How to improve procedural outcome of cryoballoon ablation in persistent AF Experience from Redo procedures Kyoung-Ryul Julian Chun Cardioangiologisches Centrum Bethanien (CCB) Markus Krankenhaus, Med. Klinik III Frankfurt am Main, Germany
DISCLOSURES Activity Advisory Board Research Grant Speaker s Honoraria Company Medtronic Biosense Webster CardioFocus Medtronic Biotronik Boston Sci CardioFocus Medtronic
Persistent AF-Cryoballoon-Redo procedures CENTRAL QUESTIONS 1. Definition of persistent AF 2. Ablation strategies in persistent AF 3. Status Cryoballoon and PVI 4. Role Cryoballoon in Redo (persistent) AF
Persistent AF-Cryoballoon-Redo procedures NEW AF DEFINITIONS Kirchhof et al. European Heart J 2016
Persistent AF Ablation HRS/EHRA/ECAS/APHRS/SOLAECE NEW DEFINITION 2017 EARLY PERSISTENT AF Early persistent AF is defined as AF that is sustained beyond 7 days but less than 3 months in duration Calkins H et al. Heart Rhythm 2017
AF Mapping, Non PV Trigger PV Trigger across AF Types (n=2168 pts) Santangelii et al. Heart Rhythm. 2015 Oct 15. pii: S1547-5271(15)01304-1
Persistent AF Ablation STAR AF II Verma A et al. N Engl J Med. 2015 May 7;372(19):1812-22
Persistent AF Ablation STAR AF II Verma A et al. N Engl J Med. 2015 May 7;372(19):1812-22
Persistent AF Ablation STAR AF II, AF TERMINATION NO PREDICTOR Kochhä user et al. Heart Rhythm 2017;14:476 483
VHF Ablation: Hochfrequenzstrom oder Ballon? CHASE AF: PVI vs. PVI + step wise (n=153 pts) Vogler J et al. JACC 2015
Persistent AF-Cryoballoon-Redo procedures ENDPOINT AF ABLATION 2017 Kirchhof P et al. European Heart J 2016 Calkins H et al. Heart Rhythm. 2017
AF Ablation, ESC Guidelines 2016 3 AF RFC Ablation procedures 92% (156/169) pts: recovered PV conduction...!! J Cardiovasc Electrophysiol, 26,pp 371-377, April 2015
Cyroballoon AF ablation METHODS, 2. Generation CB
CCB-EP Frankfurt: CRYOBALLOON
VHF Ablation: Hochfrequenzstrom oder Ballon? FRENCH AF: CB vs. RFC Providencia et al. Europace 2016
EFFICACY: Durable PVI Permanent PVI 30% 21% 70% 79% Kuck et al 2016, GAP AF Study Reddy et al 2015, SUPIR AF 93 patients 19 patients RFC PVI Remapping 3 months after index procedure CB2 PVI Remapping 3.4 months after index procedure
AF REDO FINDINGS -- 2. GENERTION CB Low rate of PV reconnection Total Parox. AF Pers. AF 91 % 56 % 34 % 0 PV Reconnected 1 PV Reconnected 2 PV Reconnected 3 PV Reconnected 4 PV Reconnected 51 56 28 50 22 65 29 32 21 38 8 24 10 11 7 13 3 9 1 1 0 0 1 3 0 0 0 0 0 0 Data @CCB Frankfurt
REDO FINDINGS -- 2. GENERTION CB Durable PVI rate (%) (n=91pts, 357 PVs) 100 95 90 88 85 85 80 78 70 60 50 40 33 30 20 10 0 0 RIPV RSPV RCV LIPV LSPV LCPV Overall Total PV PV Iso PV Reconection % Iso RIPV 91 80 11 88 RSPV 90 70 20 78 LIPV 85 81 4 95 LSPV 85 72 13 85 LCPV 6 2 4 33 Overall 357 305 52 85 Data @CCB Frankfurt
REDO FINDINGS -- 2. GENERTION CB, persistent AF 100 Durable PVI rate (%) in persistent AF (n=34 pts) 97 90 85 88 87 80 81 70 67 60 50 40 30 20 10 0 0 RIPV RSPV RCV LIPV LSPV LCPV Overall Data @CCB Frankfurt
Persistent AF-Cryoballoon-Redo procedures Atrial Fibrillation = Atrial Fibrillation???
SCAR AF - Role of AF Substrate LA Fibrosis Marrouche NF et al. JAMA 2014
SCAR AF - Role of AF Substrate LA Fibrosis Marrouche NF et al. JAMA 2014
SCAR AF - Role of AF Substrate LA Fibrosis Marrouche NF et al. JAMA 2014
SCAR AF - Role of AF Substrate Low Voltage Zone (LVZ): bipolar 0.1-0.4mV Transitional Zone (TZ): bipolar 0.4-1.3mV SR Abnormal Electrogram (SR-AE) >300 points LA map Gang Yang et al., Circulation AEP 2016
SCAR AF - Role of AF Substrate Gang Yang et al., Circulation AEP 2016
SCAR AF - Role of AF Substrate Step wise vs. Substrate Ablation 69.8% 51.3% Gang Yang et al., Circulation AEP 2016
Persistent AF Ablation Bordignon S et al. DGK 2017
Persistent AF Ablation METHODS SCAR AF Study (PAF + persistent AF) Patient in SR Carto bipolar map Patient in AF 2 CV attempts, if no SR: exclusion Time to LAA in SR AF Cycle length in 4 PVs, LAA + CS Seite 29
Persistent AF Ablation PATIENTS Bordignon S et al. DGK 2017
Persistent AF Ablation RESULTS PRIMARY ENDPOINT Bordignon S et al. DGK 2017
Persistent AF Ablation PVI: No Substrate vs. Substrate Bordignon S et al. DGK 2017
AF Substrate SMART Lines... Bordignon et al. DGK HT 2015
Persistent AF Ablation SUGGESTION PV Isolation Responder vs. PV Isolation Non-Responder
Cryoballoon AF Persistent AF (n=100pts) Koektuerk B et al., Circulation AEP 2015
Laser Balloon or Radiofrequency Ablation for Persistent Atrial Fibrillation Boris Schmidt a, MD, Peter Neuzil b, MD, Armin Luik c, MD, Joaquin Osca Asensi d, MD, Jan Wilko Schrickel e, MD, Thomas Deneke f, MD, Stefano Bordignon a, MD, Jan Petru b, MD, Matthias Merkel c, MD, Lucie Sediva b, PhD, Annemarie Klostermann a, Laura Perrotta a, MD, Oscar Cano d, MD and KR Julian Chun a, MD a Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; b Na Homolce Hospital, Prague, Czech Republic; c Stä dtisches Klinikum, Karlsruhe, Germany; d Hospital Universitari i Politè cnic la Fe, Valencia, Spain; e University Hospital, Bonn, Germany; f Herzzentrum, Bad Neustadt, Germany
LASER VERSUS RF IN PERS AF RESULTS STUDY FLOW Enrolled and Randomized (n = 152) R LB (n = 75) RF (n = 77) - 1 screening failure (PAF) - 1 withdrew consent - 2 screening failures (1 AT, 1 anatomic reasons) - 3 withdrew consent Successful PVI (n = 73) Successful PVI (n = 72) 12 Month follow-up completed (n=68) 12 Month follow-up completed (n=66) Schmidt B et al., KRJ Chun LBCT DGK 2017
LASER VERSUS RF IN PERS AF RESULTS PRIMARY ENDPOINT Schmidt B et al., KRJ Chun LBCT DGK 2017
Persistent AF Ablation Di Biase et al. Circulation. 2010 Jul 13;122(2):109-18.
Di Biase L et al. JACC 2016
Persistent AF-Cryoballoon-Redo procedures LAA Isolation in PVI Non Responder BASELINE CHARACTERISTICS Male 14/20(70%) Age (years) 68±10 Diagnosis - PAF - Pers AF 5/20 (25%) 14/20 (70%) 1/20 (5%) - AT from LAA History of AF (years) 3.4±3.,3 Arterial hypertension 16/20(80%) Diabetes mellitus 2/20(10%) History of stroke/tia 3/20(15%) NYHA >I 2/20(10%) Coronary artery disease 7/20(35%) LA diameter (mm) 44±7 Left ventricular (EF) 62±5 Procedure number 2.6±1.,3 Bordignon S. et al., Chun KRJ submitted
Persistent AF-Cryoballoon-Redo procedures LAA Isolation in PVI Non Responder Bordignon S. et al., Chun KRJ submitted
Persistent AF-Cryoballoon-Redo procedures LAA Isolation in PVI Non Responder LAAI - PROCEDURAL DATA Procedure Time (min) 67±33 Fluoroscopy Time (min) 9,0±6,2 LAA Spike Visualization 20/20 (100%) LAA Real Time Isolation - sustained LAAI - non sustained LAAI 16/20 (80%) 11/16 (69%) 5/16 (31%) LAA Time to sustained block (s) 94±57 LAA Temperature at time to sustained block ( C) -44±7 LAA Time to non-sustained block (s) 142±64 LAA Temperature at time to non-sustained block ( C) -48±3 LAA total freeze applications (n) 2.0±1.6 LAA bonus applications (n) 8/20 (40%) LAA mean occlusion grade 3.,9±0,.2 LAA mean minimal temperature ( C) -50,0±54,7 LAA mean freeze duration (s) 214±37 Bordignon S. et al., Chun KRJ submitted
Bordignon S. et al. Europace Vienna 2017
Persistent AF-Cryoballoon-Redo procedures LAA ISOLATION PATIENTS Bordignon S. et al. Europace Vienna 2017
Persistent AF-Cryoballoon-Redo procedures COMPLICATIONS Bordignon S. et al. Europace Vienna 2017
Persistent AF-Cryoballoon-Redo procedures LAA ISOLATION IMPROVES RHYTHM OUTCOME Bordignon S. et al. Europace Vienna 2017
Persistent AF-Cryoballoon-Redo procedures CONCLUSIONS PVs are critical sites in persistent AF High rate of permanent PVI (1. procedure) After durable PVI: Substrate modification (EP endpoint) Cryoballoon LAA isolation feasible Durable LAA isolation linked to sinus rhythm The role of LAA merits investigation
TEAM FFM Thanks for your attention!
SCAR AF - Role of AF Substrate Jadidi et al. Localized Reentry with Activity >70% AF Cycle Length at Low Voltage Area Voltage <0.5mV in AF Regional Activity >70% AF Cycle Length AF Termination CL=155ms 120ms 0.5mV Fig. S1
Selective Voltage guided Ablation of persistent AF Jadidi A. et al. CircEP 2016
Persistent AF Ablation RESULTS PRIMARY ENDPOINT Jadidi A. et al. CircEP 2016
Persistent AF Ablation STAR AF II, AF TERMINATION NO PREDICTOR Kochhä user et al. Heart Rhythm 2017;14:476 483