Repeat procedures: the best approach

Transcription

1 ESC Stockholm 2010 Repeat procedures: the best approach Gerhard Hindricks, MD University Leipzig - Heart Center - Dept. of Electrophysiology Leipzig, Germany

2 Presenter Disclosure Information Gerhard Hindricks has received honoraria for lectures from Biosense, Stereotaxis, St. Jude Medical, Biotronik Gerhard Hindricks is a member of the Advisory Board / consultant for Biosense, St. Jude Medical, Biotronik, Stereotaxis, Cyberheart

3 How to approach a redo ablation procedure Recurrence after AF ablation: Clinical reality Arrhythmia recurrences are common (20 40 % of pts.). Recurrence of atrial fibrillation Onset of new atrial tachycardia - focal atrial tachycardia - micro re-entrant atrial tachycardia - macro re-entrant atrial tachycardia

4 How to approach a redo ablation procedure Re-Do Procedures after AF ablation: Agenda Clinical Indication and timing Mapping: What is the electrophysiological problem? Ablation strategies for AF recurences Ablation strategies for atrial tachycaridia

5 How to approach a redo ablation procedure Timing and indication: questions to be answered What is the follow-up? need for extended ECG monitoring What is the documented arrhythmia? AF versus atrial tachycardia Is the patient symptomatic? no re-do for asymptomatic patients What is the timing of recurrences? early predicts late recurrences but, delayed cure does exist

6 How to approach a redo ablation procedure Timing and indication Re-do procedures are indicated in patients: with well documented arrhythmia recurrences (ECG) of AF and/or AT who are symptomatic (despite AA drugs) After a waiting period of about 3 months

7 How to approach a redo ablation procedure What is the electrophysiological problem? I II III incomplete PV antrum isolation too distal initial ablation incomplete PV antrum isolation gaps in initial ablation Onset of new atrial tachycardia

8 How to approach a redo ablation procedure How to approach a redo procedure: Leipzig strategy in PAF-patients Non-fluoroscopic mapping system Steerable sheath technology 3-D-LA model integration Temperature monitoring in the esophagus

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12 How to approach a redo ablation procedure What is the electrophysiological problem? I II III incomplete PV antrum isolation too distal initial ablation incomplete PV antrum isolation gaps in initial ablation Onset of new atrial tachycardia

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14 How to approach a redo ablation procedure What is the electrophysiological problem? I II III Re-isolate the PVs to achieve complete PV antrum isolation incomplete PV antrum isolation gaps in initial ablation Onset of new atrial tachycardia

15 How to approach a redo ablation procedure Common sites of PV Re-conduction LUPV RUPV LLPV RLPV

16 How to approach a redo ablation procedure Common sites of PV Re-conduction LUPV RUPV LLPV RLPV

17 How to approach a redo ablation procedure Common sites of PV Re-conduction LUPV RUPV LLPV RLPV

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20 eso I abl Abl LPO cs CS 3/4 CS 1/2 RVA

21 How to approach a redo ablation procedure What is the electrophysiological problem? I II III Re-isolate the PVs to achieve complete PV antrum isolation Close gaps until complete PV antrum isolation is achieved Onset of new atrial tachycardia

22 How to approach a redo ablation procedure Sinus tachycardia after AF ablation (?)

23 How to approach a redo ablation procedure How to approach LAMRT after AF ablation successful treatment requires a precise description of the location of the re-entrant circuit within the real atrial anatomy current electrophysiological approach for MRT mapping: sequential activation mapping + limited entrainment entrainment mapping based strategies supported by 3D mapping systems for delineation of the area of slow conduction (activation mapping) or identification of the active re-entrant circuit (entrainment mapping)

24 3-D PPI-mapping strategy Entrainment mapping II II avf avf V1 V1 V5 ABL V5 ABL CSp CSp CSd RVA PPI-ATCL= 0 CSd RVA PPI-ATCL= 155 close to the circuit distant to the circuit

25 A II avf V1 V5 ABL CSp CSd RVA B II avf V1 V5 ABL PA CSp CSd RVA C II avf V1 D II avf V1 V5 ABL CSp V5 ABL CSp CSd RVA CSd RVA Piorkowski et al., JCE 2009

26 3-D PPI-mapping strategy MRT through CTI Piorkowski et al., JCE 2009

27 3-D PPI-mapping strategy LAMRT within the CS Piorkowski et al., JCE 2009

28 3-D PPI-mapping strategy 3-D PPI-mapping in LAMRT clearly delineates the active re-entrant circuit is fast and easy to apply even in highly complex LAMRT allows the straight forward analysis of LAMRT provides all information necessary to develop an ablation strategy examples:

29 3-D PPI-mapping strategy LAMRT peri-mitral

30 3-D PPI-mapping strategy LAMRT peri-mitral

31 3-D PPI-mapping strategy LAMRT peri-mitral

32 How to approach a redo ablation procedure What is the electrophysiological problem? I II III Re-isolate the PVs to achieve complete PV antrum isolation Close gaps until complete PV antrum isolation is achieved Onset of new atrial tachycardia Identify circuit and apply linear lesions

33 How to approach a redo ablation procedure AF-recurrence despite complete PVI

34 How to approach a redo ablation procedure AF-recurrence despite complete PVI plus LL LAA SCV

35 How to approach a redo ablation procedure AF-recurrence despite complete PVI plus LL LAA SCV

36 How to approach a redo ablation procedure AF-recurrence despite complete PVI plus LL

37 How to approach a redo ablation procedure Mapping of the SVC I I I SVC 1/2 SVC 3/4 SVC 5/6 SVC 7/8 SVC 9/10 CS 5/6 CS 3/4 CS 1/2 RVA

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40 LAA-driven tachycardia LAMRT around LAA

41 How to approach a redo ablation procedure Summary Most AF recurrences are due to re-conduction of the PVs or too distal initial ablation. Re-isolation of the PVs on an antrum level will solve the problem in most cases. Atrial macro re-entrant tachycardia after ablation of atrial fibrillation may occur in of patients with recurrences. Peri-mitral or peri-ostial re-entrant circuits are most frequent. However, septal circuits, circuits within the CS, or around the LAA may also be operative. Persistent tachycardia / AF after complete PVI and linear lesion may originate from the SVC or the LAA. Isolation of SVC/LAA is an appropriate treatment strategy.

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