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Atrial Fibrillation Ablation: My personal experience 2000-2008 Helmut Pürerfellner MD, Assoc. Prof. Division of Cardiology St.Elisabeth´s Sisters Hospital.

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Presentation on theme: "Atrial Fibrillation Ablation: My personal experience 2000-2008 Helmut Pürerfellner MD, Assoc. Prof. Division of Cardiology St.Elisabeth´s Sisters Hospital."— Presentation transcript:

1 Atrial Fibrillation Ablation: My personal experience Helmut Pürerfellner MD, Assoc. Prof. Division of Cardiology St.Elisabeth´s Sisters Hospital Academic Teaching Center Linz/Austria

2 Rationale for Catheter ablation of AFib: Poor drug efficacy

3 Pulmonary vein potentials (PVP)

4 Right atriumLeft atrium Superior caval Vein Inferior caval vein Fossa ovalis Coronary Sinus Pulmonary Veins Septum

5 … critical zoneSueda Ann Thorac Surg 1997 Microreeentrant Microreeentrantcircuits Haissaguerre NEJM 1998 PV foci PV foci LOM LOM Hwang Circulation 2000

6 Ablation of AFib - Techniques Trigger approach: Focal (within PV)Focal (within PV) Segmental ostialSegmental ostial Tailored approachTailored approach Substrate approach: Circumferential atrialCircumferential atrial Additional lines (roof, mitral isthmus)Additional lines (roof, mitral isthmus) Substrate mapping (CAFE, DF)Substrate mapping (CAFE, DF) Ganglionated plexus (GP)Ganglionated plexus (GP)

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8 PV-Angiographie (LIPV)

9 Lasso Catheter Atraumatic tip Different loop diameters available Micro-catheter loop featuring 10 electrodes (3F) Deflectable Tip (B curve)

10 Ablation LIPV

11 PV-Diskonnektion

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16 … critical zoneSueda Ann Thorac Surg 1997 Microreeentrant Microreeentrantcircuits Haissaguerre NEJM 1998 PV foci PV foci LOM LOM Hwang Circulation 2000

17 Ablation of AFib - Techniques Trigger approach: Focal (within PV)Focal (within PV) Segmental ostialSegmental ostial Tailored approachTailored approach Substrate approach: Circumferential atrialCircumferential atrial Additional lines (roof, mitral isthmus)Additional lines (roof, mitral isthmus) Substrate mapping (CAFE, DF)Substrate mapping (CAFE, DF) Ganglionated plexus (GP)Ganglionated plexus (GP)

18 PV-Antrum (CT/ICE)

19 Wide areas circumferential ablation (WACA) (+ left atrial lines± ostial ablation)

20 SOI vs WACA Oral et al, Circulation 2003; 108: Decrease in local atrial electrogram amplitude >50% or amplitude 50% or amplitude <0,1mV (voltage abatement) Additional ablation within circumferential lines in 32%Additional ablation within circumferential lines in 32%

21 SOI vs WACA Oral et al, Circulation 2003; 108:

22 Success rates (extraostial)

23 Complication rates (extraostial)

24 AFib-Ablation Elisabethinen Hospital Linz Period 01/2001 – 05/2005Period 01/2001 – 05/2005 N=200 Pat.N=200 Pat. Age 53±10 aAge 53±10 a 82%m, 18%f82%m, 18%f

25 Arrhythmia Paroxysmal: n=162 (81%)Paroxysmal: n=162 (81%) Persistent: n=32 (16%)Persistent: n=32 (16%) Permanent: n=5 (2,5%)Permanent: n=5 (2,5%)

26 Procedures N=276N=276 Procedures:Procedures: 1.Lasso (segmental ostial) 2.Pappone (circumferential) 3.Combi (circumferentiell + ostial) 4.Mixed

27 Follow up Fu after 1 month (clinical examination, 24h-Holter- EKG, QOL)Fu after 1 month (clinical examination, 24h-Holter- EKG, QOL) In hospital Fu at 3, 6 und 24 months (clinical examination, Holter/Monitor, Echo, stress test, Spiral-CT, TEE, QOL; Lung scan and MRI as needed)In hospital Fu at 3, 6 und 24 months (clinical examination, Holter/Monitor, Echo, stress test, Spiral-CT, TEE, QOL; Lung scan and MRI as needed)

28 Classification of success Complete : 0 recurrences, 0 drugComplete : 0 recurrences, 0 drug Partial: 0 recurrences, + drugPartial: 0 recurrences, + drug failure: + recurrences, + drugfailure: + recurrences, + drug Clinical response: complete + partial successClinical response: complete + partial success

29 Success/patient

30 AFib paroxysmal

31 JICE 2007

32 Study design 40 consecutive patients (56.4 ± 9.6 y; 36 male)40 consecutive patients (56.4 ± 9.6 y; 36 male)

33 Multislice computed tomography imaging 16-slice MSCT16-slice MSCT Non ionic contrast agentNon ionic contrast agent Caudocranial scanningCaudocranial scanning Exspiratory breath-holdExspiratory breath-hold Barium contrast (esophagus)Barium contrast (esophagus)

34 Electroanatomic mapping 4-mm irregated tip quadripolar catheter4-mm irregated tip quadripolar catheter Contact mapping of LA and PVsContact mapping of LA and PVs EAM and MSCT displayed next to each otherEAM and MSCT displayed next to each other

35 Allignment of MSCT and EAM Landmark registrationLandmark registration Visual allignmentVisual allignment Surface registrationSurface registration

36 AF ablation procedure Circumferential approachCircumferential approach (Pappone C et al., ) (Pappone C et al., Circulation 2000;102(21):2562-4) PV-IsolationPV-Isolation (Haissaguerre M et al., ) (Haissaguerre M et al., N Engl J Med 1998;339:659–65) Additional linesAdditional lines

37 Accuracy (position error) Mean = 1.6mmMean = 2.3mm > No difference between SR and AF. > Independent of number of points.

38 Studies (J Cardiovasc Electrophysiol, Vol. 17, pp , April 2006) Position error: 2.3 ± 0.4 mm (Heart Rhythm 2005;2:1076 –1081) Position error: 2.1 ± 0.2 mm Our results: 1,6 ± 1,2 mm (pre) 2,3 ± 1,8 mm (post)

39 Conclusion Integration of MSCT scanning into 3D EAM is feasible and accurate.Integration of MSCT scanning into 3D EAM is feasible and accurate. Cardiac rhythm during procedure has no influence on the precision of fusion.Cardiac rhythm during procedure has no influence on the precision of fusion. Matching accuracy decreases after multiple ablations.Matching accuracy decreases after multiple ablations. Combining EAM and imaging methods might provide easier, faster and more reliable ablation procedures in AF.Combining EAM and imaging methods might provide easier, faster and more reliable ablation procedures in AF.

40 INTRODUCTION Does MSCT integration into 3D EAM … …lower complication rate of RF ablation?…lower complication rate of RF ablation? …improve of clinical outcome?…improve of clinical outcome? …enhance procedural efficacy?…enhance procedural efficacy? –Procedural duration –Radiation times

41 METHODS 161 consecutive patients (134 male)161 consecutive patients (134 male) Mean age 55.5 ± 9.5 yMean age 55.5 ± 9.5 y Multi-drug-resistant AF (2.4±1.1 failed AAD)Multi-drug-resistant AF (2.4±1.1 failed AAD) Serial MSCT before and 3 months after ablationSerial MSCT before and 3 months after ablation 24-hour Holter and patients questionnaire at 3 months after procedure24-hour Holter and patients questionnaire at 3 months after procedure

42 CartoXP TM vs. CartoMerge TM CARTO XP: 79 pts. CARTO Merge: 82 pts.

43 BASELINE CHARACTERISTICS

44 RESULTS - SAFETY Zero PV stenosis in the CartoMERGE group versus Five in the conventional group (p=0.021). Severe adverse events in total considerably reduced (8 vs. 2; p=0.043).

45 RESULTS - OUTCOME Outcome at 3 months Overall success after 3 months: - CARTO XP 71% - CARTOMerge 87.5% p = Martinek et al, PACE 2007

46 RESULTS - EFFICACY

47 CONCLUSION MSCT image integration into 3D EAM … … significantly improves safety … … significantly enhances success … of WACA with confirmed PV isolation and additional lines.

48 Image Integration

49 AFib Ablation Lesion Sets

50 Are you sure you know what you are doing ?

51 Journal of Cardiovasc Electrophysiol 2007

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56 Catheter Ablation of AF 2008 – Open issues AF as first-line treatment (RAAFT, CACAF, APAF)AF as first-line treatment (RAAFT, CACAF, APAF) Persistent/long standing persistent AF (chronic AF)Persistent/long standing persistent AF (chronic AF) Energy Source/Catheter designEnergy Source/Catheter design Remote navigationRemote navigation Vs AAA (CABANA), vs A+P (PABA-CHF)Vs AAA (CABANA), vs A+P (PABA-CHF) AF and CHFAF and CHF Mortality (CASTLE-AF)Mortality (CASTLE-AF) Cost-effectivenessCost-effectiveness


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