Linear Ablation Should Not Be a Standard Part of Ablation in Persistent AF The CA Heart Rhythm Symposium September 7, 2012 Gregory K. Feld, MD Professor of Medicine Director, Cardiac EP Program University of California San Diego, CA Disclosures Biotronic, Inc. Fellowship Support Boston Scientific, Inc. Fellowship support Medtronic, Inc. Fellowship support Medwaves, Inc. Director, Scientific Advisory Board, Stock Options Perminova, Inc. Founder, Member Board of Directors, Chief Medical Officer St.Jude, Inc. Fellowship Support LA Ablation vs. Segmental Ostial Ablation With PVI for PAF LA Ablation vs. Segmental Ostial Ablation With PVI for PAF Oral H, et.al., Circulation. 2003;108:2355-2360 Oral H, et.al., Circulation. 2003;108:2355-2360 1
LA Ablation vs. Segmental Ostial Ablation With PVI for PAF LA Ablation vs. Segmental Ostial Ablation With PVI for PAF Karch MR, et.al. Circulation. 2005;111:2875-80 Karch MR, et.al. Circulation. 2005;111:2875-80 AF Recurrence After Segmental Ostial PVI vs. CPVA+LALA Atypical AFL After Segmental Ostial PVI vs. CPVA+LALA Sawhney N, et.al. Circ Arrhythm Electrophysiol. 2010;3:243-8. Sawhney N, et.al. Circ Arrhythm Electrophysiol. 2010;3:243-8. 2
Persistent Atrial Fibrillation Conversion of AF to Atypical AFL During LA Linear Ablation Ablation of Atypical Left Atrial Flutter Ablation of Longstanding Persistent AF with Three Different Strategies Elayi CS, et.al. Heart Rhythm J 2008;5:1658-1664. 3
Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation 60 pts underwent sequential CPVA (with PVI), superior vena cava isolation, coronary sinus isolation, CFAE ablation, LALA and CTI ablation to restore SR After one or more ablations, at 11 ± 6 months follow-up, 57 patients (95%) were in sinus rhythm off AA drugs Catheter Ablation of Long Lasting Persistent Atrial Fibrillation Haissaguerre M, et.al. J Cardiovasc Electrophysiol 2005;16:1138-1147 Haissaguerre M, et.al. J Cardiovasc Electrophysiol 2005;16:1138-1147 AF Recurrence: Persistent AF Terminated vs. Not Terminated By Ablation AT Recurrence: Persistent AF Terminated vs. Not Terminated By Ablation O'Neill MD, et. al. Eur Heart J 2009;30:1105-1112 O'Neill MD, et. al. Eur Heart J 2009;30:1105-1112 4
AF/AT Recurrence: Persistent AF Terminated vs. Not Terminated By Ablation Freedom from MI Flutter Depending on MI Block at Initial Ablation O'Neill MD, et. al. Eur Heart J 2009;30:1105-1112 Knecht S, et. al. Eur Heart J 2008;29:2359-2366 Freedom From LA Flutter Depending on Block at Roof Line During First Ablation Atypical AFL After LALA for AF Knecht S, et. al. Eur Heart J 2008;29:2359-2366 Sawhney N, et.al. Circ Arrhythm Electrophysiol 4:832-837;2011 5
Recovery of Conduction in CTI vs. MI after Initial RFCA with Block 60 50 40 30 20 10 0 23.1% CTI Reconnected Blocked 73.11% MI Characteristics of First Ablation Procedure SR (n=40) Control (n=40) P Amiodarone <3 mo, n (%) 17 (42.5) 19 (47.5).59 AFCL (ms), 183±32 166±20.06 Procedural duration (min) 199.8±69.8 283.5±72.3 *** Fluoroscopy time (min) 51.0±24.9 96.3±32.1 *** RF duration (min) 47.5±18.9 97.0±30.6 *** Left line, n (%) 17 (42.5) 33 (82.5) *** Roof line, n (%) 14 (35.0) 33 (82.5) *** Mitral line, n (%) 7 (17.5) 30 (75.0) *** CFAE ablation, n (%) 16 (40.0) 35 (87.5) *** Ablation in the CS, n (%) 5 (12.5) 28 (70.0) *** Termination of AF, n (%) 38 (95.0) 31(77.5) * *p<.05; ***p<.001. Rivard, L, et.al. Heart Rhythm 9:1025 1030;2012 Arrhythmia-Free Survival After a Single Procedure for Patients in SR vs. AF PVI Alone in Persistent AF: An Ablation Strategy Facilitated by AA Drug Induced Reverse Remodeling Rivard, L, et.al. Heart Rhythm 9:1025 1030;2012 Kahn A, et.al. J Cardiovasc Electrophysiol 22:142-148; 2011 6
Summary Linear ablation for persistent AF frequently leads to atypical AFL or macro-reentrant AT after ablation, reducing overall success rate, especially if initial linear ablation is incomplete with gaps present. Linear ablation may not be required for comparable long-term success if electrical reverse remodeling occurs following restoration of SR (i.e. by cardioversion or AA drugs) either before or after AF ablation. Linear ablation may be associated with greater complication rate compared to PVI alone (segmental or circumferential). Rebuttal - Linear Ablation Should Not Be a Standard Part of Ablation in Persistent AF The CA Heart Rhythm Symposium September 7, 2012 Gregory K. Feld, MD Professor of Medicine Director, Cardiac EP Program University of California San Diego, CA Left Atrial Esophageal Fistula Following LA Linear Ablation Catheter Ablation of Long Lasting Persistent Atrial Fibrillation Haissaguerre M, et.al. J Cardiovasc Electrophysiol 16: 1138-1147;2005 7
MI Flutter After CPVA + LALA Termination of MI Flutter with CS Ablation Demonstration of Lateral to Medial MI Block During LAA Pacing Demonstration of Medial to Lateral MI Block During LAA Pacing 165 165 8
Prevention of Recurrence of Atypical Atrial Flutter after AF Ablation Atypical AFL or macro-reentrant AT occurs in up to 20-40% of patients undergoing LALA for AF Occurs more often after LALA ablation than after segmental PVI alone Limit linear lesions to minimum required to prevent AF recurrence Map linear ablations to ensure complete block, MI block may require ablation in CS Avoid use of proarrhythmic drugs that promote recurrence of atypical flutter (i.e. class 1c) in postablation period Fibrillating Areas Within the LA after Linear Catheter Ablation Rostock T, et.al. J Cardiovasc Electrophysiol 17:807-812;2006 Summary Linear ablation may be associated with greater complication rates compared to PVI alone (segmental or circumferential). Linear ablation may isolate areas of fibrillating LA but not eliminate them. Avoiding linear ablation results in a shorter procedure time, with less fluoroscopy exposure, and less physical stress to operator and patient. The Real Reason for Not Performing LALA in Persistent AF Picture by S. Narayan Getting to Bordeaux Wine Tasting Before All the Good Vintages are Gone! 9
Backup Slides Tissue Microwave Ablation Radiated energy Near-field effect < 3cm Field Strength 1/r 3 Thermal process Tissue Temp 45-65 Frequency 930 mhz Power 20-50 Watts Duration 120 sec Medwaves, Inc., San Diego, CA Microwave Linear Ablation Set Transmural Atrial Microwave Lesions Iwasa, et. al. Heart Rhythm 1:S267, 2004 Iwasa, et. al. Heart Rhythm 1:S267, 2004 10
ESI Map of LA Activation Before Linear Microwave Ablation ESI Map of LA Activation After Linear Microwave Ablation Iwasa, et. al. Heart Rhythm 1:S267, 2004 Iwasa, et. al. Heart Rhythm 1:S267, 2004 Non-Pulmonary Vein Ectopy Foci Triggering Atrial Fibrillation (LOM) Thorascopic Surgical Ablation of Persistent AF Chen SA, et.al. J Cardiovasc Electrophysiol 2005;16:229-32. Edgerton JR, et.al. Heart Rhythm 2009;6:S64-S70. 11
Assessing Conduction Block Across Surgical Linear Ablation Lesions Assessing Conduction Block Across Surgical Linear Ablation Lesions Lockwood D, et.al. Heart Rhythm 2009;6:S50-S63. Lockwood D, et.al. Heart Rhythm 2009;6:S50-S63. Ablation of Atypical AFL Due to Gaps In Surgical Linear Ablation Lesions Ganglionated Plexus Ablation in AF Lockwood D, et.al. Heart Rhythm 2009;6:S50-S63. Nakagawa H, et. al. Heart Rhythm 2009;6:S26-S34. 12
Phrenic Nerve Anatomy Stereotaxis Magnet System Sensei X Robotic Catheter System Reduced Fluoroscopy Exposure to Operator During Atrial Fibrillation Ablation: Benefits of Robotic Guided Navigation Steven D, et.al. J Cardiovasc Electrophysiol 21:6-12;2009 13
Fibrillating Areas Within the LA after Linear Catheter Ablation Fibrillating Areas Within the LA after Linear Catheter Ablation Rostock T, et.al. J Cardiovasc Electrophysiol 17:807-812;2006 Rostock T, et.al. J Cardiovasc Electrophysiol 17:807-812;2006 Catheter Ablation of Long Lasting Persistent Atrial Fibrillation Haissaguerre M, et.al. J Cardiovasc Electrophysiol 16: 1138-1147;2005 Sanders P, et.al. Heart Rhytym 1:176-84;2004 14
Sanders P, et.al. Heart Rhytym 1:176-84;2004 Sanders P, et.al. Heart Rhytym 1:176-84;2004 PVI Alone in Persistent AF: An Ablation Strategy Facilitated by AA Drug Induced Reverse Remodeling PVI Alone in Persistent AF: An Ablation Strategy Facilitated by AA Drug Induced Reverse Remodeling Kahn A, et.al. J Cardiovasc Electrophysiol 22:142-148; 2010 Kahn A, et.al. J Cardiovasc Electrophysiol 22:142-148; 2010 15
PVI Alone in Persistent AF: An Ablation Strategy Facilitated by AA Drug Induced Reverse Remodeling Reversal of Electrical Remodeling After Cardioversion of Persistent AF Kahn A, et.al. J Cardiovasc Electrophysiol 22:142-148; 2010 Raitt MH, et.al. J Cardiovasc Electrophysiol 15:507-512;2004 Catheter Ablation of Long Lasting Persistent Atrial Fibrillation Five Year Followup After Segmental PVI in Pts with PAF Haissaguerre M, et.al. J Cardiovasc Electrophysiol 2005;16:1125-1137 Sawhney N, et.al. Am J Cardiol 2009;104:366 372 16
Five Year F/U After Segmental PVI in Pts with PAF (w/ and w/o HTN) Single Procedure Event-Free Survival After a Single Ablation Sawhney N, et.al. Am J Cardiol 2009;104:366 372 Weerasooriya R, et.al. J Am Coll Cardiol 57:160 166;2011 Multiple Procedure Event-Free Survival Curve After Last Ablation Circumferential Pulmonary Vein Ablation for Persistent Atrial Fibrillation N=69 N=77 Weerasooriya R, et.al. J Am Coll Cardiol 57:160 166;2011 Oral H, et.al. NEJM 2006;354:934-941. 17
Catheter Ablation of Long Lasting Persistent Atrial Fibrillation Freedom from LAT Without (Group B) or With (Group A) LA Linear Ablation Haissaguerre M, et.al. J Cardiovasc Electrophysiol 2005;16:1125-1137 Knecht S, et. al. Eur Heart J 2008;29:2359-2366 18