Catheter ablation of atrial fibrillation: Indications and tools for improvement of the success rate of the method. Konstantinos P.

Ioannina 2015 Catheter ablation of atrial fibrillation: Indications and tools for improvement of the success rate of the method Konstantinos P. Letsas, MD, FESC SECOND DEPARTMENT OF CARDIOLOGY LABORATORY OF INVASIVE CARDIAC ELECTROPHYSIOLOGY EVANGELISMOS GENERAL HOSPITAL OF ATHENS KL KL

Catheter ablation of AF: 2014 AHA/ACC/HRS Guidelines for the Management of Patients With AF Class I AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired (Level of Evidence: A) Class IIa AF catheter ablation is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication (Level of Evidence: A) In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy (Level of Evidence: B) Class IIb AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication, when a rhythm control strategy is desired. (Level of Evidence: B) AF catheter ablation may be considered prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF, when a rhythm control strategy is desired (Level of Evidence: C) J Am Coll Cardiol 2014 Dec 2;64:e1-76. KL

Catheter ablation vs. AAD drug therapy Arch Int Med 2008;168: 581 586 KL

Radiofrequency ablation vs. AAD therapy as first line treatment of symptomatic AF RAAFT-2 trial: Among patients with paroxysmal AF without previous antiarrhythmic drug treatment, radiofrequency ablation compared with antiarrhythmic drugs resulted in a lower rate of recurrent atrial tachyarrhythmias at 2 years Morillo et al. JAMA. 2014 ;311:692-700. KL

Radiofrequency ablation vs. AAD therapy as first line treatment of symptomatic AF Europace 2015 doi:10.1093/europace/euu376

Efficacy Outcomes for Catheter Ablation of AF The single procedure success rate of catheter ablation of AF off AAD therapy was 57% (50% to 64%) in 31 arms with 2800 patients. After multiple or uncertain number of procedures, the off-aad success rate increased to 71% (65% to 77%) in 34 arms with 3481 patients. The ablation success rate was 77% (73% to 81%) in 3562 patients in 42 arms after multiple or uncertain number of procedures in patients on AAD therapy and 72% in 4786 patients in 52 arms after a single procedure on AAD therapy. Calkins et al. Circ Arrhythm Electrophysiol 2009;2:349 361 KL

Pre-ablative predictors of AF recurrence following pulmonary vein isolation Hypertension [hazard ratio (HR) 3.127; 95% confidence interval (CI) 1.269-7.706, P = 0.013] Left atrial diameter (HR 1.077; 95% CI 1.014-1.144, P = 0.015) WBC count (HR 1.423; 95% CI 1.067-1.897, P = 0.016) were independent pre-ablative predictors of AF recurrence following PVI. Letsas et al. Europace 2009;11:158-63. KL

Gastroesophageal reflux disease is a predictor of AF recurrence following left atrial ablation The final study population consisted of 88 patients (60 males, mean age 55.6 ± 13.1 years) with paroxysmal AF. The diagnosis of GERD was set up in 20 subjects (22.7%). All subjects proceeded for AF ablation within the first month of completion of PPI therapy. Following a mean follow-up period of 8.3 ± 3.1 months, 63 patients (71.6%) remained in sinus rhythm. After constructing a multiple logistic regression model using a stepwise method, only GERD (OR =8.501, 95% CI 1.637 44.149, p=0.011) and LAD (per 1 mm increase, OR = 1.796, 95% CI 1.351 2.387, p = 0.001) were independently associated with AF recurrence. Lioni et al. International Journal of Cardiology 2015; 183:211 213

CHADS2 and CHA2DS2-VASc scores as predictors of left atrial ablation outcomes for paroxysmal AF In the multivariate analysis, both CHADS2 (P: 0.023) and CHA2DS2- VASc (P: 0.012) were independently associated with AF recurrence. Cut-off analysis showed that a score 2 for both the CHADS2 and CHA2DS2-VASc score showed the highest predictive value for AF recurrence. Letsas et al. Europace. 2014;16:202-7 KL

Catheter ablation of atrial fibrillation in the elderly Lioni et al. J Geriatr Cardiol. 2014;11:291-5.

Catheter ablation of atrial fibrillation in patients with concomitant left ventricular impairment Heart, Lung and Circulation 2014

Association of quality of life, anxiety, and depression with left atrial ablation outcomes Furthermore, there was a significant improvement in QoL, anxiety, and depression after left atrial ablation. Efremidis et al. Pacing Clin Electrophysiol 2014;37:703-11. KL

What we are doing up to now?? Ablation strategies which target the PV ostium or the PV antrum aiming at electrical disconnection of the PVs are the cornerstone of AF ablation procedures Wide circumferential lesions (antral isolation) Commonly irrigated radiofrequency ablation and pointby-point strategy is used nowadays Circumferential PVAI is performed using electroanatomical 3D mapping systems (CARTO 3, Biosense Webster, NavX, St. Jude medical) KL

Pulmonary vein antral isolation KL

Electrical pulmonary vein isolation: the end-point of antral circumferential ablation KL

Electrical reconnection between pulmonary veins and left atrium: is this the cause of AF recurrence? KL

Early pulmonary vein reconnection as a predictor of left atrial ablation outcomes for paroxysmal atrial fibrillation Acute reconnection was associated with AF recurrence over a followup of close to 1.5 year. Despite intensive effort with additional ablation in patients who had reconnection at 30 min, a non-significant effect was observed in terms of improved post-ablation SR maintenance rates. Efremidis et al. EUROPACE 2015; doi:10.1093/europace/euu216

New contact force-sensing catheters allow deeper lesions (transmural lesions) KL

Contact force-sensing catheters More predictable and reliable lesions can be created with excellent catheter contact to the endocardium. Lesion size correlates with contact force and contact time. Monitoring electrode tissue contact improves the procedure success rate.

Paroxysmal AF Catheter Ablation With a Contact Force Sensing Catheter: SMART-AF Trial mean CF 17.9 g preselected working CF ranges (5-40g) in 73.3 ± 18.35% of the time J Am Coll Cardiol 2014;64:647 56

Pulmonary vein isolation using contact force ablation: The effect on dormant conduction and long-term freedom from recurrent atrial fibrillation (Heart Rhythm2014;11:1919 1924

A comparison between Thermocool SF and SmartTouch catheters Group 1: 144 patients underwent PVAI with Thermocool SF irrigated catheter (Biosense Webster, Inc). Group 2: 56 patients underwent PVAI with Thermocool SmartTouch irrigated catheter (Biosense Webster, Inc). Pulmonary vein reconnection 30 min after ablation was observed in 44% of patients in group 1 and in 31% of patients in group 2 (p: 0.089).

Catheter ablation of persistent atrial fibrillation Circ Arrhythm Electrophysiol. 2014 Dec 20

Ablation of AF based on the pathophysiology Nishida et al. J Am Coll Cardiol 2014;64:823 31 KL

Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation: the Bordeaux approach PVAI isolation SVC isolation CS disconnection: dissociation or abolition of sharp endocardial potentials. Substrate ablation: electrograms-guided ablation Linear ablation involved cavotricuspid isthmus LA roof and mitral isthmus. Termination of persistent AF can be achieved in 87% of patients by catheter ablation. J Cardiovasc Electrophysiol 2005;16: 1125-37

The impact of catheter ablation in the interpulmonary isthmus on atrial fibrillation ablation outcomes: a randomized study Letsas et al. J Cardiovasc Electrophysiol. 2014;25:709-13 KL

Optimal Method and Outcomes of Catheter Ablation of Persistent AF: The STAR AF 2 Trial No benefit in AF reduction when additional substrate ablation (CFΑEs or Lines) was performed on top of PVI PVI alone achieved freedom from recurrence in about 50% of patients KL

Active or passive pulmonary vein in AF: Is pulmonary vein isolation always essential? Passive PVs are observed: 0% paroxysmal AF 40% persistent AF 76% long-standing persistent AF PV activity during AF decreases with AF chronicity, left atrial dilatation, and left ventricular ejection fraction. Heart Rhythm 2014;11:579 586

Catheter Ablation persistent AF: what left to do? Wide PVAI Linear lesions Complex fractionated atrial electrograms (CFAEs) High density voltage mapping: Scar homogenization / Scar isolation Dominant frequency (DF) guided ablation Identification and ablation of focal sources Letsas et al. World Journal of Cardiology 2015. In Press

High density electroanatomic bipolar voltage mapping Left atrial mapping Right and left atrial mapping KL

DE-MRI of atrial scar and co-registration with electroanatomic voltage mapping during AF There was a significant association between scar identified by DE-MRI and low-voltage regions of the LA (0.39±0.61mV). There was no association between scar gaps and PV reconnection sites. Electroanatomic voltage map DE- MRI Combined projection of scar and voltage data Heart Rhythm 2012;9:2003 2009 KL

High density voltage mapping: scars DIFERENT TYPES OF FIBROTIC SCARS PATCHY SCAR DENSE SCAR KL

Homogenize the scar! HEALTHY PAF PersAF SCAR HOMOGENIZATION Circ Arrhythm Electrophysiol. 2014 KL

High density voltage mapping for PV-LA conduction gaps in redo ablation procedures Meticulous high density voltage mapping RSPV Conduction gap RIPV KL

Identification and catheter ablation of focal sources J Am Coll Cardiol 2013;62:138 47 April KL2012

Direct or Coincidental Elimination of Stable Rotors or Focal Sources May Explain Successful AF Ablation: On-Treatment Analysis of the CONFIRM Trial Stable AF sources lie in patient-specific locations with 40% to 50% near PVs and left atrial roof, and 20% to 30% in right atrium. AF source locations were more widely distributed for persistent than paroxysmal AF (~ 20% around the PVs). J Am Coll Cardiol 2013;62:138-47 KL

Driver domains in persistent AF Accurate biatrial geometry relative to an array of 252 body surface electrodes was obtained from a non-contrast CT. Reentries were not sustained (median, 2.6 rotations), meandered substantially but recurred repetitively in the same region. Of these, 69% reentries and 71% foci were in the left atrium. Driver ablation alone terminated 75% and 15% of persistent and long-lasting AF, respectively. The prevalence of reentrant drivers involving the left PV appendage and right PV regions is 97% and 94%, respectively. Focal breakthroughs originated more specifically from the PV ostia and the right and left appendages. The termination rate sharply declined after 6 months. At 12 months, 85% patients with AF termination were free from AF, similar to the control population (87%). Circulation. 2014;130:530-8.

Dominant frequency mapping: the RADAR-AF Trial J Am Coll Cardiol 2014;64:2455 67

Catheter ablation of persistent atrial fibrillation PVAI Electrograms-guided ablation DF-guided ablation End-points SR restoration Conversion to AT

Catheter ablation of persistent AF: termination

Catheter ablation of persistent AF: conversion to atrial tachycardia

Catheter ablation of persistent atrial fibrillation 15 patients with persistent AF underwent the stepwise ablation approach AF duration >6 months in 10 patients Passive pulmonary veins: 50% Sinus rhythm restoration in 3 patients (20%) Conversion to AT in 4 patients (26%) Overall success rate: 46% Two patient with tachycardia-induced cardiomyopathy displayed near-complete recovery of LV function

Up stream therapies following left atrial ablation Colchicine for prevention of early atrial fibrillation recurrence after pulmonary vein isolation (Deftereos et al. J Am Coll Cardiol 2012;60:1790-6). Central sympathetic inhibition with Moxonidine to reduce post-ablation atrial fibrillation recurrences in hypertensive patients (Giannopoulos et al. Circulation 2014). KL

Thank you very much for your attention Second Department of Cardiology Evangelismos General Hospital of Athens A. Sideris E. Sioras N. Xatzis M. Efremidis D. Manolatos S. Xydonas E. Prappa E. Zarkos J. Lakoumentas K. Letsas K. Valkanas D. Asvestas D. Karlis K. Vlachos L. Lioni V. Kareliotis C. Tsimplis K. Megalou A. Konstantopoulou S. Georgopoulos K. Vogiatzi A. Bakalakos N. Karamichalakis