19Wide areas circumferential ablation (WACA) (+ left atrial lines± ostial ablation)
20SOI vs WACA Oral et al, Circulation 2003; 108:2355-60 Decrease in local atrial electrogram amplitude >50% or amplitude <0,1mV (voltage abatement)Additional ablation within circumferential lines in 32%
21SOI vs WACA Oral et al, Circulation 2003; 108:2355-60
27Follow up 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)
34Electroanatomic mapping 4-mm irregated tip quadripolar catheterContact mapping of LA and PVsEAM and MSCT displayed next to each other
35Allignment of MSCT and EAM Landmark registrationVisual allignmentSurface registration
36AF ablation procedure Circumferential approach PV-Isolation (Pappone C et al., Circulation 2000;102(21):2562-4)PV-Isolation(Haissaguerre M et al., N Engl J Med 1998;339:659–65)Additional lines
37Accuracy (position error) Mean = 1.6mmMean = 2.3mm> No difference between SR and AF.> Independent of number of points.
38Studies Our results: 1,6 ± 1,2 mm (pre) 2,3 ± 1,8 mm (post) Position error:2.3 ± 0.4 mm(J Cardiovasc Electrophysiol, Vol. 17, pp , April 2006)Our results:1,6 ± 1,2 mm (pre)2,3 ± 1,8 mm (post)Position error:2.1 ± 0.2 mm(Heart Rhythm 2005;2:1076 –1081)
39ConclusionIntegration of MSCT scanning into 3D EAM is feasible and accurate.Cardiac rhythm during procedure has no influence on the precision of fusion.Matching accuracy decreases after multiple ablations.Combining EAM and imaging methods might provide easier, faster and more reliable ablation procedures in AF.
40INTRODUCTION Does MSCT integration into 3D EAM … …lower complication rate of RF ablation?…improve of clinical outcome?…enhance procedural efficacy?Procedural durationRadiation timesThe study, which I am able to present here today, investigated whether the use of CT integration into the EAM provided by the CARTO Merge system translates into a lower complication rate with the endpoints PV-stenosis, phrenic nerve injury, Stroke/TIA or pericardial effusion. Secondly we investigated the potential improvement of clinical outcome or procedural efficacy evaluated by procedure and radiation times in comparison with conventional 3D EAM.
41METHODS 161 consecutive patients (134 male) Mean age 55.5 ± 9.5 y Multi-drug-resistant AF (2.4±1.1 failed AAD)Serial MSCT before and 3 months after ablation24-hour Holter and patients questionnaire at 3 months after procedure161 consecutive patients (134 male, mean age 55.5±9.5y) with multi-drug-resistant AF (2.4±1.1 failed AAD) entered the study. Patients underwent serial MSCT before and 3 months after ablation to screen for significant PV stenosis which was defined as luminal narrowing over 50%. Outcome was evaluated by 24-hour Holter and patients questionnaire at 3 months after procedure.
42CartoXPTM vs. CartoMergeTM 79 pts.CARTO Merge:82 pts.79 pts. were included in the conventional group, 82 in the CT integration group.
43BASELINE CHARACTERISTICS These were the baseline characters, which did not differ between the gruops.
44RESULTS - 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).RESULTS: Comparison of outcome data between conventional EAM (CartoXP, 79 patients) and image integration (CartoMERGE, 82 patients) resulted in a significant improvement in procedural safety with no single PV stenosis more than 50% in the CartoMERGE group versus 5 in the conventional group (p=0.021) of which one had to be treated with ballon angioplasty due to hemoptyses. Severe adverse events (PV stenosis, TIA, cerebral infarction, pericardial effusion, phrenic nerve injury) in total were also considerably reduced (8 vs. 2; p=0.043).
45RESULTS - OUTCOME Martinek et al, PACE 2007 Overall success after 3 months:- CARTO XP 71%- CARTOMerge 87.5%p =Overall success was furthermore drastically improved in the image integration group (71% vs. 87.5%; p=0.019).Martinek et al, PACE 2007Outcome at 3 months
46RESULTS - EFFICACYBoth procedure and fluoroscopy times remained unchanged in our cohort. But keep in mind, we did compare conventional EAM vs. EAM plus CT integration, not EAM and conventional fluoroscopic approach.
47CONCLUSION MSCT image integration into 3D EAM … … significantly improves safety …… significantly enhances success …of WACA with confirmed PV isolation and additional lines.MSCT image integration into EAM avoids severe complications and significantly improves safety and success of WACA with confirmed PV isolation and additional lines.
56Catheter Ablation of AF 2008 – Open issues AF as first-line treatment (RAAFT, CACAF, APAF)Persistent/long standing persistent AF („chronic AF“)Energy Source/Catheter designRemote navigationVs AAA (CABANA), vs A+P (PABA-CHF)AF and CHFMortality (CASTLE-AF)Cost-effectiveness