Cardiology Update 2011 Catheter Ablation of Atrial Fibrillation Laurent Haegeli University Hospital Zurich February 16, 2011
Willem Einthoven and Sir Thomas Lewis
The first ECG in 1903 Willem Einthoven (Leiden/NL)
First ECG Documentation of Auricular Fibrillation Dear Professor Einthoven, By this post I am sending you some curves, experimental and clinical. Please treat the curves I send as if they were your own. Sir Thomas Lewis, London, January 30, 1910
The Nature of Auricular Fibrillation Definition: conspicuous and continuous oscillations of varying form and dimensions, and of auricular origin, in ECG leads from the limbs. Mechanism: in general the whole auricular surface is covered by the same excitation wave or offshoots from it. Sir Thomas Lewis, Heart 1921; 8: 193-227
Atrial Fibrillation Increased prevalence in the elderly Feinberg WM, Blackshear JL, Laupacis A. Arch Intern Med. 1995;155:469-473
Growing Epidemic of Atrial Fibrillation Miyasaka et al, Circulation 2006
1998 Haïssaguerre et al. NEJM
Mapping of 45 patients with paroxysmal AF AF originating in 94% in pulmonary veins Response to local radiofrequency ablation Haïssaguerre et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339: 659-66.
Pulmonary Vein = Trigger Extrasystole in PV Initiation of atrial fibrillation Haïssaguerre et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339: 659-66.
Electrical Isolation of Pulmonary Veins by RF Ablation A P A Haïssaguerre et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339: 659-66.
Steerable Ablation Catheter (uni-/bi-directional)
Circular Mapping Catheter
Procedural Endpoint: Pulmonary Vein Isolation
Pulmonary Vein Isolation: Cornerstone of AF Ablation Point-by-point RF lesions Encircling 2 left and 2 right PVs Irrigated RF ablation catheter Circular mapping catheter 3-dimensional mapping system Integration of pre-acquired MRI/CT image of left atrium/pvs Calkins H et al. HRS/EHRA/ECAS expert consensus statement on catheter ablation and surgical ablation of atrial fibrillation. Heart Rhythm 2007.
Mapping System CARTO TM GPS navigation within the heart Navistar mapping- and ablation-catheter CARTO XP TM
Electro-Anatomical 3D-Mapping CARTO TM Posterior view
3D-Mapping + Image-Integration CARTO TM CT Posterior view
3D-Mapping + Image-Integration CARTO TM CT Posterior view
3D-Mapping + Image-Integration CARTO TM CT Posterior view
Merge of CT and Map Posterior view CARTO TM + CT Anterior view
Posterior view
Posterior view RPO view
AF SR
Success Rates?
RF Ablation versus AAD 66% - n=167-19 hospitals - Paroxysmal AF - 1 AAD failed - After 9 months: no AF 16% 66% in ablation arm 16% in AAD arm - 1 pericardial effusion 1 pulmonary oedema 1 pneumonia - 2 life-threatening arrhythmia Wilber DJ et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation. JAMA 2010; 333-340.
Quality of Life Assessment from Baseline to 3 Months Wilber DJ et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation. JAMA 2010; 333-340.
Success Rates of Pulmonary Vein Isolation for Paroxysmal AF Katritis D et al. Catheter ablation of atrial fibrillation. The search for substratedriven end points. JACC 2010; 55: 2293-8.
Randomized Trials Ablation versus AAD Camm AJ et al. Guidelines for the management of atrial fibrillation. Eur Heart J 2010.
Patient selection Success Rates? Type of AF (paroxysmal, persistent, or long-lasting persistent) Comorbidities (obesity, sleep apnea) Ablation strategy Definition of success HRS consensus: freedom of symptomatic or asymptomatic AF, atrial tachycardia, or atrial flutter lasting 30s one year following AF ablation Duration of rhythm monitoring Duration of F/U Small randomized clinical data from highly experienced centers
Ablation as First-Line Therapy for AF - Prospective, randomized - n=70 (19 hospitals) - Paroxysmal AF - Flecainide, sotalol - No AF after 12 months 87% in RF group 37% in AAD group - Hospitalization rate 9% in RF group 54% in AAD group Wazni OM et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA 2005; 293: 2634-40.
Success Rates of Ablation in Patients with Chronic AF?
Pulmonary Vein Isolation for Persistent AF Oral, H. et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002;105:1077-1081
Electrical and structural remodelling AF Progressive Atrial Cardiomyopathy Right time for ablation? time
Significance Relative Bedeutung Trigger and Substrate Paroxysmal Persistent Permanent Trigger/Initiation Substrate/Maintenance AF duration
Left Atrium = Substrate for Chronic AF Ganglionic plexi Wavelets, drivers, rotors Non-PV triggers Calkins H et al. HRS/EHRA/ECAS expert consensus statement on catheter ablation and surgical ablation of atrial fibrillation. Heart Rhythm 2007.
Common Lesion Sets in AF ablation PVI + Substrate Modification for Chronic AF Calkins H et al. HRS/EHRA/ECAS expert consensus statement on catheter ablation and surgical ablation of atrial fibrillation. Heart Rhythm 2007.
PV Isolation Plus for Chronic AF Brooks et al. Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review. Heart Rhythm 2010;7:835-46.
Stepwise Ablation Approach for Chronic AF O Neill MD et al. The stepwise ablation approach for chronic atrial fibrillation. JICE 2006;16:153-67.
Stepwise Ablation Approach for Chronic AF O Neill MD et al. The stepwise ablation approach for chronic atrial fibrillation - evidence for a cumulative effect. JICE 2006;16:153-67.
Long Term Success Rates?
Long Term Success Rates? 100 patients 175 procedures After a single procedure 63% paroxysmal AF F/U 5 years 40%, 37% and 29% success rates after 1, 2 and 5 years Weerasaooriya R et al. Catheter ablation of atrial fibrillation. Are results maintained at 5 years of follow-up? JACC 2011;57:160-6.
Long Term Success Rates? After multiple procedures 100 patients 175 procedures 63% paroxysmal AF F/U 5 years 87%, 81% and 63% success rates after 1, 2 and 5 years Weerasaooriya R et al. Catheter ablation of atrial fibrillation. Are results maintained at 5 years of follow-up? JACC 2011;57:160-6.
Risks of AF Catheter Ablation Pulmonary vein stenosis (<1%) Avoidance of ablation inside of PV Pericardial tamponade (1-2%) Percutaneous drainage Thromboembolism (1%) TEE beforehand, anticoagulation during and after procedure LSPV Ösophagus RSPV Atrio-esophageal fistula (<1:10.000) Esophageal monitoring during procedure, energy reduction, antacids Vascular access complication LIPV RIPV Left-atrial flutter (Pro-arrythmia) Redo procedure Total = 2-4 % Bertaglia et al., Heart Rhythm 2007
Technical Advancements Energy sources Application Mapping Remote catheter control and much more
Point-by-point ablation Single-shot ablation by balloon shaped catheter Ernst S. The future of atrial fibrillation ablation: new technologies and indications. Heart. 2009 Feb;95(2):158-63.
Cryoballoon Catheter Arctic Front (Medtronic CryoCath LP Ltd.)
Laser Energy Reddy VY et al. Visually-guided balloon catheter ablation of atrial fibrillation: experimental feasibility and first-in-human multicenter clinical outcome. Circulation 2009; 120:12-20.
Energy Delivery Visually Guided Reddy VY et al. Visually-guided balloon catheter ablation of atrial fibrillation: experimental feasibility and first-in-human multicenter clinical outcome. Circulation 2009; 120:12-20.
Multielectrode Ablation Catheter Ablation Frontiers (Medtronic Ltd.) Boersma LVA et al. Pulmonary vein isolation by duty-cycled bipolar and unipolar radiofrequency energy with a multielectrode ablation catheter. Heart Rhythm 2008; 5:1635-42.
Rotational Angiography Andrikopoulos et al. Invasive therapy for atrial fibrillation: recent developments in ablation, navigation and mapping technology. Heart 2011; 97:237-43.
Remote Magnetic Catheter Navigation NIOBE magnetic navigation system (Stereotaxis Inc., USA)
Remote Robotic Catheter Navigation Sensei robotic navigation system (Hansen Medical, USA)
Catheter Contact Measurement
Good candidates for AF ablation? P?!
AF Ablation in the Elderly
Camm AJ et al. Guidelines for the management of atrial fibrillation. Eur Heart J 2010.
2011 ACC/AHA/HRS Guidelines Wann LS et al. 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guidelines). Heart Rhythm 2011;8:157-76.
Indications for Catheter Ablation of AF - Symptomatic patients with paroxysmal and persistent atrial fibrillation!
Indications for Catheter Ablation of AF - Symptomatic patients with paroxysmal and persistent atrial fibrillation! - After one antiarrhythmic drug failure - No indications are: - asymptomatic patients with AF - patient wish to discontinue anticoagulation
Summary Catheter ablation of atrial fibrillation has become an established therapy in cardiology Success rates for paroxysmal atrial fibrillation are 70-90% (with 1-2 procedures) Major complications occur in 2-3 %
100 Years Ago Auricular fibrillation! It s a pitty that it cannot be treated.
Today Yes, We Can!
Thank you!