATION PVAC experience Boersma et al. Heart Rhythm. 2008;5: Scharf et al. J Am Coll Cardiol. 2009;54: pts 50 pts Fredersdorf et al. J Cardiovasc Electrophysiol. 2009;20: pts Duytschaever et al. Pacing Clin Electrophysiol Nov 18. [Epub ahead of print] 27 pts Wieczorek et al. J Interv Card Electrophysiol Nov 24. [Epub ahead of print] 73 pts Wieczorek et al. J Cardiovasc Electrophysiol Nov 10. [Epub ahead of print] 88
32 LSPV RSPV RIPV LIPV
33 LSPV RSPV RIPV LIPV
34 LSPV RSPV RIPV LIPV
35 LSPV RSPV RIPV LIPV
36 ABLATION TECHNIQUES FOR ATRIAL FIBRILLATION Demosthenes G. Katritsis, MD, PhD(Lon), FRCP Athens Euroclinic
37 ABLATION TECHNIQUES FOR ATRIAL FIBRILLATION Demosthenes G. Katritsis, MD, PhD(Lon), FRCP Athens Euroclinic
38 Ablation for AF Incidence of Ablation-Induced Tachycardias Athens Euroclinic, Athens, Greece Medical College of Virginia, Richmond, VA, USA patients Katritsis et al. JICE 2006;16:123 Incidence of Atrial Flutter/AT PV ostial/antral PV and linear CPVA CPVA and linear %
39 AF Ablation Long-term Results (Athens Euroclinic and Medical College of Virginia Hospital) Katritsis et al. Europace. 2008;10: Freedom from AF recurrence Freedom from AF recurrence Months after the initial ablation procedure Months after the last ablation procedure Freedom from AF recurrence after the initial procedure for patients subjected to a single procedure. Freedom from AF recurrence after the last procedure among all patients.
40 Ablation for AF Katritsis et al. Europace 2007;9:785-9 EPS is mandatory 409 pts referred for AF ablation 6.7% additional inducible arrhythmia 5 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 A Flutter AVNRT AVRT AT Additional Arrhythmia (%)
41 Ablation for AF Treat hypertension 292 pts with AF, 32 pts with lone AF 13 out of 14 pts with latent HT: AF recurrence Katritsis et al. JICE 2005;13:203 Comparison of bisoprolol vs carvedilol for SR maintenance after cardioversion of persistent AF Katritsis et al. Am J Cardiol 2003;92:1116 Response / partial response No response Hypertension P= Follow-up in months
42 Ablation for AF Impact of LA Size Predictors of PV reconnection Sauer et al. Heart Rhythm. 2006;3:1024 Relative risk P-value HTN 1.45 (1.21, 2.43) 0.02 LA size >4.5 cm 1.69 (1.12, 2.5) 0.01 Age (years) 1.05 (1.03, 1.09) <0.01 Sleep apnea 2.16 (1.32, 3.94) 0.01 Persistent 1.34 (1.09, 1.87) <0.01
43 PV isolation Ablation for Persistent AF Tailored Procedures Katritsis et al. PACE 2007;30:102 CFAE/Voltage abatement near the PV (GP) Lines (LS-RS/MV isthmus)
44 Ablation for AF: Euroclinic Practice Pokushalov and Katritsis: 101 pts selective GP vs GP and CFAE HeartRhythm (In Press)
45 AF ABLATION Athens Euroclinic Persistent AF PV isolation Pts No F-U (months) AF-free % Combined Pts No F-U (months) AF-free %
46 AF Ablation ΕΥΡΩΚΛΙΝΙΚΗ ΑΘΗΝΩΝ ασθενεις 14 LoM 92 PV isolation (Lasso) 65 circumferential (CARTO) 59 GP ablation (40 PVAC) 37 combined procedure 1 CVA (full recovery) 4 επιπωματισμοι (1.4%)» 2 χειρουργικη αντιμετωπιση
47 Ablation for AF THE FUTURE 1. PVAC or Cryo for PV 2. CARTO or NAVEX for GP ablation or CFAE ablation (near the PV) 3. New electrodes
48 Copyright 2009 American College of Cardiology Foundation. Restrictions may apply. AF ABLATION PVAC, MASC, MAAC
49 Catheter Ablation for AF: Euroclinic Practice Conclusions 1. Treatment of hypertension (Bb, ACE/ARB, statins ) and comprehensive EPS 2. Paroxysmal AF: Anatomic GP ablation (CARTO) + PV isolation (PVAC) 3. Persistent AF: Pt <75 years, LA<5, No VHD PV isolation (PVAC) or Circumferential ablation (CARTO) + anatomic GP ablation (CARTO) + additional within the lesion voltage abatement (CARTO) or CFAE near the PV ablation 4. Recurrence of persistent AF: LSPV to RSPV and mitral isthmus lines
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