Catheter ablation of AF Where do we stand, where do we go?

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1 Catheter ablation of AF Where do we stand, where do we go? Sébastien Knecht MD, PhD Hôpital cardiologique du Haut L Evêque, Bordeaux

2 Declaration of conflict of interest

3 ABLATION STRATEGIES Duration proc: 12 H Complications ++ 62% SR (off TT) RA lines % LA lines % Swartz, Kay & Packer 1994 Haïssaguerre, Jaïs JCE 1996

4 Pulmonary Veins are the main triggers of Paroxysmal AF PV PV Haissaguerre M, Jais P, Shah D et al NEJM 1998

5 PV arrhythmogenicity Abnormal automaticity Five human embryos Antibodies (HNK-1) sended to the conduction system Antibodies also evidenced at the myocardium around the PVs Blom et al. Circulation. 1999

6 LSPV LA ENDO PV EPI LA ENDO

7 Hocini et al Circulation. 2002;105:

8 without AAD PV electrical isolation is mandatory 67% 49% 110 patients (67 PAF and 43 PsAF) Randomization: isolation of each individual PV (group 1) or isolation of large areas around both ipsilateral PVs (group 2). Verification of PV electrical isolation in both groups After one procedure Follow-up period of 15±4 months Arentz et al. Circulation 2007

9 HRS/EHRA/ECAS consensus. Europace 2009

10 PAF ablation efficacy Jais et al. Circulation 2009

11 PAF-PsAF : 2 different worlds Paroxysmal AF: mapping and ablation centered on the PVs (even if LA substrate ablation is necessary in ~ 30% of PAF) Persistent / longstanding persistent AF: much complex substrate and much extensive ablation where PV ablation is only the initial step

Meta-Analysis: Persistent AF Ablation Single procedure success = Comparable among techniques (47%) (Inferior exceptions: Small PVI ablation, CFAE only

12 Meta-Analysis: Persistent AF Ablation Single procedure success = Comparable among techniques (47%) (Inferior exceptions: Small PVI ablation, CFAE only ablation) Success rate improves with repeat procedures (65%; 1.4 procedures) and/or previously ineffective drugs (79%). Brooks AG et al. Heart Rhythm. 2010;7:

13 THE STEPWISE APPROACH Goal of AF termination and SR restoration Include: PV isolation Electrogram based ablation Linear lesions AT ablation Monitoring of the AFCL

14 AFCL LEFT ATRIUM LAA CORONARY SINUS

15 HYPOTHESIS CONCERNING THE AF CL Elements «at work» Number of elements ERP AF CL Haissaguerre et al. Europace

Monitoring during ablation 220 Conversion to AT 200 AFCL Prolongation 180

16 Monitoring during ablation 220 Conversion to AT 200 AFCL Prolongation Mapping and ablation to sinus rhythm Haïssaguerre et al. Europace 2008

17 PRONOSTIC V1 Matsuo et al. JACC 2009

18 GUIDELINES

19 Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk

20 Localization of sources 50 pts with organized AF by prior ablation (consistent activation sequences for 75% of the time) Source: site or region centrifugally activating the remaining atrial tissue. Activation mapping (and RF ablation) identified 1 to 3 sources in 38 pts (76%) predominantly in the LA and CS regions. In 4 pts, the driving source was isolated, surrounded by the atrium in sinus rhythm. Haissaguerre et al. Circ 2006

21 CS AS A SOURCE CAUSING AF Knecht et al. JCE 2007

23 CFAE Konings et al. Circ 1997;95:1231

24 CFAE CL 204 CL 261 PASSIVE ACTIVATION IN 84% OF THE CASES Rostock, Heart Rhythm, Vol 3, No 1, January 2006

25 Predictive value of EGM during AF ablation Duration CEA Voltage CEA Dominant Frequency 12Hz 5Hz Takahashi et al. JACC 2008

26 Predictive value of EGM during AF ablation Favorable ablation sites (CL 5ms or AF Term): 72 Unfavorable ablation sites: 99 Continuous activity duration Voltage of continuous activity Local DF DF difference with LAA 1.50±3.05 Fractionation index Specificity: 156±64 ~ 65% Local mean cycle length 173±24 Cycle length difference with LAA Temporal gradient 78 (45-90) 0.18± ±3.12 Sensitivity: ~ 65% -7±17 16 (22%) 55 (25-85) 0.20± ± ± ±50 167±23-10±18 10 (10%)

27 Takahashi et al JACC 2007;49: WHERE?

28 Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk

29 PVI DURABILITY 302 patients ablated 158 ER nd ablations 1.6±1.3PVs reconnected Lellouche JCE 2008;19:

30 Results - Durability Single procedure Muliple procedures Weerasooriya et al. JACC 2011

31 Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk

32 Left atrial linear lesions are required for successful treatment of persistent atrial fibrillation 58% 42% 84% 71% 16% 29% Knecht et al, EHJ, (2008) 29,

33 Left atrial linear lesions are required for successful treatment of persistent atrial fibrillation Knecht et al, EHJ, 2008; 29,

34 Pre ablation: 3 mm Post ablation: 6 mm Abl CS LA

35 Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk

36 Circ Arrhythm Electrophysiol. 2010;3:32-38.

37 Implications for the future, with improvements?

38 Waiting List For AF Ablation will be even longer!

Catheter ablation in AF patients with heart failure. What is possible?

Catheter ablation in AF patients with heart failure What is possible? Sébastien Knecht, MD PhD Hôpital cardiologique du Haut L Evêque, Bordeaux HEART FAILURE AND AF Ehrlich. JCE 2002 (13): 399-405, Wang