Debate-STAR AF 2 study. PVI is not enough
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1 Debate-STAR AF 2 study PVI is not enough
2 Debate about STAR AF 2 trial
3 STAR AF trial Substrate and Trigger Ablation for Reduction of Atrial Fibrillation EHJ 2010
4 STAR-AF 2 trial
5 One Size Fits All?
6 PVI is enough for persistent AF?
7 STAR-AF 2 trial The first randomized, multicenter trial addressing the best approach to AF ablation in persistent AF -NEJM 2015
8 STAR AF 2 trial PVI is enough for persistent AF - despite of chronicity and LA size? - despite of coexisting or induced atrial flutter? - despite of organized atrial tachycardia during PVI? Completeness of linear ablation Termination of AF after CFAE ablation Non PV trigger or rotor
9 Chronicity and LA size the definition of persistent AF is not suitable for ablation strategy. the persistent AF population is not homogeneous. Exclusion criteria for STAR AF 2 study - paroxysmal AF - sustained AF lasting more than 3 years - left atrial diameter of 60 mm or greater.
10 Coexisting or induced atrial flutter Ablation of the CTI is recommended based on consensus opinion, in patients with a history of typical atrial flutter or inducible CTI dependent atrial flutter Expert Consensus STAR AF 2 Protocol permitted to performing a right atrial CTI line is allowed in any of the three randomization strategies and will be left to investigator discretion.
11 Organizing AT during PVI STAR AF 2 protocol permitted that investigators have the option of either ablating any additional atrial tachycardias or flutters that arise, or simply cardioverting the patient back to sinus rhythm. Performing additional lesions that would involve creating lesions prescribed by one of the other arms of the study is strongly discouraged. For example, if the patient is randomized to PVI+CFE, performing either a roof or mitral line would be strongly discouraged and vice versa.
12 Linear ablation in STAR AF 2 Roof line Mitral isthmus line (either posterior or anterior approach). The goal of all linear lesions will be to achieve complete block. pulmonary-vein isolation achieved in 97% of all patients and conduction block across ablation lines achieved in 74%
13 Ablation predominantly using unipolar RF rather than cryoablation NEJM 2015
14 Linear ablation in STAR AF 2 ablation technique using unipolar catheter techniques do not reliably produce the permanent transmural and longitudinally continuous lesions. Therefore, the failure of the study may simply be due to the relative ineffectiveness of the unipolar catheter techniques.
15 CFE ablation in STAR AF2 The endpoint for CFE ablation of protocol: - Elimination of all CFE sites in the LA, CS and RA or - AF termination. The termination of AF, the end point of ablation with CFE, was achieved in only 45% of participants, which may explain the poor long-term outcomes in this group
16 Chronic Atrial Fibrillation is a Biatrial Arrhythmia Arrhythmia Termination Using Squential Ablation Approach 55% 26% 19% Rostock T et al. Circ Arrhythmia Electrophysiol. 2008;1:
17
18 EHJ 2009
19
20 Non PV foci of Af Although most triggering focus of Af is PV, other non PV foci also serves as a triggering focus of Af in 20-40%. PV isolation is not sufficient in persistent Af, which require additional ablation at LA, RA and other thoracic vein such as SVC, CS, LOM. These structures are important in maintaining the Af. If a focal trigger is identified outside a PV at the time of an AF ablation procedure, ablation of that focal trigger should be considered Expert Consensus
21 Non-PV Foci in PeAF SVC (3, 7.5%) posterior free wall (5, 12.5%) LAA ostium (2, 5%) crista terminalis (8, 20%) CS ostium (4, 10%) interatrial septum (23, 58%) Hong Euy Lim, et al. Unpublished, 2007 Hong Euy Lim, et al. Unpublished, 2007
22 The LAA appears to be responsible for arrhythmias in 27% of patients presenting for repeat procedures. Isolation of the LAA could achieve freedom from atrial Circulation 2010
23 Catheter Ablation of AF Beyond PVI PV Isolation is enough in pts with persistent AF?
24 Cox Maze Procedure Overall success rate=82% Profile: James L Cox
25 PVI is not enough for persistent AF
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