Presentation on theme: "Substrate Ablation (CAFE) A Promising or Vanishing Technique"— Presentation transcript:
1 Substrate Ablation (CAFE) A Promising or Vanishing Technique Walid I. Saliba, M.D.Director, Atrial Fibrillation CenterSection of Pacing and Electrophysiology, Department of Cardiovascular MedicineTHE CLEVELAND CLINIC FOUNDATIONCleveland, Ohio1
3 Natural History of AF Dual Substrate Model Ablation of TriggersModification of SubstratePersistentSinus can be restored electrically or chemicallyParoxysmalSelf terminating AF episodesPermanentSinus cannot be maintainedAtrial remodeling:↓Refractory Period ↓ Conduction velocityFavors Arrhythmia“AF begets AF”Trigger initiationSubstrate maintenance
4 Alternative Strategies More AblationWhere?Why?How much more?CAFEDominant FrequencyGanglionic PlexiStepwise/TailoredAF NestSVC / CS / Septum / CristaLAA, LoMFlutter? CTILines, circles …Primary therapyAdjunctive therapy to PVI
5 What are CAFÉ’s EGMs with CL < 120 ms EGMs with continuous electrical activityEGMs with low amplitude and more than 2 deflectionsEGMs with CL shorter than in the CS or LAA
6 Mechanisms Underlying CAFE Pathological anisotropic conductionSlow 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 CAFÉ’s in Atrial Fibrillation Ablation Stand Alone Targets ( Nademaneee)Hybrid approach with PVI
8 Substrate-Guided Ablation: CAFÉ’s Nademanee et al, JACC 2004RationaleTarget key atrial regions responsible for perpetuating AF rather than targeting the triggers in the PV’sEnd PointsComplete elimination of areas with CFAE’sConversion of AF to SR
9 Substrate-Guided Ablation: CFAE Fractionated electrograms composed of 2 deflections or more and continuous deflection of baselineAtrial EGMs with very short CL <120 msecNademanee et al, JACC 2004
10 Substrate-Guided Ablation: CFAE’s Median RF lesions: 6460% patients had CFAEs clustered around PV’s87% patients had CFAEs clustered around septum and roof, close to PVs.Nademanee et al, JACC 2004
11 Substrate-Guided Ablation: CFAE’s Only 121 pts(51 PAF, 64 Chronic AF)91% of pts free of arrhythmia23% required a 2nd. Ablation13% on AADNademanee et al, JACC 2004
12 Stepwise Ablation Approach Haissaguerre et al. JCE 2005Ablation of CAFÉ’s as part of a stepwise approach to achieve conversion to SRRationale:Structures contributing to initiation and maintenance of AF are sequentially targetedWith increasing ablation of left atrial structures, there is a cumulative increase in AFCL resulting in “AF termination” with each ablation step performed.
13 The Stepwise Ablation Approach Lasso Guided PV IsolationRoof Line AblationAblation of CS & Complex LA activitiesMitral Isthmus AblationRight Atrial / SVC AblationCardioversion
14 EGM Based AblationHaissaguerre et al. J CardiovascElectrophysiol2005;16:
15 Stepwise Ablation Approach 60 pts with Non-PAF87% (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 proceduresSinus rhythm at 11±6 months f/u ,without AAD’sGood atrial transport functionHaissaguerre et al., J C E, Vol. 16, pp Nov 2005
16 Some ObservationsThe greatest magnitude of prolongation of fibrillatory cycle length occurred during ablation at thePV-LA junction (Antrum)Coronary sinusAnterior LAAlmost half of the residual atrial tahycardias originated these same sites.
17 RF ablation of CAFÉ’s in PV’s, LA and CS 100 pts with Chronic AFRF ablation of CAFÉ’s in PV’s, LA and CSEnd point: All CAFÉ’s eliminated or AF terminationCirculation.2007;115:2606
18 CAFÉ’s 1 PV 46% CS 55% Septum/roof All CFAEs EGM: CL< 120 msec CL < CL n CSFractionated and/or continuous electric activity1 PV 46%CS 55%Septum/roof All
19 Results 33% in SR after a single ablation procedure Repeat ablation in 44%CAFÉ’s 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 Oral et al. J Am Coll Cardiol 2009;53:782–9) A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AFn=119Group A:Termination with PVAI (n=19)Group B:No Termination→Cardioversion (n=50)Group C:No termination →CFAE* (n=50)*LA and CS for up to 2 hrs additional ablationOral et al. J Am Coll Cardiol 2009;53:782–9)
23 A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AFAfter a single AblationSR at 10 monthsGroup A:Termination with PVAI (n=19)Group B:No Termination→Cardioversion (n=50)Group C:No termination →CFAE (n=50)79%36%P=0.8434%Up to 2 h of additional ablation of CFAEs after PVAIdoes NOT appear to improve clinical outcomes in patients with long-lasting persistent AF.Oral et al. J Am Coll Cardiol 2009;53:782–9)
24 Repeat Ablation in 34 randomized patients. SR at 9 monthsGroup B:No Termination→Cardioversion (n=50)Group C:No termination →CFAE (n=50)68%P=0. 460%No Difference even with repeat ablationOral et al. J Am Coll Cardiol 2009;53:782–9)
25 Methods Elayi et al. ;Heart Rhythm. 2008 5(12):1665 144 patients with permanent AF randomized to:Group I: Pulmonary Vein Antrum Isolation .(PVAI) n=48Group II: Hybrid approach. (CFAE’s + PVAI) n=49Initial defragmentation: targeting bi-atrial and CS CFAE, and started randomly in the right or left atrium followed by PVAIGroup III: Large area circumferential ablation. (LACA) n=47Targeting voltage reduction using electroanatomic mapping. (CARTO)
26 Defragmentation +PVAI Acute ResultsGroup IGroup IIPVAIN=48Defragmentation ONLYN=49Defragmentation +PVAIP valueSR3(6%)(0%)2(4%)NSAT18(38%)1(2%)34(70%)P<0.001AF27(56%)48(98%)13(26%)P=0.01Defragmentation alone did not have a significant effect on AF organization.Defragmentation as an adjunctive strategy to PVAI increases the rate of conversion from AF to organized arrhythmias.
27 Long Term ResultsGroup IPVAIn=48Group II CFAE+PVAIn=49Mean follow-up (months)11.4 ± 1.111.2 ± 1.2Patients in sinus rhythm after a single procedure42%61%Patients in sinus rhythm after two procedures and with AAD if needed83%94%Better success rate when defragmentation was performed in conjunction with PVAI
30 In high-burden paroxysmal/persistent AF, Substrate vs. Trigger Ablation for Reduction of AF: An International, Multicenter, Randomized Trial (STAR-AF)In high-burden paroxysmal/persistent AF,PVI+CAFE has the highest freedom from AFversus PVI or CAFE alone after one procedure.CAFE alone has the lowest procedure success rates with a higher incidence of repeat proceduresComparison of 3 strategies of AF ablation:(n=100 pts, 35% persistent)CFE ablation alonePVI ablation alonePVI+CFE hybrid ablation74%47%Freedom from AF29%Verma et al, HRS LBT 2009
31 Outcomes of Different Ablation Approaches That Incorporated CFAE Ablation in Patients With Persistent AFNAFCAFÉ onlyPVI onlyPVI + CAFÉNademanee et al (2004)121P+C91%Oketani et al (2008)41081%Verma et al (2007)40C82%Star AF (2009)10029%47%74%Haissaguerre (2005)6095% *Orale at al.(2009)5060%Orale et al.(2006)57%Meulet et al.(2007)9667%66%Elayi et al. (2008)9783%94%60%66%83%After 1-2 ablationsF/U ~1 year
32 Does CAFÉ substrate modification offer additional success? ConclusionDoes CAFÉ substrate modification offer additional success?Different techniques, Different Operators, Different Skills, Different interpretations, Different endpoints, different experiences, different follow up’s:Can we generalize the informationCan 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
34 Overlap of CFAE and PVI?Majority of ablated CFAE in tailored approach were in the LAExtensive “fixed” PV antral isolation includes most areas of CAFÉ.
35 Is More ablation better? More Ablation: Potential for More atrial FlutterMore ablation: Compromise LA mechanical functionMore ablation: Interatrial / intraatrial dyssynchronyMore ablation: More fluoro / More potential complications
41 Stepwise Ablation Approach Number of Patients Terminating with each Step of AblationCumulative benefitProgressive decrease in incremental benefit per stage after five stages of ablation beyond which further LA ablation is probably of no clinical benefitup to a limit