Radiofrequency Ablation of Atrial Fibrillation: Comparison of Success Rate of Circular Ablation vs Point-by-Point Ablation with Contact Force Assessment in Paroxysmal and Persistent Atrial Fibrillation Raphael Rosso MD, Yuval Levi Med. Eng., Sami Viskin MD Tel Aviv Sourasky Medical Center
Disclosures Biosense-Webster Consultation Fee
RF ablation is the treatment of choice for patients with symptomatic, drug refractory atrial fibrillation Suboptimal results and long procedural time New technologies aimed to improve efficacy and shorten the procedures
Poor contact inaccurate mapping poor efficacy of Ablation processing time lengthened > 30% Redo Excessive Contact Inaccurate mapping risk of perforation damage to tissues / adjacent organs Char steam pop
Radiofrequency ablation lesion volume is proportional to applied contact force. Contact force catheters provide real-time feedback of the force applied between the catheter tip and the myocardium Use of contact force catheters in RF ablation of AF has led to less acute pulmonary vein reconnection, fewer gaps in the circumferential isolation lines and has significantly improved outcome after atrial fibrillation ablation. Yokoyama K et al. Circ Arrhythm Electrophysiol2008; 1:354 362. Reddy VY et al. Heart Rhythm 2012; 9:1789 1795. Gerstenfeld EP et al. Circ Arrhythm Electrophysiol 2014; 7:5 6. Neuzil P et al. Circ Arrhythm Electrophysiol 2013; 6:327 333 Natale A et al. J Am Coll Cardiol. 2014 Aug 19;64(7):647-56. doi: 10.1016/j.jacc.2014.04.072.
Carto 3 Smart Touch TRANSMITTER coil in the tip sends location reference signal about the Spring. PRECISION SPRING allows small amount of electrode deflection. SENSORS receive transmitter coils location signal and micromovements of the spring.
7
nmarq TM Catheter Loop 10 ring electrodes (Circular) 7 ring electrodes (Crescent) 3 mm long each 4 mm inter-electrode spacing Irrigated electrodes 2.5mm 2 effective surface area 10 irrigation ports per electrode 20-35 mm variable loop diameter (Circular) 25-40 mm variable loop diameter (Crescent) Compatible with 8.5 Fr Sheath Fix or Deflectable
86 consecutive patients with drug refractory paroxysmal and persistent AF referred for ablation between May 2013 and August 2014
Combined Modality Imaging 1. Fluoroscopy 2. High resolution gated CT 3. 3-D electroanatomic mapping Carto3 4. General anesthesia and conscious sedation 5. TEE or ICE
Pulmonary vein isolation in PAF Persistent AF patient underwent DCR on amiodarone a month prior to the ablation Pulmonary vein isolation ±CFAEs and linear ablation in persistent AF (5/8 with nmarq, 5/11 in SmartTouch)
Pre procedural care: Antiarrhythmic agents usually continued before ablation In patients with persistent AF DCR after amiodarone loading and RF during sinus NOACs stopped 24 hours prior to the ablation and restarted the day after the procedure Uninterrupted warfarin General anesthesia or conscious sedation according to a sedation protocol
Post procedural care Antiarrhythmic therapy continued for 1-3 months Anticoagulation continued for at least 2 months and indefinitely if CHA2DS2vasc 2 Omeprazole for 2 months
Follow up Clinical and electrocardiographic follow-up performed at 3, 6, 9, and 12 months, respectively, and every 6 months thereafter 24 Holter monitoring performed at 2 and 3 months post procedure and then twice every six months Holter recordings and trans-telephonic monitoring also performed when symptoms suggested recurrence AF recurrence defined by the presence of symptoms suggestive of AF and/or electrocardiographic documentation of > 30 seconds AF/atrial flutter/atrial tachycardia > 3months after the procedure.
PV isolation was achieved in 100% of pulmonary veins ablated nmarq mean follow up of 10.6±3 months Smart Touch mean follow-up of 11.4± 7.3 months
90 80 70 60 50 40 30 20 10 0 PAF single Per single nmarq 82 69 Smart Touch 85 75
Pulmonary vein isolation could not be achieved with the nmarq in 4 (11%) patients and was completed with a Navistar. Crossover from Navistar to nmarq was never necessary. nmarq group 5 pts. underwent CPVI with additional CFAEs and linear ablations. 2 out of 5 atrial fibrillation organized into atrial tachycardia and terminated during ablation. 3 pts. the arrhythmia could not be terminated during the ablation and required electrical cardioversion. The three patients who underwent cardioversion had recurrent atrial flutter Smart Touch group 5 pts. underwent CPVI with additional CFAEs and linear ablation. In two out of five the atrial fibrillation organized into atrial tachycardia and terminated during ablation. Both remained in sinus rhythm during follow up. In the remaining 3 pts. electrical cardioversion was perfomed. All three developed recurrent atrial fibrillation during follow up
Conclusions: nmarq and Smart Touch give similar results in AF ablation of both paroxysmal and persistent AF Need for crossover from nmarq to Smart Touch in 11% of patients nmarq can be used to perform linear ablation and CFAEs ablation Reassessment of the study results with the second generation of the nmarq catheter