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Catheter Ablation of Atrial Fibrillation
Laurent Haegeli
February 13, 2013
20th Cardiology Update 2013
University Hospital Zurich
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• 5-6% of population ≥ 60 y
• 5x increased risk for thrombo-embolism (stroke)
• Antiarrhythmic drug therapy often not successful
Atrial Fibrillation
Wolf et al. Stroke 1991
Feinberg WM et al. Arch Intern Med 1995
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Atrial Fibrillation
Increased prevalence in the elderly
Feinberg WM, Blackshear JL, Laupacis A. Arch Intern Med. 1995;155:469-473
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Growing Epidemic of Atrial Fibrillation
Miyasaka et al, Circulation 2006
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Willem Einthoven and Sir Thomas Lewis
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The first ECG in 1903
Willem Einthoven (Leiden/NL)
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“Dear Professor Einthoven,
By this post I am sending you somecurves, experimental and clinical.
Please treat the curves I send as if they
were your own.”
Sir Thomas Lewis, London, January 30, 1910
First ECG Documentation of
„Auricular“ Fibrillation
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The Nature of Auricular Fibrillation
Definition:
“conspicuous and continuous oscillations of varying form
and dimensions, and of auricular origin, in ECG leads from
the limbs.”
Sir Thomas Lewis, Heart 1921; 8: 193-227
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Haïssaguerre M et al. N Engl J Med. 1998;339:659-66.
Pulmonary Vein = Trigger
Extrasystole from pulmonary vein Initiation of atrial fibrillation
Vorho
f
Lungenvene
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Arentz T, Haegeli LM et al. J Cardiovasc Electrophysiol. 2007;18:31-38.
High-Density Mapping of Pulmonary Veins
• Intracardiac registration with 64-poles Basket-Catheter (35 Pts)
• Short coupling interval of extrasystole from pulmonary vein induces atrial
fibrillation
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Goal of AF Ablation:
Electrical Isolation of Pulmonary Veins
Muscle fibers = electricalconnection between left atrium
and pulmonary veins
Catheter ablation of musclefibers with radiofrequency
energy
Electrical isolation ofpulmonary veins
Wazni O et al. N Engl J Med. 2011;365:2296-304.
Posterior view
Left atrium and pulmonary veins
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Steerable Ablation Catheter(uni-/bi-directional)
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Circular Mapping Catheter
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Procedural Endpoint:
Pulmonary Vein Isolation
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Pulmonary Vein Isolation:
Cornerstone of AF Ablation
Calkins H et al. HRS/EHRA/ECAS expert consensus statement on catheter
ablation and surgical ablation of atrial fibrillation. Heart Rhythm 2012.
• Point-by-point RF lesions
• Encircling 2 left and 2 right PVs
• Irrigated RF ablation catheter
• Circular mapping catheter
• 3-dimensional mapping system
• Integration of pre-acquired
MRI/CT image of left atrium/PVs
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Targeted Myocardial Injury by Ablation
Haegeli LM et al. Europace. 2008;10:273-5.
20x increased troponin T after AF ablation
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Transseptal Puncture„Door“ to the left atrium and the pulmonary veins
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Transseptal Puncture
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Electro-Anatomical Mapping System
„GPS Navigation System in the Heart“
CARTO XPTM
Haegeli LM et al. Cardiovascular Medicine. 2010;13:272-80.
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3D-Mapping and Image Integration
MRI/CT
CARTOTM
Posterior view
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Electrical Isolation of Pulmonary Veins
*
*
Posterior View
Left lower pulmonary vein
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Electrical Isolation of Pulmonary Veins
*
*
*
*
Posterior View
Left lower pulmonary vein
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Success Rates ?
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- n=167
- 19 hospitals
- Paroxysmal AF
- ≥ 1 AAD failed
- After 9 months: no AF
66% in ablation arm
16% in AAD arm
- 1 pericardial effusion
1 pulmonary oedema
1 pneumonia
- 2 life-threatening arrhythmia
RF Ablation versus AAD
Wilber DJ et al. Comparison of antiarrhythmic drug therapy and radiofrequency
catheter ablation in patients with paroxysmal atrial fibrillation. JAMA 2010;
333-340.
66%
16%
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Haegeli LM et al. Postgrad Med J. 2010;86:395-8.
Haegeli LM et al. Cardiol Res Pract. 2011;854205:1-8.
• 206 patients (230 procedures, 89% outpatients)
• 56 years old, 74% male
• 171 paroxysmal / 35 persistent AF
• Duration 7.6 years
• 86% with significant reduction (>90%) of symptomatic AF
• Complication rate 3% (1 TIA and 6 pericardial tamponade)
Success Rate of AF Ablation
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Metaanalysis: Efficacy of AF Ablation
Calkins H et al. Treatment of Atrial Fibrillation With Antiarrhythmic Drugs or Radiofrequency Ablation: Two
Systematic Literature Reviews and Meta-Analyses. Circ Arrhythm Electrophysiol 2009:;2;349-361
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Risks of AF Catheter AblationPericardial tamponade (1-2%)
Percutaneous drainage
Thromboembolism (1%)
TEE beforehand, anticoagulation during
and after procedure
Pulmonary vein stenosis (<1%)
Avoidance of ablation inside of PV
Atrio-esophageal fistula (<1:10.000)
Esophageal monitoring during procedure,
energy reduction, PPI
Vascular access complication
Left-atrial flutter (Pro-arrythmia)
Redo procedure
→ Total = 2-4 %
Bertaglia et al. Heart Rhythm 2007
ÖsophagusLSPVLSPVRSPV
LIPVRIPV
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TEE before Ablation
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Pre
• CT or MRI heart
• Echo and TEE
Abl
• PVI ± substrate modification
• Monitoring esophagus
Post
• F/U 3, 6 and 12 months incl Holter
• OAC ≥ 3 months
USZ Clinical Care Track for AF
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Double Transseptal Puncture
Haegeli LM et al. Cardiol Res Pract. 2010;295297:1-5.
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P ?
Good Candidates for AF Ablation ?
!
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Haegeli LM et al. J Interv Card Electrophysiol. 2010;28:193-7.
Haegeli LM et al. Future Cardiol. 2011;7:415-23.
AF Ablation for Patients > 65 y
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Cryoballoon Catheter
Arctic Front® (Medtronic CryoCath LP Ltd.)
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Risk of X-Ray for Patient and Staff
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Risk of X-Ray for Patient and Staff
• Single AF ablation confers an additional lifetime
risk for fatal cancer of 0.2% for patient 1
• Lifetime risk for fatal cancer following a 15-year
X-ray exposure is 0.5% for operator 2
• Birth defects
• Cataracts
1 Lickfett L et al. Circulation 20042 Bedetti G et al. Br J Radiol 2008
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Minimize Radiation Exposure !
• Complex procedure (double TSP, extensive RF
application)
• Often CT scan beforehand (alternatively MRI !)
• Sometimes invasive coronary angiograms
• Repeated procedures (cumulative dose !)
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The USZ Zero-Fluoroscopy AF Ablation
University Hospital Zurich
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University Hospital Zurich
The USZ Zero-Fluoroscopy AF Ablation
Intra-cardiac echo
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Laser Energy
Reddy VY et al. Visually-guided balloon catheter ablation of atrial fibrillation: experimental
feasibility and first-in-human multicenter clinical outcome. Circulation 2009; 120:12-20.
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Visually Guided Energy Delivery
Reddy VY et al. Visually-guided balloon catheter ablation of atrial fibrillation: experimental
feasibility and first-in-human multicenter clinical outcome. Circulation 2009; 120:12-20.
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Magnetic Catheter Steering System
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Camm AJ et al. Guidelines for the management of atrial fibrillation. Eur Heart J 2010.
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Camm AJ et al. Guidelines for the management of atrial fibrillation. Eur Heart J 2010.
Early Care in AF
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• 3000 patients
• 200 European centers
• Follow-up 4 years
EAST Trial
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Indications for Catheter Ablation of AF
- Symptomatic patients with paroxysmal
and persistent atrial fibrillation !
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- Symptomatic patients with paroxysmal
and persistent atrial fibrillation !
- After one antiarrhythmic drug failure
- No indications are:
- asymptomatic patients with AF
- patient wish to discontinue anticoagulation
Indications for Catheter Ablation of AF
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• Success rates for paroxysmal atrial
fibrillation are 70-90% (with 1-2
procedures)
• Major complications occur in 2-3 %
AF Ablation Therapy
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Thank you !
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Questions ?