State of the Art EP Lab: What’sGoing On in There?

Bob WestIowa Heart Hospital

Disclosure of Relationships

Bob West, B.S., RCVT, CEPS

Participated in Bachmann Bundle pacing study.

Currently working with Voltage mapping study.

Participated in TTOP trial ………………Ablation Frontiers

Participated in STOP AF trial …………..Arctic Front balloon CryoCath

Briefly participated in ENABLE study …………….Cardiofocus Laser balloon

Disclosure of Relationships

History of Arrhythmia Ablation

1969: Surgical division of WPW pathways 1982: Catheter ablation using DC shock 1987: Catheter ablation using

radiofrequency energy (RF) ‐ cure of SVT 1992: Catheter RF ablation of atrial flutter 1995: Catheter RF ablation of atrial fibrillation=20 years of RF catheter ablation experience

ABLATION sources

RF, standard and irrigatedRadiofrequency energy---resistance heats tissue

4mm,5mm,8mm 10mm deeper and wider lesions

Cryo, standard and balloonnitrous oxide freezes tissue

Laser, balloonCardiofocus diode laser

High intensity focused ultrasoundfocused ultrasound energy to selectively destroy biological tissue at depth

Linear RFAblation Frontiers

Minimal technology

High resolution fluoroscopy

EP 120 channel physiology recorder with programmable stimulator

High resolution signals for diagnosis

PVI goal is to electrically isolate the pulmonary veins

Safe and reliable transeptal accessa steerable introducer gives added flexibility for achieving good lesions

INTRA CARDIAC ECHO imaging for Ablation Pre ablation anatomic orientation

Ablation Goals(what is all this stuff for?)

Maximize Success

Reduce Complications

Death as a complication of catheter ablation of atrial fibrillation (AF) occurs in 1 of every 1000 patients

Thirty-one centers reported 32 deaths in 32,569 patients

tamponade (in 8 patients) stroke (5 patients) atrioesophageal fistula (5 patients) massive pneumonia (2 patients).

J Am Coll Cardiol 2009;53:1798-1803,1804-1806

J Am Coll Cardiol 2009;53:1798-1803,1804-1806

32 deaths out of 32,569 patients

tamponade25%

stroke16%

other37%

pneumonia6%

A E fistula16%

avoidable complications

Monitor the vital signs---old school!

We routinely monitor femoral artery pressure throughout the PVI procedure

"It is of the utmost importance that tamponade (i.e., the most frequent cause of death in our survey) be recognized promptly, before it is too late."

Dr. Riccardo Cappato from the Policlinico San Donato, Milan, Italy

Have the vital signs changed?Stable hemodynamics Early recognition

Quick action and calm heads

Have equipment for tap available now

Critical to act soon!

Can recent additions to technology improve outcomes?

3-D MappingEnsite and Carto

Current improvement include CT or MRI fusion

Better understanding of anatomic variable

Map arrhythmia real-time and in review

Pinpoint critical path to determine ablation strategy

Ensite with fusion on CT

Non-contact Array maps Left atrial tachycardia from right atrium

Carto- Merge

Right septal Accessory Pathway Mapping

Retrograde map cryo lesions

Remote Robotic Navigation Magnetic Robotic

Sensei Robotic Catheter System

Steriotaxis

Steriotaxis Magnetic Navigation

High initial cost Closed architecture No irrigated catheters Soft catheter (light RF contact) Applications for ventricular rhythms, coronary

access and coronary sinus access.

Natale, Gallinghouse,Horton 1/5/09The Use of Remote Robotic Navigation

in Complex Arrhythmias webcast

Hansen MedicalSensei Robot 14F introducer Only useful in atriums (primarily LA) Open architecture Complication rate similar to manual No cryo (8.5F lumen limitation)

Natale, Gallinghouse,Horton 1/5/09The Use of Remote Robotic Navigation

in Complex Arrhythmias webcast

Current Investigations

STOP AF trial Cryo balloon Pulmonary vein isolation

Round balloon in an oval/egg shape hole!Some part of the ring will be missed!!

To touch up missed area Freezor Max is used or the Balloon repositioned and repeated

PVI goal is to electrically isolate the pulmonary veins

Pre cryo Post cryo

EGD damage after EGD damage after PV Isolation with the CryoballoonPV Isolation with the Cryoballoon Catheter

Presented at the Heart Rhythm Society 2008 Scientific Sessions, San Francisco, CA May 14-17.

To date no esophageal fistula has been seen in cryo procedures.

Conclusions: This case clearly demonstrates that Cryoballoon ablation can cause esophageal ulceration. Perhaps the absence of atrial-esophageal fistula formation with cryoablation may be related to the post-ablation healing process, rather than an inherent inability of cryoenergy to cause esophageal damage.

Ablation technology by definition causes cellular damage

TTOP Linear Ablation Ablation Frontiers

Linear lesions to the roof and Septum Ablation Frontiers

technology to improve outcome

Variation in anatomy

Location, size, branching and number of pulmonary veins

Size and location of atrial appendage Proximity of esophagus to PV antrum Phrenic nerve proximity to ablation site Coronary artery proximity to ablation

site

Location, size, branching and number of pulmonary veins

PA CT of Left atrium Red LA Green distal PV’s White esophagus

Size and location of atrial appendage

Proximity of esophagus to PV antrum

Pulmonary vein ostia are not round

If you know there is a risk

Take every effort to avoid a bad outcome

Phrenic nerve proximity to ablation site

(A)pre ablation (B)phrenic palsy (C)recovery

Sanchez-Quintana found the anterior wall of the RSPV is <2mm from the right phrenic nerve in 32% of their autopsy series

Coronary artery proximity to isthmus ablation site common atrial flutter 68 yo man

Is deeper and wider better? 13 yo maleSTEMI during Posterior wall accessory pathway ablationEarly recognition of a complication is critical ……… emergent coronary stent interrupted this boys MI

Distal RCA occlusion

Is something important near the ablation site?.......... Two reported coronary occlusions in Epstein’s WPW

Incidence of coronary artery injury immediately after catheter ablation for supraventricular tachcardias in infants and children.

Heart Rhythm, Volume 6,Issue 4, Pages 461-467

15 year old male Epstein's anomaly with WPW pacing RV- right side posterior Accessory Pathway is common

RCA 4mm from right atrial endocardial surface

Cryo lesion paint to RCA posterior to Kent bundle

No acute or residual symptoms

Lower Incident of Thrombus Formation With Cryoenergy Versus Radiofrequency Catheter AblationKhairy et al. ,Circulation 2003;107

What is the future?

built in Safety and a quick arrival at the goal Beautifully engineered

Beautiful simplicity

"Things should be made as simple as possible, but not simpler." — Albert Einstein (1879–1955)

addendum

Fall and winter 2009

Voltage substrate mapping

LA voltage substrate map in NSR

Reflexion HD™ High Density Mapping Catheter

Criteria for definingLow voltage bridges

HVR

LVB

HVR

Low voltage bridges occur in both atriums and their veins

LSVC LSVC

RAA

Importance of low voltage bridges

“Ideally, a method to identify abnormal atrial substrate would offer the best chance to understand the underlying atrial disease, as well as, offer the best chance to intervene with ablation.”

Steven J. Bailin, MD Iowa Heart Center

10 patients undergoing AF ablation

Cryo lesions

The ability to map atrial substrate makes apparent the fundamental structures necessary to maintain and propagate AF

In all 10 patients, AF was terminated to sinus rhythm

The voltage gradients as well as high voltage areas were dramatically altered

Voltage pre ablation Voltage post ablation

Only time and follow up will tell if this is a better method.