Fibrillation Atriale Paroxystique : ablation, résultats, complications DIU Rythmologie Paris, le 27/01/16 sboveda@clinique-pasteur.com
1 A disease with bad consequences RR de patients en FA comparé avec des patients sans FA ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation Population de FA X 2 entre 1995 et 2030 Go et al, JAMA 2001
2 Afib ablation : theoretical aspects Haissaguerre M et al. NEJM 1998
2 Afib ablation : theoretical aspects Foyer FA
2 Afib ablation : theoretical aspects
2 Afib ablation : theoretical aspects * * * * *
Strategy of Afib ablation Initiation = Paroxysmal = Persistent Sustained = LA substrate Primary focuses (95% PV) Focal ablation Altered Tissue Linear lesions
2 Afib ablation : theoretical aspects
2 Afib ablation : theoretical aspects 3-D + Irrigated Single shot tools Kuck, Pappone Lasso + Irrigated Bordeaux 2000 Bordeaux 1999 Bordeaux 2001
3 Afib ablation : technical aspects Kato R. et al. Circulation 2003;107:2004-2010.
3 Afib ablation : technical aspects 1. All 4 veins disconnection assessed by the absence of PV potential at the ostium of each vein 2. Control of the 4 veins just before removing the catheters (frequent recurrences +++) 3. ATP?...
Follow-up - Holter just after the procedure, after 3, 6 and 12 months - OAC at least during 3 months in case of AF recurrences - Then, depending on the CHA²DS²-Vasc score
PVI Longterm Results Weerasooryia et Al., JACC 2011
114 Pts, symptomatic AF 7-Days Holter before/after ablation/3/6/12 months Symptoms recording by the Pts Hindricks G, Circulation 2005
Why are these episodes asymptomatic? Nocturne episodes (during the sleep ) Shorter and slower episodes Low acceleration of the cardiac rythm in comparizon with other SVT (Flutter, AVNRT ): Page 1994: HOLTER + TT Monitoring 14 patients with SVT, 30 detected events, 0 asymptomatic Roche 2002 : HOLTER + R test 109 SVT episodes, 12% were asymptomatic (16% of the patients), 31% of AF episodes were asymptomatic (54% of the patients). Page RL et al. Circulation 1994; 89: 224-227; Roche F, PACE 2002; 25 : 1587-1593
Why still so much recurrences?
3 Afib ablation : technical aspects Navigation systems Nowadays:
Circumferential PVI Arentz T. Circulation 2007
PV Isolation: the larger the better? 110 Patients Ostial segmental PVI = small isolation Circumferential Isolation = large isolation Arentz et al. Circulation 2007
PV Isolation: the larger the better? Arentz et al. Small or large isolation areas around the PVs. Circulation 2007
«Large» PVI Fragmented potentials Autonomous GPs Others??? (substrate, rotors ) 28 mm balloon
Europace 2014 150 Pts, 12 months FU CF-guided radiofrequency and cryotherapy present very similar performances in the setting of paroxysmal AF catheter ablation
PAF Typical baseline ECG
Afib coming from RSPV
LSPV before RF ablation
LSPV after first RF application : 1 st degree PV block
LSPV after RF ablation
Pacing inside LSPV showing LA dissociation
Pacing inside LIPV : still connected
RSPV pre RF ablation
RSPV dissociation after RF ablation
23 mm 28 mm
LSPV /Achieve
Achieve in the LSPV, isolation at 35 s freeze during CS pacing
Paroxysmal AF, Achieve in the LSPV, without pacing - Where is the A potential? - Where is the venous potential? - Where is the ventricular potential? (1)
(2) During cryo ablation at 15 sec
Europace 2014
4 Afib ablation : results PAF Ablation : Randomized Studies AF - ESC Guidelines, EHJ 2010
Study Design of the STOP-AF Trial Inclusions: Patients >2 AF episodes in 2 months w ECG doc. of 1 Rx Failure of > 1 AA Rx AA Rx failure n=304 Randomized 2:1 to ablation vs. Drug Rx Cryoballoon ablation n=163 Drug Rx n=82 Blanking period (90 day) Redo ablation n=31 Drug optimization 90 days Followup 1,3,6,9, &12 mo Holters Weekly TTMs Screening Exclusion n=46 Consent withdrawal n=7 Screening failure n=6 Cross-over n=65
Treatment success (%) Primary Effectiveness Analysis Treatment Success 100 30 days 80 CRYO 69.9% 114/163 60 40 P<0.001) 20 Blanked DRUG Rx 7.3% 6/82 0 0 100 200 300 400 500 Days KM estimate 68.6% (SE 3.9%) vs 7.3% (SE 2.9%)
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 4 Afib ablation : global 700 600 500 400 300 200 Per AF Par AF Cryo 100 0
4 Afib ablation : results in elderly Observational studies of catheter ablation suggest similar long-term efficacy and safety rates in elderly and very elderly populations in comparison with younger groups Johnson DL, Clinic Geriatric Med 2012
5 Afib ablation : complications Update ww survey > 16 000 pts Cappato R et Al., Circ EP 2010
Circulation 2013; 128:2104-2112
Types de complications Tamponnade : incidence = 1 à 2%, plutôt actuellement 0,3 à 0,5%... Drainage sous-xyphoïdien Chirurgie +++ Wu R, J Cardiovasc Electrophysiol 2002
Types de complications AVC : incidence = 1 à 2%, plutôt actuellement 0,1 à 0,2% ACT 300-350 (per-op + post-op) Surveillance clinique per-op + post-op Stroke center / Fibrinolyse Troughton R, Heart 2003 Dixit S, Heart Rhythm 2007
COMPARE Trial Di Biase L et Al., Circulation 2014
Sticherling et Al., Europace 2015
Types de complications - Fistule atrio œsophagienne : incidence < 0.25% - Sous-estimée?... Sra J, J Interv Card Electrophysiol 2008 Dixit S, Heart Rhythm 2007
AE Fistula Symptoms Cummings, Ann Intern Med 2006
Distance and Esophageal Temperature RF: < 39 C Cryo: > 15 C
Types de complications PV stenosis : Severe >70% : 1-3%, actuellement proche de 0% (WACA, Cryo+++) Sra J, J Interv Card Electrophysiol 2008
Paralysie (Transitoire) Phrénique Dte <0,5% depuis 2013
6 Looking at the Guidelines www.escardio.org/guidelines European Heart Journal 2012
6 Looking at the Guidelines AF - ESC Guidelines, EHJ 2012
6 Looking at the Guidelines AF - ESC Guidelines, EHJ 2010
6 Looking at the Guidelines
6 Heart 2013
6 14 studies were identified enrolling a total of 4782 patients (1823 treated with dabigatran and 2959 with warfarin) In the setting of AF catheter ablation, this first pooled analysis suggests that patients treated with dabigatran have a similar incidence of thromboembolic events and major bleeding compared to warfarin, with low event rates overall Heart 2013
7 Should we ablate before? This suggests that the selection of patients for the invasive strategy should be considered at an earlier stage of the disease, even before AAD Europace 2011
Take Home Message 1. Symptomatic parox Afib ablation after AAD failure is a I / IIa indication with a 75% success and 2-3% complication rates 2. Afib ablation is cost-effective in these patients 3. Afib type, absence of SHD, LA enlargement, LA fibrosis/srm seem to be important factors for a better outcome after ablation 4. try to ablate before Afib becomes persistent 5. at earlier stages of the disease