af ablation: a single operator’s experience over 3 years (2007 – 2009) barker d, patwala a, damm...
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AF ablation:A single operator’s experience
over 3 years (2007 – 2009)
Barker D, Patwala A, Damm E, Hall M, Snowdon R, Gupta D
Liverpool Heart and Chest Hospital, UK
Background
• Inconsistent results of AF ablation
• ? Due to Heterogeneity amongst AF population
• Role of Trigger removal vs Substrate modification
Hypotheses
• Substrate modification can be achieved with linear lesions
• Incremental lesion set depending upon disease stage
• Individualised approach may standardise single procedure success rates across AF population
• ? Safety and feasibility of this approach
Methods: Definition of AF groups
• 131 consecutive patients coming for AF ablation (DG)
• Sustained PAF: Patients with PAF, with ≥ 2 of
• Any individual AF episodes > 24 hours
• History of AF > 5 years
• LA size on Echo > 4.5 cm
• Age > 65 years
• Documented flutter
• True PAF
• Persistent AF (> 7 days/ Needed Cardioversion)
• Longstanding Persistent AF (>12 months)
Methods Ablation approach
• PVAI with Wide area circumferential ablation
• PVAI guided and confirmed by PV catheter
• Continuous RF:
• LA: 35 W, 50°C, 10 ml/ min flow
• CS: 25 W, 50°C, 30 ml/ min flow
• CTI: 50W, 50°C, 30 ml/ min flow
• 3D mapping:
• 80% with CT image integration
Methods: Prescribed lesion set
PAF Sustained PAF
Persistent AF Longstanding PsAF
Methods • Linear lesion integrity tested by
• Loss of recordable signals along line
• Double potentials across line if in SR/ flutter
• Conduction detour not confirmed routinely
• Mitral Isthmul Line not usually attempted
• unless peri-procedural peri-mitral flutter(s)
• Procedure limit of 4/5 hours
Patients not offered Catheter ablation if
• Very long standing Persistent AF (>3 years)
• Very large LA (>5.5 cm)
• Morbid Obesity (BMI >40)
Methods Exclusion criteria
Follow-up strategy
• AAD therapy continued for 2/3 months
• Clinic and ECG review at least every 3 months
• HRN Contact Line for inter-current support
• Ambulatory monitoring to assess symptoms
• Early post-op arrhythmias
• DC CV if sustained and poorly tolerated
• Redo ablation deferred for at least 5-6 months
PAF (n=47) Sustained PAF (n=26)
% Male 46.8% 76.9%
Age (yrs) 57.3 ± 10.5 [32-78]
59.2 ± 8.3 [41-77]
BMI 28.4 ± 3.9 27.6 ± 3.5
AF duration (yrs) 5.5 ± 5.2 7.2 ± 6.7*
Number of prior AADs
2.6 ± 1.4 2.2 ± 1.2
Ejection Fraction 63 ± 11% 62 ± 6%
LA diameter (echo)
4.6± 0.5 cm 4.2 ± 0.4 cm
LA diameter (CT) 4.2 ± 0.6 cm 4.5 ± 0.8 cm
LA volume (CT) 126 ± 24 ml 149 ± 32 ml *
* = p < 0.05
Results: Baseline data
Persistent AF (n=27) Longstanding PsAF (n=31)
% Male 85.0% 93.5% **
Age (yrs) 53.6 ± 12.6 [16-68] 57.4 ± 8.3 [40-72]
BMI 30.2 ± 4.7 30.6 ± 5.3
AF duration(yrs) 4.9 ± 3.3 3.5 ± 2.1
Time in persistent AF (months)
9.4 ± 7.1 19.0 ± 17.9
Number of prior AADs
1.9 ± 0.6 2.5 ± 0.8
Prior CV 79% [1-5] 97% [1-4]*
CV successful (%) 63% 53%
Ejection Fraction 54.3 ± 11.5% 49.8 ± 17.0%
LA diameter (echo)
4.5 ± 0.8 cm 4.7 ± 0.6 cm
LA diameter (CT) 4.76 ± 0.85 cm 5.15 ± 0.93 cm
LA volume (CT) 148.1 ± 47.1 mls 161.7 ± 41.9 mls * P < 0.05 * * P = 0.001
Results: Ablation procedure
PAF Sustained PAF
PsAF Longstanding PsAF
PVs isolated
3.65 (2-4) 3.64 (2-4) 3.65 (3-4) 3.84 (3-4)
Procedure duration (min)
173 ± 46 192 ± 46 216 ± 39** 229 ± 47*
Fluoro time (min)
29.1 ± 9.9 37.7 ± 11.4 33.6 ± 12.6 38.0 ± 15.1**
Fluoro dose(cGy)
4029 ± 3601
2984 ± 3249
4908 ± 2357
5026 ± 2753 **
Cardioversion n (%)
3(7) 7 (27) 15 (56) 23 (74)
Complications
1 tamponade1 pseudo-aneurysm
0 1 pseudo-aneurysm
1 embolic TIA
* P = 0.001 ** P < 0.0005
Mean Follow up duration
PAF 12.0 ± 1.0 months
Sustained PAF 11.0 ± 1.7 months
Persistent AF 10.6 ± 1.1 months
Longstanding Persistent AF
12.6 ± 1.4 months
All patients followed up for approximately 12 months
3 months 6 months 12 months
PAF (n=47) N=47
Cured/ Significant Improvement
76.6 83.0 78.7
Some Improvement 12.8 8.5 14.9Same/ worse 10.6 8.5 2.1
Sustained PAF (n=26) N=26
Cured/ Significant Improvement
96.2 88.5 92.3
Some Improvement 3.8 7.7 3.8Same/ worse 0 3.8 3.8
Persistent AF (n=27) N=27
Cured/ Significant Improvement
81.5 77.8 74.1
Some Improvement 11.1 7.4 11.1Same/ worse 7.4 11.1 14.8
LS Persistent AF (n=31) N=31
Cured/ Significant Improvement
67.7 67.7 67.7
Some Improvement 9.7 9.7 9.7Same/ worse 22.6 22.6 22.5
Symptomatic cure – patient satisfaction
0
20
40
60
80
100
PAF (n=46)
Sustained PAF (n=26)
Persistent AF (n=27)
Longstanding PsAF (n=31)
Percentage symptom free
3 months 6 months 12 months
Longstanding PsAF (n=31)
12 month follow up results
81%
68%
88%
79%
Cured/significant improvementSome improvementNo better/worse
Sustained PAF (n=26)
PAF (n=47)
Persistent AF (n=27)
79%
92%
74%
Freedom from documented AF/ AT
0
20
40
60
80
100
PAF Sustained PAF Persistent AF Longstanding PsAF
Percentage free from AF
3 months 6 months 12 months
Follow upRedo
Ablation Pts/ablation
Time to Redo ablation
MAT on follow-up
PAF 9 (20%)/9* 10.5 ± 6.1 months (range 5 – 13)
1 atrial tachy
Sustained PAF
5 (21%)/6 (re-redo for flutter)
17.8 ± 5.2 months (range 9 – 22)
3 (2 typical, 1 atypical)
Persistent AF
3 (16%) /4 (re-redo for flutter)
7.7 ± 2.5 months (range 5 – 11)
2 (1 typical, 1 atypical)
Longstanding PsAF
8 (40%)/10 8.6 ± 3.8 months (range 4 – 14)
3 (3 atypical)
* 8 of the 9 redo cases had incomplete initial PVI
Conclusions
• Individualised ablation strategy based on incremental linear lesion placement feasible on practical grounds
• Not associated with greater risk of procedural complications
• Anatomical (3D mapping based) approach to linear lesion creation associated with acceptably low risk of MAT
• This strategy may result in some uniformity of results across the spectrum of AF patients