Catheter Ablation of Atrial Fibrillation Persistent Atrial Fibrillation Catheter Ablation : where are we? F. HIDDEN-LUCET francoise.hidden-lucet@aphp.fr Pitié-Salpétrière APHP FRANCE
Disclosure Statement of Financial Interest I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Compensation for courses: MEDA Research Grants: Biotronik, Boston Scientific France, Medtronic France Consultant: Biotronik, Medtronic France
Shall we perform it? Randomised trials RFCA or surgical ablation (lone AF) vs AA drugs, non parox AF, 12 Mo FU min. 3 studies (Forleo 2009, Stabile 2006, Mont 2014) : 261 pts (RFCA 159, AA 102) Primary End Point : Freedom of Atrial Arrhythmias, Need for Cardioversion, Cardiac Hospitalisation Secondary End Point : Significant bradycardia, periprocedural complication, all cause mortality, fatal or non fatal stroke, QOL. NYONG et al. Cochrane Database of Systematic Reviews 2016; Issue 11. Art CD012088
Shall we perform it? NYONG et al. Cochrane Database of Systematic Reviews 2016; Issue 11. Art CD012088
What technique shall we use? KIRCHHOF P. et al. ESC HERA EACTS ESO Guidelines 2016. Europace 2016;18:1609-1678 VERMA A. et al N Engl J Med 2015;372:1812-22
Why linear lesions and CFAEs have been of limited help? Linear lesions : pale copy of MAZE procedure Incomplete lines lead to high % of AT Anatomical and not tailored pt Various appreciation of CFAEs Various end point (domestication, total elimination) Not a reproducible technique ablation NADEMANEE et Al. J Am Coll Cardiol 2004; 43:2044 53 CONTI S. et al Heart Rhythm 2016;13:2101-2103
Towards a more tailored ablation technique : Rotors ablation? 43 pts, 21% parox AF, 72% prior PVI Rotors mapped in spontaneous (52%) or induced (49%) and alated (5% SR restauration) Low efficacy : mapping technique, comprehensive mechanism? STEINBERG JS. Et al. Heart Rhythm 2016;0:1-6 ZAMANJA. et al. 2015
Towards a more tailored ablation technique : Low Voltage Areas Meta analysis : PVI + LVA ablation compared to PVI alone or associated to conventional wide empirical ablation (CFAEs) 6 studies, 885 pts (64% Persistent AF + 28% long standing AF). FU 17 Mo. Results favouring PVI + LVA ablation: More Effective vs PVI + PVI and wide ablation (FA/TA free) 70% vs 43%, OR = 3.41, 95%CI 2.22-5.24, p<0.001 Less AT (vs PVI + extensive RF) : 14% vs 46%, OR=0.16, 95%CI 0.07-0.37, p<0.001 Lower procedure time : 176 min vs 220 min, OR = 0.36, 95%CI 0.24-0.56, p<0.001 Lower fluoroscopy time : 25 min vs 32 min, OR = 0.22, 95%CI 0.12-0.39, p<0.001 Lower RF time : 55 min vs 90 min,or = 0.49, 95%CI 0.27-0.90, p=0.021 BLANDINO A. et al. doi:1011/pace.13015
Towards a more tailored ablation technique : Low Voltage Areas 201 pts, 82% permanent AF. Mapping LVA (bipolar EGM < 0.5 mv in AF), then PVI, then LVA ablation if present. LVA performed in 159 pts. High comparable SR rate at FU (3.1 Years) Remaining questions : catheter used, value of 0.5 MV in AF (what about SR? ), no randomisation, correlation with anatomic fibrosis? YAGISHITA A.et al. J Cardiovasc Electrophysiol 2016 doi:10.111/jce.13122
Towards a more tailored ablation technique : Spatiotemporal Electrogram Dispersion Endocardial mapping in AF with a PentaRay catheter : cartography of spatio-temporal dispersion (vicinity of a driver). 105 pts. Ablation at dispersion sites : termination of AF in 95% FU 18 Mo. Comparison with 47 pts with a classic stepwise ablation. SEITZ J. et al J Am Coll Cardiol 2017;69:303-21
Towards a more tailored ablation technique : Spatiotemporal Electrogram Dispersion FU at M 18 Single Procedure Spatiotemporal Electrogram Dispersion (n=105) Multiple Procedures Classic Stepwise ablation (n=47) Recurrent rate 15%(1.4 + 0.4 procedure/pt) 41%% (1.5 + 0.5 procedure/pt) < 0.001 RF Time (min) 49 + 21 85 + 34.5 0.001 Procedure Time (min) 168 + 42 230 + 67 < 0.0001 p SEITZ J. et al J Am Coll Cardiol 2017;69:303-21
Targetting Difficult Patients : Surgical or Hybrid Therapy More extensive lesions on the epicardial site Thoracoscopy : non incision Concomittant appendage exclusion Courtesy C.D ALESSANDRO Pitié Salpétrière
Targetting Difficult Patients : Surgical or Hybrid Therapy 78 pts Median FU 24 Mo Endocardial touch up to complete the box : 38% PISON L. et al. Ann Cardiothorac Surg 2014;3(1):38-44
Recent Guidelines Recommandations «There is no current indication for catheter ablation to prevent cardiovascular outcomes (or desired withdrawal of anticoagulation), or to reduce hospitalization». «For patients with persistent AF, ablation of complex fractionated electrograms, ablation of rotors, or routine deployement of linear lesions or another additional ablations does not seem justified in the first procedure» «However, additional ablation on top of complete PVI may be considered in patients with recurrent AF after the initial AF ablation procedure». KIRCHHOF P. et al. ESC HERA EACTS ESO Guidelines 2016. Europace 2016;18:1609-1678
Where are We? Still in a moving field!!! PVI remains the corner stone for persistent AF ablation in the guidelines Tailored ablations techniques focusing on AF mechanism and imaging developpement improving but need randomised studies and reproducibility Surgery and hybrid therapy welcome in the guidelines due to mini invasive techniques. KIRCHHOF P. et al. ESC HERA EACTS ESO Guidelines 2016. Europace 2016;18:1609-1678