1. Catheter Ablation of Atrial Fibrillation in the Last 10 Years: Breakthroughs and Advances Dr. Feifan Ouyang Asklepios Klinik St. Georg Hamburg Sept. 19th, 2008, Hangzhou

2. Haissaguerre et al. NEJM 1998, 339: 659-666

4. Success: 62% with a median FU of 8±6 M

6. Haissaguerre et al. Circulation 2000; 102: 2463-2465

7. Haissaguerre et al. Circulation 2000; 102: 2463-2465 Recurrence in 31 out of 70 pts (44%) -Reablation in 29 of these 31 pts -Reablation in 29 of these 31 pts -Freedom of AF: 73% at a median of FU of 4±5 M -Freedom of AF: 73% at a median of FU of 4±5 M No PV stenosis ！ 162 PVs (no RIPV) in 70 Pts -one breakthrough in 34 PV -two breakthroughs in 77 PVs ->two breakthrough in 51PVs

8. Catheter ablation of atrial fibrillation 1. Successful acute PV isolation rate almost 100% in experienced centers 2. Clinical success rate: variable 50-93 (65)% with multiple procedures 3. „Recovered“ PV spikes in ~ 95% pts during reprocedures 4. PV severe stenosis/occlusion ~ 1% 5. Effect only on the PV, but not in the PV antrum Segmental PV isolation

9. Cappato et al. Circulation 2003;108:1599–1604

10. Ernst et al. Circulation 1999; 100:2085 13 pts 32 pts

11. Ernst et al. Circulation 1999; 100:2085 No SR SR in 2/32 pts

13. Schmidt et al. JCE 2006;17:957–964

14. 2000 2004 1999 2001 Pappone C et al. Circulation 1999, 2000, 2001, and 2004 Focal? Small circle within PVs 1.6 cm 1.94 cm 1.74 cm

15. Pappone et al Circulation 2001 Validation of ablation area: Voltage mapping <0.1 mV

16. Pappone: PV „Encircling“ patientssuccess Complications Circ 1999 27 Pts 70.4 % (10.5±4M) No Circ 2000 26 Pts At FU of 9±3M 86% in PAF 83% in chron. AF No Circ 2001 251 pts (PAF 179) At FU of 10.4+4.5M 85% in PAF Cardiac tamponade in 2 Cardiac effusion in 2 68% in Chronic AF No stroke or pb stenosis Paris AF 2008 >20000 pts > 90% in interm. AFib >90% in chron. AFib no detailed information, one with LA-Eso fistula

18. Oral et al, Circulation 2003;108 Karch et al, Circulation 2005;110

19. Karch et al Circulation 2005;110Oral et al Circulation 2003;108

20. Oral et al, Circulation 2003;108Karch et al, Circulation 2005;110 Segmental PVI vs Circumferential PV Ablation

21. Circumferential PV ablation Catheter ablation of atrial fibrillation Procedure endpoints Procedure endpoints –Potential amplitude within the isolated area <0.1 mV –No information on PV potentials –No information on line completeness –Gap-related LAMRT –Clinical outcome: not reproducible

22. Atrial fibrillation – Surgery Todd et al, Circulation 2003;108

23. AF ablation with Surgery Todd et al, Circulation 2003;108

24. AF abation with Surgery 13 / 14 Patient: complete PVI 13 / 14 Patient: complete PVI FU of 25 ± 11 months: SR in 13 pts FU of 25 ± 11 months: SR in 13 pts Isolated PV-LA Region: Isolated PV-LA Region: –spontanenous AF: 4 pts –inducible AF:1 pt The remaining atrium: The remaining atrium: –SR:13 pts –Non-sustained AF:1 pt Todd et al, Circulation 2003;108

26. Simultaneous isolation of ipsilateral PV in ≈95%

27. PV Antrum Isolation Cleveland Group. HR 2005 Successful rate ≈ 90%

28. Catheter ablation of AF in experienced center Verma A & Natale A. Circulation 2005;112:1214–1231

30. Arentz T et al. Circulation 2007

33. Jais et al. JCE 2005 Oral et al. Circulation 2004 Inducibility of AF on clinical outcome after PVI

34. Satomi K,.., Ouyang F. Europace 2008

35. Satomi K et al. Europace 2008

36. Inducibility of AF after Circumferential PVI Non-inducibility of AF was used as endpoints after AF ablation, but there were some differences in the published studies - definition of sustained AF - ablation techniques - procedure endpoints - induction protocol

38. Location of fragmented potentials Nadamanee et al, JACC 2004;43:2044–2053

39. Catheter Ablation of AF Fragmented mapping and ablation Termination of AFib: 115/121 (95%) pts During one year follow-up: -110 (91%) pts: SR -92 after one ablation -18 after two ablations -110 (91%) pts: SR -92 after one ablation -18 after two ablations Nadamanee et al, JACC 2004;43:2044–2053 Ablation of fragmented potentials

40. Wanzi et al. JAMA 2005

41. Study time: 12/1/2001-7/1/2002

42. Wanzi et al. JAMA 2005 1.A small group of Pts 2.High success with segmental PVI?

43. Improvement of LV-EF after AF ablation Hsu et al. NEJM 2004; 351:2372 Nademanee K, et al. JACC 2008; 51:843-9

44. COMPLICATIONS - World Wide Survey Cappato et al. Circulation 2005; 111; 1100-1105 Catheter ablation of atrial fibrillation % n=

45. Paroxysmal Atrial Fibrillation Verma A & Natale A. Circulation 2005;112:1214–1231 Total 2.9%

46. Balloon techniques Steerable HIFU balloon Diameter: 20, 25, 30 mm Steerable Cryo-balloon 23, 28 mm

48. The finding of PV spikes is the cornerstone in catheter ablation of AF The finding of PV spikes is the cornerstone in catheter ablation of AF Ablation strategy has been changed into circumferential PV isolation for PAF in the majority of centers Ablation strategy has been changed into circumferential PV isolation for PAF in the majority of centers Maintenance of stable SR can improve left ventricular EF after catheter ablation of AF Maintenance of stable SR can improve left ventricular EF after catheter ablation of AF Long-term FU >5 years is still very limited except surgical approach Long-term FU >5 years is still very limited except surgical approach Improved mortality and reduced stroke is still to be investigate Improved mortality and reduced stroke is still to be investigate Conclusions Catheter ablation of AF