Presentation on theme: "AF ablation with 3D mapping: our technique and results"— Presentation transcript:
1AF ablation with 3D mapping: our technique and results Dr Dhiraj Gupta MRCP MD DMLiverpool Heart and Chest HospitalNorthern UK AF experts Best Practice meetingLangdale Hotel, Cumbria 5 Feb 2010
2Schema Our approach to AF ablation at LHCH Our reasons for each step Our in-lab and follow-up results
3Our approach in a nutshell PVAI with Wide area circumferential ablationCT image integration using CARTOIndividualised lesion set prescriptionAim to ablate out of AF, ideally to SRProcedure duration limit of 5 hours
4CT image registration Critical part of the process 2 steps Single point Landmark registrationSurface Registration with Fast Anatomical MappingTakes 5-10 minutes
8Why the individualised approach? Heterogeneity amongst AF populationTrigger removal vs Substrate ModificationAim to achieve high single procedure success ratesIncremental risk with multiple proceduresThat’s what the patient wantsThat’s what the health economists want!
9Patient selection criteria Patients not offered Catheter ablation ifVery long standing Persistent AF (>3 years)Very large LA (>5.5 cm)Morbid Obesity (BMI >40), Sleep ApneaSignificant RA dilatation (>LA)Patients not offered first redo at least for 6 monthsNot offered Second redo if still in PsAF
10Not all AF patients are the same True PAFShort lived episodes, short history, normal sized LASustained PAF: 2 or more of the followingAF episodes>24 hours, History of AF > 5 years, LA size >4.5 cm, Age >65 years, Documented flutter, High AF burden (most days)Persistent AFLong standing Persistent AF (>12 months)
11Minimum RF Lesion set True PAF PVAI using WACA Sustained PAF + LA roof line + RA flutter linePersistent AF+ LA floor line + Mitral isthmus lineLong standing Persistent AF+ Epicardial CS ablation+ CAFÉ ablation
16Surgical Maze for ‘Permanent AF’ Still the Gold standard in terms of results96% free of AF at 5 years** SM Prasad et al, J Thorac Cardiovasc Surg 2003; 126:
17Results with ‘Catheter Maze’ NRedoAAD therapyResultsComplicationsHaissaguerreJCE 2005601/2Stopped at ablation95% at 11 months2 TamponadesOralNEJM 2006771/3Amio 6/52 pre & 3/12 post77% at 1 yearPostchCirc 20088881% at 20 months1 TIALoJCE 2009871/4AAD for 2/12 post79% at 21 months1 Tamponade
19Why CT image integration? Forewarned is forearmed: PV anatomical variationsCommon Left Pulmonary VeinAdditional pulmonary vein(s)Important anatomical informationthickness of the LAA ridge, intervenous carinaextent of the PV antralength of the mitral isthmus
22Why CT image integration? Dramatically reduces procedural fluoro times:<10 minutes for PAF cases10-20 minutes for PsAF casesDecreases fatigueRemoves ‘the fear of the unknown’…..Demystifies AF ablation for the nurses/ radiographers!
26Why CARTO rather than ESI? Unmatched catheter stabilityno catheter ‘dive’ with onset of RF deliveryAllows linear lesionsNo need for stable intracardiac referenceAbility to perform activation mapping if neededGreat CT image integration software
27Advances with CARTO-3Hybrid of impedance and magnetic catheter locationAbility to see all cathetersAbility to create fast anatomical mapsMakes CT image integration easierMore streamlined patient set-up
28Why WACA? PV ostial/ antral triggers Substrate modification by Atrial debulkingLess risk of PV stenosisQuicker than segmental PVIEasy to anchor linear lesions on either side‘Et tu, Bordeaux?!’
29Why our RF settings? Continuous RF: 35 W, 50°C, 10 ml/ min flow Quicker signal obliteration than 30/25 WShort procedure time (20-30’ per WACA)Prevents peri-lesion edema (? reconnection risk)RF controlled by Foot pedalFrees up a cardiac physiologistImposes discipline on use of X-ray pedal!
30131 consecutive pts. between Jan 08-July 09 Our results131 consecutive pts. between Jan 08-July 09
31Individualised ablation strategy True PAF (n=45)PVAI using WACASustained PAF (n=31)+ LA roof line+ RA flutter linePs AF (n=22)+ LA floor line+ Mitral isthmus lineLong standing Ps AF (n=33)+ Epicardial CS ablation+ CAFÉ ablation
32In-lab results All patients received prescribed minimum lesion set Mean Procedure time 173 min (98-300)Fluoroscopy timesMean 26.5 min (13-58) (as pre-CARTO 3 era)Now with CARTO-3 (n=36): Mean 14 min (6-21)Complications1 tamponade (PVI group), 1 AV fistula
33Our follow-up strategy Antiarrhythmic drug therapy for 2-3 monthsEarly post-op arrhythmiasDC CV if sustained and poorly tolerated (n=1)No redo ablation procedure for at least 6 monthsMean follow up 11.3 months (6-24)
34Our Clinical Results Definition of Procedural Success: No symptoms beyond 3 months, ANDAbsence of AF/AT on 24 hour Holter at 6 moSingle procedure success rates at 6 monthsPAF 84%PsAF 86%Sustained PAF 77% (p=0.05)Long standing PsAF 64% (p<0.001)
35Conclusions Single procedure success should be the goal Most patients need substrate modification in addition to trigger removalThis needs application of linear lesions3D mapping guided ablation the gold standard
36Acknowledgements to Dr Richard Schilling, my mentor and guide Thank You