1. Atrial Fibrillation Ablation Cardiology Symposium December 6, 2004 Paul R. Steiner, M.D. Cardiac Electrophysiology

2. Case Background: 46 yr old athletic woman (cyclist, runner) 3 yr h/o increasingly frequent rapid palpitationsparoxysmal AF Often immediately following exercise More recently may occur randomly No other medical conditions

3. Initial Evaluation: ECG : Sinus bradycardia at rest 54 bpm, normal morphology Labs : T4, TSH, lytes, etc. are WNL Echo : Structurally normal heart Holter : Frequent APCs, occas PVCs; salvos of AT and AF, some that are associated w/ symptoms on the patient log.  Heart rate range (in sinus): 46 – 138 bpm

4. Treatment History: Rate control strategy: Digoxin β – blockers CCBs Rhythm control strategy: Propafenone (Rhythmol) Flecainide What next?

5. Question: What would you do next to effectively treat her life-style altering paroxysmal AF? [ A ] Trial of a class IA drug (ex. quinidine). [ B ] Amiodarone treatment (with regular careful monitoring). [ C ] Referral for AV junction ablation and high-quality pacemaker [ D ] Refer for atrial defibrillator implant [ E ] Refer for catheter ablation of AF

6. Atrial Fibrillation Ablation (What we did…) FOR WHOM? ( Paroxysmal or Persistent ) 1. AF w/ “significant symptoms” associated 2. Refractory to AADs 3. Absence of severe structural heart dz. [ E ]

7. Left Atrium Posterior Basal View R. superior pulmonary vein R. inferior pulmonary vein Coronary sinus L. inferior pulmonary vein L. atrium L. superior pulmonary vein L. auricle L. pulmonary artery R. pulmonary artery Netter F. Atlas of Human Anatomy. 1989;Plate 202.

8. Nathan, Circ Res, 1969? Left Atrium, Posterior Wall Variable Anatomy (Common) RIPV RSPV LIPV LSPV IVC SVC LAA RAA

9. Left Atrium, Posterior Wall

10. Atrial Fibrillation Initiation Mechanism – PV Triggers

11. Nathan, Circ Res, 1969? Left Atrium, Posterior Wall Pulmonary Vein Isolation

12. Mediastinum Axial Superior View Netter F. Atlas of Human Anatomy. 1989;Plate 230. Esophagus Right Pulmonary Veins Left Pulmonary Veins Aorta Azygous Vein Left Atrium Right Atrium

13. T8 Axial View Courtesy of M. Ramsey, PhD, CEO CardioCommand Right PVs Left PVs Esophagus Aorta Left Ventricle

14. Atrial Fibrillation Ablation Technique Combined Modality Imaging 1. Fluoroscopy (biplane, for rapid 3-D estimates) 2. High resolution gated CT or MRI 3. 3-D electroanatomic mapping 4. Intracardiac echo In the future: Multi-modality image co-registration combining real-time anatomy and function… Current

15. Left Atrium (LA) and Pulmonary Vein Anatomy 3-D CT Reconstruction (Extreme PA Cranial View) LA Roof Esophagus Left PVs Right PVs LA Appendage

16. Side-by-Side Geometry Electroanatomic Map & 3-D CT: Cranial View ESI Nav-X 3-D Geometry 3-D CT via CardEP (Cranial View) LA Roof Esophagus Left PVs Right PVs LAA

17. ESI Nav-X 3-D Geometry3-D CT via CardEP Side-by-Side Geometry RF catheter pointing away from esophagus

18. Pulmonary Vein Isolation Segmental Approach Haïssaguerre, M. et al., Circulation. 2000;102:2463–2465. Going…Going… Gone !

19. LA Mapping and Catheter Ablation Visualization: Intracardiac Ultrasound  Facilitate transeptal access to LA  Visual guidance of catheters at PV ostium  RF energy delivery titration via “bubble” monitoring  Doppler PV flow (assess for size and stenosis)  Direct visualization of: PV ostial size Anatomic abnormalities Pericardial effusion Thrombus

20. Left Atrial Mapping and Catheter Ablation Visualization: Intracardiac Ultrasound Transeptal Access to LA Tenting of the intra-atrial septum during transeptal catheterization AcuNav 10 Fr Phased Array Diagnostic Ultrasound Catheter (by Acuson)

21. Left Atrial Mapping and Catheter Ablation Visualization : Intracardiac Ultrasound Optimizing Catheter Placement at PV Os

22. Caution STOP ! Marrouche N and Natale A. Electromedica 70 (2002) no. 1

23. PV Isolation by RF Lesion Before …

24. Electronically Isolated PV After …

25. FOR WHOM? ( Paroxysmal or Persistent ) 1. AF w/ “significant symptoms” associated 2. Refractory to AADs 3. Absence of severe structural heart dzHOW? 1. Electrical isolation of pulmonary veins 2. Atrial tissue substrate modification 3. Accomplished via catheter ablation combined w/ multiple imaging modalities SUMMARY Atrial Fibrillation Ablation