catheter ablation of atrial fibrillation: who? how? how good? john d. day, m.d. director, utah...
TRANSCRIPT
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Catheter Ablation of Atrial Fibrillation: Who? How?
How Good?John D. Day, M.D.
Director, Utah Cardiovascular Research Institute
Utah Heart Clinic Arrhythmia ServiceLDS Hospital
*Disclosure: No conflicts of interest, no relationships to disclose*
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Atrial Fibrillation: Magnitude of the Problem
• 15-30% of all strokes from atrial fibrillation• Heart failure risk increased with atrial fibrillation• 2.5x mortality increase with atrial fibrillation
(Framingham data)• 1 in 4 people age 40 will develop Afib• No effective or safe medications for atrial fibrillation• Anti-arrhythmics may increase mortality or expose
patient to significant toxicities• Increasing risk factors: age, hypertension, heart
failure
JACC 2003;41:2185-2196, Circulation 2004;110:1042-1046
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Ablation of Atrial Fibrillation
1. Mechanisms of Atrial Fibrillation2. Historical Approach to Catheter
Ablation of Atrial Fibrillation3. Our Approach to Catheter
Ablation of Atrial Fibrillation4. Future Directions
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Mechanism: Wavelet Hypothesis
• Multiple wavelets – Moe and Abildskov 1959
• “Multiple independent reentrant wavelets are necessary to maintain fibrillation. These wavelets are always changing in position, shape, size and number with each successive excitation”
• Confirmed by animal/human mapping techniques
Moe, Am Heart J; 1959
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Results• 94% of atrial
fibrillation triggers (premature atrial beats) arise from pulmonary veins
• Pulmonary Veins as source of atrial fibrillation (Winterberg, 1906)
New England Journal of Medicine 1998;339;659-666
RA LA
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Why the Pulmonary Veins? Myocardial Tissue Lines the
Pulmonary Veins
Pulmonary vein lumen
Left Atrium
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Pulmonary Vein Isolation 1998-Present
• Electrical isolation of pulmonary vein triggers (premature atrial beats)
• Success: 50-90%• Increased success without pulmonary
vein stenosis by isolating outside of vein (antrum)
• Evolution of Technique– Focal– Circumferential– Segmental– Antrum isolation
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Mapping of Atrial Fibrillation Trigger to Left Upper Pulmonary
Vein
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Sinus rhythm by EKG
Atrial fibrillation in pulmonary vein by Lasso catheter
A A A A A A A A A A A A AA A
A VSinus rhythm by left atrial recordings from coronary
sinusA V
Electrical Isolation of Pulmonary Vein
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J Cardiovasc Electrophysiol 2003;14:150-153
Limitations of Pulmonary Vein Isolation: Pulmonary Vein
StenosisBefore Ablation
After Ablation
>50% reduction in ostium of left superior
pulmonary vein
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2003: Wavelets and Pulmonary Vein Triggers
Both Important
Moe, Am Heart J; 1959
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Convergence of Techniques:Pulmonary Vein Isolation and Left
Atrial Substrate Modification: 2003-Present
• Isolation of pulmonary veins (triggers) and modification of substrate both important (wavelet mechanism)
• New technique: left atrial ablation, wide area circumferential ablation, circumferential left atrial pulmonary vein ablation (Pappone, Morady, and others)
• Increased success by isolating/encircling outside of the pulmonary veins (pulmonary vein stenosis eliminated)
• Ongoing issue: Electrical isolation of pulmonary veins by Lasso catheter or anatomic lesion set with pulmonary vein conduction delay (no Lassovoltage reduction)
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Circulation 2003;108:2355-2360,
Journal of the American College of Cardiology 2005;46:1060-1066
Ablation lesion Set Proposed by Morady in 2003 (based on Pappone approach):
• Anatomic ablation lesion set
• Success rate similar if pulmonary veins isolated by Lasso catheter versus voltage reduction with an anatomic approach (Lasso not used)
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2004: Targeting Autonomic Inputs/Fractionated
Electrograms
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Location of the Left Atrial Ganglionic Plexi
Heart Rhythm 2005;2:S11
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Autonomic/Fractionated Electrogram Approach
Journal of the American College of Cardiology 2004;43:2044-2053
Lesion sets similar to the wide area pulmonary vein
circumerferential ablation approach!!!
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New Paradigm for Atrial Fibrillation
Pulmonary Vein and Autonomic Triggers
MultipleWavelets
Electrical Remodeling
Substrate• Atrial Size• Fibrosis• Stretch
DrugsIn progression to persistent and permanent atrial fibrillation triggers become less important
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Mortality and Morbidity with Atrial Fibrillation
Ablation• 1,171 consecutive patients referred for
ablation in Milan, Italy (January 1998 March 2001)
• 589 ablated versus 582 drug treated (1/3 amiodarone, 1/3 class Ic, 1/3 sotalol/class Ia)
• End-points: mortality, morbidity (heart failure/stroke), & quality of life (900 day follow-up)
Journal of the American College of Cardiology 2003;42:185-197
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Pappone ApproachEach pulmonary vein encircled
(voltage reduction)
2 Posterior wall ablation lines
Mitral valve flutter ablation
lineRight atrial cavo-tricuspid isthmus
flutter line
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Ablation versus Drug Success
Journal of the American College of Cardiology 2003;42:185-197
78%
37%
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Mortality After AF Ablation
Journal of the American College of Cardiology 2003;42:185-197
Mortality After AF Ablation = Expected for Italian
Population
54% Mortality Reduction with
Ablation versus DrugAtrial Fibrillation mortality on
Drug Less than Expected Italian Mortality
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Morbidity After AF Ablation
Journal of the American College of Cardiology 2003;42:185-197
hello
p<0.001
55% reduction in heart failure or stroke at 3 years in ablated patients versus drug treated
patients
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Our Current Approach: 3D CT and CARTO Electroanatomic
Imaging
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Our Results: LDS Hospital• 49 consecutive patients age 59±11 (Jan 1, 2004 –
October 1, 2004—now 300+)
• 7±3 months follow-up
• Drug refractory symptomatic atrial fibrillation (failed 2.3 ± 1.2 anti-arrhythmic drugs)
• 36 paroxysmal and 13 persistent atrial fibrillation
• LA size: 48 ± 8 mm, 16 with structural heart disease
• Follow-up: Pacemaker/ICD logs, Holter, event monitor
• Approach: Encircle pulmonary veins (end-point of voltage reduction), roof and mitral line, target autonomics and complex fractionated electrograms
12th World Congress of Cardiology, Vancouver 2005
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Atrial Fibrillation Ablation Results:
LDS Hospital
92%
72%
0%
20%
40%
60%
80%
100%
Freedom from Atrial Fibrillation (4+ Months Out)
Atrial Fibrillation Free Atrial Fibrillation Free (no drugs)
n=49
12th World Congress of Cardiology, Vancouver 2005
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Complications• 300+ cases now performed utilizing this
technique (2004-2005)• No strokes• 3 pericardial effusions requiring
pericardiocentesis (1%, experience related)
• 1 atrio-esophageal fistula*• 1 esophageal perforation*
– Successful temporary esophageal stenting– No long-term problems*Early in experience before ultrasound monitoring
12th International Congress of Cardiology, Vancouver 2005
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New Achilles Heel: Potential Esophageal
Injury
Posterior LA Wall
Esophagus
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Our Approach to Minimize Esophageal Risk: Intracardiac Echo Monitoring During
Radiofrequency Delivery and Esophageal Temperature Probes
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Future Directions: Ultrasound/Cryo Isolation of
Pulmonary Veins?
Problem: “One size doesn’t fit all”
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Robotic Approach to Ablations? Stereotaxis Magnetic Navigation?
Journal of the American College of Cardiology 2003;42:1952-1958
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As most strokes from atrial fibrillation arise from the left
atrial appendage…Closure after ablation?
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Final Points• Who?
– Ideal patient: Young, paroxysmal atrial fibrillation with no structural heart disease
– Success rate lower with permanent atrial fibrillation and structural heart disease
• How? 3 main “techniques” – All 3 with similar ablation lesion sets– Pulmonary vein isolation, wide area
circumferential ablation, Autonomic/fractionated electrograms
– Our approach: Integration of all 3 techniques
• How Good?– 80-90% success rate in experienced hands with
any technique