CATHETER ABLATION FOR ATRIAL FIBRILLATION WHEN and HOW Carlo Pappone, MD, PhD, FACC San Raffaele University Hospital, Milan, Italy
ATRIAL FIBRILLATION FOR CLINICIANS FIRST DETECTED PAROXYSMAL PERMANENT PERSISTENT Matter of name? What is Chronic?
ATRIAL FIBRILLATION FOR EPs FIRST DETECTED PAROXYSMAL PERSISTENT PERMANENT
ATRIAL FIBRILLATION FOR EPs Vagal Ganglia Pappone Circulation 2004 Microreeentrant circuits Sueda Ann Thorac Surg 1997 PV foci Haissaguerre NEJM 1998 LOM Hwang Circulation 2000 CS Oral JCE 2003 Mandapati Circulation 2000 Dominant Spiral Wave
PROGRESSION FOR CLINICIANS 1.0 Permanent AF Cumulative incidence of AF (%) 0.8 0.6 0.4 0.2 Recurrent AF Persistent AF 0.0 0 12 24 36 48 Follow-up (months) Pappone et al. Unpublished data
PROGRESSION FOR EPs Paroxysmal Persistent Permanent Triggers Substrates Initiation Maintenance Adapted from D. Packer 1/2000
EARLY STAGE? AMIO WORKS Amio 60% Sotalol 35% Fleca/Propa 20%
SHOULD WE WAIT PROGRESSION? Ablation versus Amio trial
LONG-TERM AMIO? Amio discontinuation (34%) prolongation of the QT interval 1 Heart failure 2 serious bradyarrhythmias 6 gastrointestinal events 8 central nervous system events 2 Insomnia or fatigue 6 visual or dermatologic events 2 Roy, NEJM 2003
SHOULD WE ABANDON SR?
AND STAY LONG-LIFE LIFE IN AF? Why AAD therapy is not do effective for AFib?
OF COURSE NOT! it the intrinsically presence of unlikely SR but that not SR AAD is use per se is associated harmful with and a lower one can risk argue of death. that the These results warning suggest trend toward that if an a higher effective mortality method for could maintaining be attributable SR with to fewer the means side effects, used to it might achieve improve SR. survival. AFFIRM REVISITED JACC 2003
HPW EPs CAN FIGHT AGAINST AF Different but similar techniques * PVI - 1 LASSO CPVA CFE ABLATION Vagal
ABLATION STEP: 1 - ANATOMY Pappone et al, Heart Rhythm 2006 Impedance map
ABLATION STEP: 2 ISOLATE PV PV Isolation 3D-guided
ABLATION STEP: 3 MODIFY THE SUBSTRATE Pappone et al. Circulation 2001
ABLATION STEP: 4 DENERVATE WHEN POSSIBILE Circulation. 2004;109:327-334. 334.
ABLATION STEP: 5 TEST YOUR JOB
The MILAN Experience with AF Ablation N~14.000 CPVA ENDPOINTS 1. PV ISOLATION 2. SUBSTRATE MODIFICATION 3. VAGAL DENERVATION 4. NOT INDUCIBLE AF/AT Pappone et al JACC 2006
No. Pts F/u (mo.) Efficacy PAPPONE 1 ablation drugs 12 12 87% 22% NATALE 2 ablation drugs 12 12 87% 56% STABILE 3 ablation drugs 12 12 56% 9% Paroxysmal AF Studies 1 JACC 2006 2 JAMA 2005 3 EHJ 2005
Worldwide Survey of Catheter Ablation of AF LA ablation in 7,154 pts at 181 centers Complications: Stroke 0.3% TIA 0.7% Tamponade 1.2% PV stenosis 1.3% Circulation 2005
Ablation for Paroxysmal AF
AF FREEDOM 1 ABLATION 87% vs 22% P<0.001 Patients at risk CPVA 99 90 88 85 85 85 85 84 84 84 84 84 84 AAD 99 63 53 47 41 39 36 35 34 33 30 30 29 Pappone JACC 2006
GUIDELINES FOR PAF 8.3 Maintainance of SR 6. Catheter ablation is a resonable alternative to AAD to prevent recurrent symptomatic paroxysmal AF (level( of evidence: : C) C Source: Revised Guidelines for AFib 2006 AHA/ESC/ACC/HR
Ablation for Chronic AF Pappone, NEJM 2006
PERSISTENT/PERMANENT AF Pappone, NEJM 2006
180 assessed for eligibility 146 randomized 77 assigned to CPVA 69 assigned to control AT ablation (n=5) Repeat CPVA (n=25) 53 crossed over to CPVA 69 included in the analysis 77 included in the analysis 74% in SR w/o amio 75% in SR with CPVA 4% in SR w/o CPVA Pappone, NEJM 2006
GUIDELINES FOR CAF 8. MANAGEMENT OF CAF 8.1.2.2. Catheter ablation should be considered to maintain SR in selected patients who failed to respond to AAD (Oral( Oral,, NEJM 2006) 8.3.4.2. Catheter ablation is associated with rteduced mortality and morbidity due to HF nd thromboembolism (Pappone, JACC 2003) Source: Revised Guidelines for AFib 2006 AHA/ESC/ACC/HR
OPEN ISSUE IN CATHETER ABLATION FOR AF Late stage AF Can we cure incurable permanent AF? Early stage AF Can we prevent progression with limited ablation Learning curve Can we ensure optimal treatment wherever?
1. WHAT CLINICIANS CONSIDER INCURABLE Long-lasting (>5 yr duration) Severe LA dilation (>50 mm) Heart disease (HF, Valve) Actually standard ablation techniques do not perform very well Redo rate (30%) Unsatisfactory success rate (75%)
Evidence to date suggests that the mechanisms of chronic AF are more complex than those causing paroxysmal AF. The use of more extensive ablation procedures that modify the electrical substrate as well as the initiators of atrial fibrillation is often necessary to prevent chronic (?) atrial fibrillation. Wood & Ellenbogen, NEJM 2006
WHAT WE TARGET LA-CS Disconnection Mitral isthmus Septum Ablation Roof Line But also CS-LA Disconnection SVC Disconnection PV Disconnection CFAE
WHAT WE TARGET Common sites for AF termination Ligaments of Marshall Coronary sinus Septum
A Stepwise Strategy extensive substrate modification Goal: organization of a chaotic AF into a single mappable AT or SR Method: progressive substrate ablation to de-complex AF tailored in individual patient
WHAT IS SUBSTRATE MODIFICATION? Conversion to SR (55%) Direct FA to SR conversion (30%) Intermediate AT (70%) Atrial activity organization (45%)
PERMANENT AF (n = 387 pts) Mean F/U 11 ± 9 Mo. AF-free 90%
A Paradigmatic case 56 y old patients Very rich person from Slovenia 20 y ago paroxysmal AF started Early became drug-resistant And permanent starting from 91
A Paradigmatic case LA 55 mm Only E wave Normal LV
A Paradigmatic case January 2006 First Procedure Standard CPVA
A Paradigmatic case Organized but still fibrillating atria 2 days later
A Paradigmatic case AF AT Second Procedure 1 Gap April 2006
A Paradigmatic case Second Procedure AT1 198 ms 1 Gap April 2006
A Paradigmatic case AT SR Second Procedure 2 Gap April 2006
A Paradigmatic case Well organized left atrial tachycardia 1 month later
A Paradigmatic case Third Procedure AT 1 240 ms October 2006 Endocardial CS-LA Disconnection
A Paradigmatic case Third Procedure AT 2 260 ms July 2006 CS-RA Disconnection
LA Destruction! AT SR Gray means no endocardial activity
today
today LA 39 mm E/A =1.05 Normal LV
LATE STAGE AF Despite 20 y of chronic AFib, we were able to restore sinus rhythm and preserve atrial contractility The human cost for the patient and the operator was unacceptable Total procedure time: 20 hours!!! But is enough to destroy the LA?
LESSONS FROM SURGEONS Post-ablation voltage map of a patient who underwent to surgical PVI All the LA was destroyed except the perimitral tissue
We have to do more
LATE STAGE AF It would be best to ablate paroxysmal AF and to prevent its progression to chronic incurable AF Unfortunately, 60% of patients are chronic ones and there is no chance to be cured without ablation
Early stage AF Can we prevent progression with limited ablation? KEY POINTS In the next decade, we will recognize different AFibs Target: the main mechanism in the single patient Construction of a tailored ablation Treat AF in very early stage Preserve the LA Prevent progression
Selective vagal Denervation Pappone, Circulation 2004 Scannavacca, Circulation 2006
Selective vagal Denervation
Early stage AF Can we prevent progression with limited ablation? to destroy more or to destroy less?
Learning curve Can we ensure optimal treatment wherever? Learning curve represents the major limitation to widespread application of AF programs and to reproduce clinical results High costs Time consuming Volume dependent Operator dependent (gifted hands?)
A NEW VISION aimed at improving the quality and at amplifying the performance of human beings ACTIONS
From the manual hands to the mouse and joystick Are we coming back to adolescenthood? Pappone,, JACC 2006
In a few weeks you can navigate and ablate in the LA like you have years of expertise Pappone,, JACC 2006
Standard vs. Robotics Learning Standard from years to weeks Robotic Years Pappone,, JACC 2006 Weeks
CONCLUSIONS At present LA ablation represent the only available tool to cure paroxysmal and early chronic AF ablation for late chronic AF patients is difficult and time consuming Although it is not thinkable to cure a heart disease by destroying an its part
we are morally devised to offer to our patients, otherwise destined to remain life-long in AF, the possibility to regain the rhythm in which they were born
OF COURSE NOT! it the SR intrinsically presence maintainance of unlikely SR was but that associated not SR AAD is use per with se is the associated significantly harmful presence with and lower of a lower one SR mortality was can risk argue associated of and death. that adverse the These with a event results warning rates, suggest trend lower questioning toward that risk if of an a death. results higher effective of mortality AFFIRM, method for could maintaining be attributable RACE SR with and to fewer PIAF. the means AFFIRM side effects, used REVISITED to it might achieve improve SR. survival. JACC 2003 AFFIRM REVISITED JACC 2003