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Substrate Ablation (CAFE) A Promising or Vanishing Technique Walid I. Saliba, M.D. Director, Atrial Fibrillation Center Section of Pacing and Electrophysiology,

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Presentation on theme: "Substrate Ablation (CAFE) A Promising or Vanishing Technique Walid I. Saliba, M.D. Director, Atrial Fibrillation Center Section of Pacing and Electrophysiology,"— Presentation transcript:

1 Substrate Ablation (CAFE) A Promising or Vanishing Technique Walid I. Saliba, M.D. Director, Atrial Fibrillation Center Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine THE CLEVELAND CLINIC FOUNDATION Cleveland, Ohio Director, Atrial Fibrillation Center Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine THE CLEVELAND CLINIC FOUNDATION Cleveland, Ohio

2 Goal To confuse you

3 Paroxysmal Self terminating AF episodes Permanent Sinus cannot be maintained Persistent Sinus can be restored electrically or chemically AF begets AF Atrial remodeling: Refractory Period Conduction velocity Favors Arrhythmia Trigger initiation Substrate maintenance Natural History of AF Dual Substrate Model Ablation of Triggers Modification of Substrate

4 Alternative Strategies More Ablation Where? Why? How much more? CAFE Dominant Frequency Ganglionic Plexi Stepwise/Tailored AF Nest SVC / CS / Septum / Crista LAA, LoM Flutter? CTI Lines, circles … Primary therapy Adjunctive therapy to PVI

5 What are CAFÉs EGMs with CL < 120 ms EGMs with continuous electrical activity EGMs with low amplitude and more than 2 deflections EGMs with CL shorter than in the CS or LAA

6 Mechanisms Underlying CAFE Pathological anisotropic conduction Slow conduction, Pivot and anchor points or Collision of the wavelets (Alessie 1996) Focal microreentry (Gardner/Alessie 1985) Wave break and fibrillatory conduction at the Borderzone of the mother rotors and areas of dominant frequencies. (Kalifa et al Circ 2006) Calcium transient triggering activities from hyperactive autonomic ganglionic plexi with shortening of the RP (Scherlag et al. 2004)

7 CAFÉs in Atrial Fibrillation Ablation Stand Alone Targets ( Nademaneee) Hybrid approach with PVI

8 Substrate-Guided Ablation: CAFÉs Rationale Target key atrial regions responsible for perpetuating AF rather than targeting the triggers in the PVs End Points Complete elimination of areas with CFAEs Conversion of AF to SR Nademanee et al, JACC 2004

9 Substrate-Guided Ablation: CFAE Nademanee et al, JACC 2004 Fractionated electrograms composed of 2 deflections or more and continuous deflection of baseline Atrial EGMs with very short CL <120 msec

10 Substrate-Guided Ablation: CFAEs 60% patients had CFAEs clustered around PVs 87% patients had CFAEs clustered around septum and roof, close to PVs. Nademanee et al, JACC 2004 Median RF lesions: 64

11 Nademanee et al, JACC 2004 121 pts (51 PAF, 64 Chronic AF) 91% of pts free of arrhythmia 23% required a 2 nd. Ablation 13% on AAD Substrate-Guided Ablation: CFAEs Only

12 Ablation of CAFÉs as part of a stepwise approach to achieve conversion to SR Rationale: Structures contributing to initiation and maintenance of AF are sequentially targeted With increasing ablation of left atrial structures, there is a cumulative increase in AFCL resulting in AF termination with each ablation step performed. Stepwise Ablation Approach Haissaguerre et al. JCE 2005

13 The Stepwise Ablation Approach Lasso Guided PV Isolation Roof Line Ablation Ablation of CS & Complex LA activities Mitral Isthmus Ablation Right Atrial / SVC Ablation Cardioversion

14 EGM Based Ablation Haissaguerre et al. J CardiovascElectrophysiol2005;16:1125-37

15 87% (52) had AF termination during ablation (SR:7 ; AT:45) 60% success rate with a single procedure (40% required repeat ablation) 95% success rate with multiple procedures Sinus rhythm at 11±6 months f/u,without AADs Good atrial transport function Stepwise Ablation Approach Haissaguerre et al., J C E, Vol. 16, pp. 1138 Nov 2005 60 pts with Non-PAF

16 Some Observations The greatest magnitude of prolongation of fibrillatory cycle length occurred during ablation at the PV-LA junction (Antrum) Coronary sinus Anterior LA Almost half of the residual atrial tahycardias originated these same sites.

17 Circulation.2007;115:2606 100 pts with Chronic AF RF ablation of CAFÉs in PVs, LA and CS End point: All CAFÉs eliminated or AF termination

18 CAFÉs CFAEs EGM: CL< 120 msec CL < CL n CS Fractionated and/or continuous electric activity 1 PV 46%1 PV 46% CS 55%CS 55% Septum/roofAllSeptum/roofAll

19 Results 33% in SR after a single ablation procedure Repeat ablation in 44% CAFÉs in antrum, PV tachycardia, Macroreentrant flutter and circuits…… 57% in SR at ~1 year follow up.

20 The modest efficacy attained in this study despite extensive ablation of left atrial and coronary sinus CFAEs suggests either that CFAEs do not accurately identify sites that are critical to the maintenance of chronic AF or that ablation of CFAEs is not sufficient to eliminate the driving mechanisms of chronic AF in a large proportion of patients.

21 A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF Oral et al. J Am Coll Cardiol 2009;53:782–9) Group A: Termination with PVAI (n=19) Group B: No TerminationCardioversion (n=50) Group C: No termination CFAE* (n=50) n=119 *LA and CS for up to 2 hrs additional ablation

22 CAFÉ: LA sites

23 A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF Oral et al. J Am Coll Cardiol 2009;53:782–9) Group A: Termination with PVAI (n=19) Group B: No TerminationCardioversion (n=50) Group C: No termination CFAE (n=50) SR at 10 months 36% 34% 79% P=0.84 Up to 2 h of additional ablation of CFAEs after PVAI does NOT appear to improve clinical outcomes in patients with long-lasting persistent AF. After a single Ablation

24 Repeat Ablation in 34 randomized patients. Oral et al. J Am Coll Cardiol 2009;53:782–9) Group B: No TerminationCardioversion (n=50) Group C: No termination CFAE (n=50) SR at 9 months 68% 60% P=0. 4 No Difference even with repeat ablation

25 Methods 144 patients with permanent AF randomized to: 1. 1.Group I: Pulmonary Vein Antrum Isolation.(PVAI) n=48 2. 2.Group II: Hybrid approach. (CFAEs + PVAI) n=49 Initial defragmentation: targeting bi-atrial and CS CFAE, and started randomly in the right or left atrium followed by PVAI 3. 3.Group III: Large area circumferential ablation. (LACA) n=47 Targeting voltage reduction using electroanatomic mapping. (CARTO) Elayi et al. ;Heart Rhythm. 2008 5(12):1665Heart Rhythm. 2008 5(12):1665

26 PVAI N=48 Defragmentation ONLY N=49 Defragmentation +PVAI N=49 P value SR 3 (6%) 0 (0%) 2 (4%) NS AT 18 (38%) 1 (2%) 34 (70%) P<0.001 AF 27 (56%) 48 (98%) 13 (26%) P=0.01 Acute Results Group IGroup II 1. 1.Defragmentation alone did not have a significant effect on AF organization. 2. 2.Defragmentation as an adjunctive strategy to PVAI increases the rate of conversion from AF to organized arrhythmias.

27 Long Term Results Group I PVAI n=48 Group II CFAE+PVAI n=49 Mean follow-up (months)11.4 ± 1.111.2 ± 1.2 Patients in sinus rhythm after a single procedure 42%61% Patients in sinus rhythm after two procedures and with AAD if needed 83%94% Better success rate when defragmentation was performed in conjunction with PVAI

28 LAA Cristal Terminalis CS Pre RFCS Post RF

29 LSPV Presenting for Ablation Post Antral Isolation Post CS & LA-CAFE AT Ablation

30 Substrate vs. Trigger Ablation for Reduction of AF: An International, Multicenter, Randomized Trial (STAR-AF) Comparison of 3 strategies of AF ablation: (n=100 pts, 35% persistent) – CFE ablation alone – PVI ablation alone – PVI+CFE hybrid ablation Verma et al, HRS LBT 2009 Freedom from AF 74% 47% 29% In high-burden paroxysmal/persistent AF, PVI+CAFE has the highest freedom from AF versus PVI or CAFE alone after one procedure. CAFE alone has the lowest procedure success rates with a higher incidence of repeat procedures

31 Outcomes of Different Ablation Approaches That Incorporated CFAE Ablation in Patients With Persistent AF NAFCAFÉ onlyPVI onlyPVI + CAFÉ Nademanee et al (2004)121P+C 91% Oketani et al (2008)410P+C 81% Verma et al (2007)40C 82% Star AF (2009)100P+C 29%47%74% Haissaguerre (2005)60C 95% * Orale at al.(2009)50C 60% Orale et al.(2006)100C 57% Meulet et al.(2007)96C 67%66% Elayi et al. (2008)97C 83%94% After 1-2 ablations F/U ~1 year 60%66%83%

32 Does CAFÉ substrate modification offer additional success? Different techniques, Different Operators, Different Skills, Different interpretations, Different endpoints, different experiences, different follow ups: – Can we generalize the information – Can we trust the data: Is this Science? Significance of CAFÉ: Active vs Passive role? Is it just more Controlled Debulking? (CEDCA) I will let you draw your own conclusion Conclusion

33 PV Antrum Isolation

34 Overlap of CFAE and PVI? Majority of ablated CFAE in tailored approach were in the LA Extensive fixed PV antral isolation includes most areas of CAFÉ.

35 Is More ablation better? More Ablation: Potential for More atrial Flutter More ablation: Compromise LA mechanical function More ablation: Interatrial / intraatrial dyssynchrony More ablation: More fluoro / More potential complications

36 CAFE OK, but what else can we ablate?…

37 END

38 Well connected cells Loose cells, anisotropic conduction Continuous Spectrum Segmented Spectrum AF-NestsAF-Nests 50 Hz 40 Hz 120 Hz 200 Hz Spectral Mapping Guided AF Nests Ablation in Sinus Rhythm An Adjunctive Approach to PVAI and SVCI

39 AF NEST Typical Sites Post RF CS Pre RF CS AF NEST CS FibrillarMyocardium AF NEST

40 157 Pts Prospectively Studied 91Pts > 2mo F/U Randomized 46Pts AFN+PVAI+SVCI 45PtsPVAI+SVCI Recurrences PAF 11% Pers/Perm 20% Recurrences PAF 20% Pers/Perm 30%

41 Stepwise Ablation Approach Cumulative benefit Progressive decrease in incremental benefit per stage after five stages of ablation beyond which further LA ablation is probably of no clinical benefit up to a limit Number of Patients Terminating with each Step of Ablation


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