Catheter ablation of AF Where do we stand, where do we go? Sébastien Knecht MD, PhD Hôpital cardiologique du Haut L Evêque, Bordeaux
Declaration of conflict of interest
ABLATION STRATEGIES Duration proc: 12 H Complications ++ 62% SR (off TT) RA lines 11-33 % LA lines 40-56 % Swartz, Kay & Packer 1994 Haïssaguerre, Jaïs JCE 1996
Pulmonary Veins are the main triggers of Paroxysmal AF PV PV Haissaguerre M, Jais P, Shah D et al NEJM 1998
PV arrhythmogenicity Abnormal automaticity Five human embryos Antibodies (HNK-1) sended to the conduction system Antibodies also evidenced at the myocardium around the PVs Blom et al. Circulation. 1999
LSPV LA ENDO PV EPI LA ENDO
Hocini et al Circulation. 2002;105:2442-2448.
without AAD PV electrical isolation is mandatory 67% 49% 110 patients (67 PAF and 43 PsAF) Randomization: isolation of each individual PV (group 1) or isolation of large areas around both ipsilateral PVs (group 2). Verification of PV electrical isolation in both groups After one procedure Follow-up period of 15±4 months Arentz et al. Circulation 2007
HRS/EHRA/ECAS consensus. Europace 2009
PAF ablation efficacy Jais et al. Circulation 2009
PAF-PsAF : 2 different worlds Paroxysmal AF: mapping and ablation centered on the PVs (even if LA substrate ablation is necessary in ~ 30% of PAF) Persistent / longstanding persistent AF: much complex substrate and much extensive ablation where PV ablation is only the initial step
Meta-Analysis: Persistent AF Ablation Single procedure success = Comparable among techniques (47%) (Inferior exceptions: Small PVI ablation, CFAE only ablation) Success rate improves with repeat procedures (65%; 1.4 procedures) and/or previously ineffective drugs (79%). Brooks AG et al. Heart Rhythm. 2010;7:835-46.
THE STEPWISE APPROACH Goal of AF termination and SR restoration Include: PV isolation Electrogram based ablation Linear lesions AT ablation Monitoring of the AFCL
AFCL LEFT ATRIUM LAA CORONARY SINUS
HYPOTHESIS CONCERNING THE AF CL Elements «at work» Number of elements ERP AF CL Haissaguerre et al. Europace
Monitoring during ablation 220 Conversion to AT 200 AFCL Prolongation 180 160 Mapping and ablation to sinus rhythm Haïssaguerre et al. Europace 2008
PRONOSTIC V1 Matsuo et al. JACC 2009
GUIDELINES
Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk
Localization of sources 50 pts with organized AF by prior ablation (consistent activation sequences for 75% of the time) Source: site or region centrifugally activating the remaining atrial tissue. Activation mapping (and RF ablation) identified 1 to 3 sources in 38 pts (76%) predominantly in the LA and CS regions. In 4 pts, the driving source was isolated, surrounded by the atrium in sinus rhythm. Haissaguerre et al. Circ 2006
CS AS A SOURCE CAUSING AF Knecht et al. JCE 2007
CFAE Konings et al. Circ 1997;95:1231
CFAE CL 204 CL 261 PASSIVE ACTIVATION IN 84% OF THE CASES Rostock, Heart Rhythm, Vol 3, No 1, January 2006
Predictive value of EGM during AF ablation Duration CEA Voltage CEA Dominant Frequency 12Hz 5Hz Takahashi et al. JACC 2008
Predictive value of EGM during AF ablation Favorable ablation sites (CL 5ms or AF Term): 72 Unfavorable ablation sites: 99 Continuous activity duration Voltage of continuous activity Local DF DF difference with LAA 1.50±3.05 Fractionation index Specificity: 156±64 ~ 65% Local mean cycle length 173±24 Cycle length difference with LAA Temporal gradient 78 (45-90) 0.18±0.10 7.62±3.12 Sensitivity: ~ 65% -7±17 16 (22%) 55 (25-85) 0.20±0.11 7.38±2.47 0.97±2.51 157±50 167±23-10±18 10 (10%)
Takahashi et al JACC 2007;49:1306-1314 WHERE?
Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk
PVI DURABILITY 302 patients ablated 158 ER 143 2 nd ablations 1.6±1.3PVs reconnected Lellouche JCE 2008;19:599-604
Results - Durability Single procedure Muliple procedures Weerasooriya et al. JACC 2011
Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk
Left atrial linear lesions are required for successful treatment of persistent atrial fibrillation 58% 42% 84% 71% 16% 29% Knecht et al, EHJ, (2008) 29, 2359 2366
Left atrial linear lesions are required for successful treatment of persistent atrial fibrillation Knecht et al, EHJ, 2008; 29, 2359 2366
Pre ablation: 3 mm Post ablation: 6 mm Abl CS LA
Needed improvements Too much tissue destruction Durability of the lesions/results Impossible in some patients to create complete linear block Procedure duration increasing the risk
Circ Arrhythm Electrophysiol. 2010;3:32-38.
Implications for the future, with improvements?
Waiting List For AF Ablation will be even longer!