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Atrial fibrillation ablation techniques, imaging,
complications, results
Richard Schilling
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Definitions
• PVI – segmental ostial isolation of individual veins guided by activation on PV mapping catheter
• WACA – Wide area ablation to enclose veins as pairs (with/without ablation between veins). May be guided by PV mapping catheter
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Paroxysmal AF
• Pulmonary vein triggers majority of PAF
• Non venous triggers
• Autonomic modification
• Fractionated potentials/substrate modification
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Persistent AF
• PV isolation is not sufficient
Willems et al EHJ 2006
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Target PV trigger
LIMITED BY:
•Absence of spontaneous ectopy
•Multiple triggers
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Wide area circumferential ablation
Milan: 8mm 100W Pappone et al
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PVI vs WACA
• WACA with no assessment of isolation
–Cheaper
–Simpler
–Quicker
–?As effective
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Disadvantages of WACA without isolation
• No clear end point
• Dependent on operator experience and skill
• No definition of “WACA” varies
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Wide encirclement without isolation
• Pappone 2002 n=72
– 68% success (32 on drugs)
– Overall complications (permanent and parox) 0.8% (2 tamponade)
– Atachy not reported follow up by transtelephonic monitoring
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The wider the line the greater the success rate
Sites of ganlgionic plexi
Danik et al Am J C 2008
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PVI vs WACA
• 8mm tip
• Ablation of signal within lines
• 50W
Oral et al Circulation 2003
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PVI vs WACA
• N=20
• No ablation within lines
• Veins isolated individually
• 45% isolated
Hocini Eur H J 2005
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• WACA
• 65% on drugs
Results are not always easy to interpret
Stabile et al Circ 2003
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• N=100
PVI vs WACA
Kirch et al Circ 2005
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Wide encirclement with electrical isolation
• Double lasso technique
• N=41
• Recurrence 25%
• PV reconnection in all undergoing repeat procedure
Ouyang et al Circ 2004
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Segmental vs Wide encirclement
- with electrical isolation • Single PV cath – irrigated, same
powers for both
• PAF and persistent
Arentz Circ 2007
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Sites resistant to isolation
• Resistance 2o
– epicardial fibres?
– thickened myocardium? Kistler et al JCE 2006
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Complications
• In theory:
–Segmental isolation associated with:
•PV stenosis
–Wide encirclement
•Oesophageal fistula
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Complications
Segmental PVI Wide
encirclement
PV stenosis 1.5% (non
clinical)
1.5% non-clinical
Tamponade 1.5% 1.5%
Oesophageal
Fistula
? 0.05-0.4%
Stroke 0.1 0.1
Death Unrelated to
technique Pappone et al Circ 2004 Cappato JACC 2009
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How do we interpret these data?
• There is little proof that PVI or WACA are superior
• Recurrence with isolation is rare therefore: – Isolation seems to be important for
success in many – Safer ablation is probably away from the
vein
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How do we do it in practice?
• On warfarin (INR 2-3.5)
• Single PV catheter
• Wide encirclement
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Procedural Endpoints
1. Electrical isolation of all veins
2. Termination of AF during Ablation.
3. Verification of Linear Ablation sets important to prevent recurrence and LA flutter.
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Goal of AF Ablation
• Trigger elimination
• Substrate Modification
• Minimum number of RF applications
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Endpoints – electrical isolation of all veins
• Validated by PV catheter demonstrating:
– Change in electrical signal – separation of local from far-field
– Silent veins
– Dissociated potential
– PV pace capture without LA capture
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Endpoint - isolation of all veins
• Change in electrical signal
– Continuous monitoring helpful particularly in LUPV
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Endpoints – isolation of all
• Silent veins – Usually only
RPV and sometimes LLPV
veins
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Electrical - isolation of all PVs
• Dissociated potentials – Usually
decrease in frequency after PVI
– Can be triggered by cath manipulati on
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Endpoint - isolation of all veins
• Ive isolated the LLPV but didn’t have my lasso in the LUPV– what do I do?
• LUPV signals after llpv isolation
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Endpoints – isolation of all
• Pacing from map cath in llpv with PV cath in LUPV
veins
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v
Endpoints – isolation of all
• Pacing from PV cath capturing local PV potential
eins
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Endpoints validation of lines
• Mitral isthmus line
– Pacing from Lasso in LAA
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Principal Procedural Endpoints
1. Termination of AF during Ablation – • Controversial probably similar recurrence
because of PV reconnection but does indicate good ultimate prognosis
2. Verification of Ablation sets important to prevent recurrence and LA flutter.
3. Non-inducibility of AF following Ablation
• Little evidence
4. Waiting/adenosine/isoprenaline
• Some evidence
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Conclusions
• Wide encirclement is theoretically better
• Validation of PV isolation is critical
• Balancing success (power/temp) with safety is where the skill comes in
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Question 1 • Catheters are in
the standard positions what is the most likely diagnosis?
a) Typical AVNRT
b) AVRT with left sided pathway
c) AVRT with posteroseptal pathway
d) Pre-excited AVRT
e) AVRT with right sided accessory pathway
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• Catheters are Question 2 in the standard positions the following is shown:
a) Orthodromic AVRT
b) Typical AVNRT
c) Atypical AVNRT
d) Antedromic AVRT with septal pathway
e) Antedromic AVRT with lateral pathway
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Question 3
• The following is standard for ablation of AVRT:
a) Power 30W, Temp 600, Time 60s
b) Cooled RF – Power 30W, Temp 450, Time 60s
c) Power 60W, Temp 600, Time 60s
d) Cryo for 2 minutes
e) Cryo for 4 minutes
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Question 4
• The following are useful techniques for distinguishing AVNRT from AVRT :
a) His synchronous Ventricular premature beats advance A
b) A PPI-TCL of <115msecs
c) A preexcitation index of >85msec
d) All of the above
e) None of the above
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Question 5
• Pathways with mahaim characteristics always:
a) Connect nodofascicular
b) Connected to the V at the AV annulus
c) Decrement
d) Block conduction with pressure
e) Result in orthodromic tachycardia