Ablacion de Venas Pulmonares:  Pasado, Presente, y Futuro           9 de Octubre, 2010       Javier E. Sanchez MD     Texa...
Texas Cardiac Arrhythmia Institute          at St. Davids Medical Center                     Austin, TexasElectrophysiolog...
G. Neal Kay
Meta• Proveer una perspectiva personal de como  nuestro campo surgio, como ha  evolucionado, y como progresara en el  futu...
PASADO
Surgical Cox Maze Procedure     Cox JL. Cox J Thoracic Card Surg 1991;101:406     and J Cardiovasc Electropysiol 2004;2:250
Surgical Cox Maze Series•   276 patients (Sept 1987-June 2003)•   Lone surgery on 160•   Concomitant surgery on 113    –  ...
Success rate with Maze Procedure            J Thoracic and Cardiovasc Surg 2005;129:104
Success according to duration of AF          before surgery            J Thoracic and Cardiovasc Surg 2005;129:104
Maze may not “cure” all Afib, but itdramatically decreases the incidence             of strokes                           ...
Catheter “Maze Procedure”The First Catheter Ablation Procedure for AF• J Swartz .Circulation 1994;90:I-335  – Patient with...
Catheter Maze Procedure• Swartz, Kay, Packer 1995-1996  – 23/29 in sinus rhythm off antiarrhythmic    therapy after 2 year...
Catheter Maze Procedure:            First Published Series• Haissaguerre JCE1996;7:1132• 45 patients  – 3 groups in base o...
Catheter Maze Procedure:First Published Series: Haissaguerre , JCE1996;7:1132
Catheter Maze Procedure:First Published Series: Haissaguerre , JCE1996;7:1132                                  Focal ablat...
Left Superior PVRight Anterior Oblique       Left Anterior Oblique                         3
Initial Linear Ablation System Designed       for Catheter Maze Procedure          Kay, Ellenbogen, Calkins
Initial Linear Ablation System Designed       for Catheter Maze Procedure          Kay, Ellenbogen, Calkins               ...
Initial Linear Ablation System Designed       for Catheter Maze Procedure          Kay, Ellenbogen, Calkins
Strategy• Patients with structural heart disease;  with permanent or persistent atrial  fibrillation  – RA ablation  – LA ...
Results• 49 Patients underwent RA linear  ablation; in 7, SR obtained• 28 Patients underwent LA linear ablation  – In 13, ...
62% Success Rate at 8 + 6 Months                   25%            45%                   9%              16%               ...
Aislamiento de las Venas Pulmonares      (Ablación en segmentos) • Resultados clínicos mas sostenidos • Menos estenosis de...
Circulation 2000;101:1409-1417       3
Segmental Ostial AblationRAO                 LAO
Ablation at 2 segments                                around this vein achieves                                electrical ...
Basket in Right Superior PVRight Anterior Oblique   Left Anterior Oblique
Before Segmental Ostial Ablations         Circulation 2003;108:590
After Segmental Ostial Ablations       Circulation 2003;108:590
An uncommon case
Basket in Left Superior PVRight Anterior Oblique                         3   Left Anterior Oblique
Basket in Left Inferior PVRight Anterior Oblique                         3   Left Anterior Oblique
Basket in Right Superior PVRight Anterior Oblique                         3   Left Anterior Oblique
Basket in Right Inferior PVRight Anterior Oblique   3   Left Anterior Oblique
Basket in SVCRight Anterior Oblique       Left Anterior Oblique                         3
Ablación Circular del Atrio Izquierdo        (sin aislar las venas)        Pappone et al., Circulation. 2001;104:2539
Registro (vs casos controles)            Freedom from Atrial Fibrillation                                    JACC 2003:42;...
Probabilidad de Eventos Adversos                Decreased incidence of strokes,                CHF admissions, and death  ...
Circular Ablation Vs Segmental        Ostial Isolation      Oral et al. Circulation 2003;108:2355
AF Catheter Ablation Strategies          Exit (Os)     FocalAntrumMore Proximal ablation: The PV Antrum
Atrial Esophageal Fistula   Pappone et al. Circulation 2004;109:2724
Left atrial circular ablation achieving vein isolation      with the use of Intracardiac echo (ICE)                       ...
ICE guided ablation-The presence of microbubbles indicates excessive heating-Decreasing ablation power when microbubbles a...
Improved safety and success with          use of ICE                   Circulation. 2003;107:2710
Ablation of Fractionated Electrograms                  (Dr Nademanee)    JACC 2004;43:2044      HRJ 2006;8:981
Lessons Learned
Right Atrium
Right Atrium
Considerations for AF          Transseptals• For the lasso: anterior is better
Considerations for AF           Transseptals• For the ablation a more inferior and  posterior approach is better
PFO is Superior and Anterior to AF                Transseptal Ideal SiteTo use the transseptal for the ablation prolongs t...
Transseptal Sheath not in PFO
Transseptals During Redo            Procedures• Tend to be a little higher• Septum tends to be a little tougher  – May cos...
Bending Needle to Resemble a       BRK 1 Useful         PACE 2007:30:1506
Transseptal Needles – BRK™            Series Direction   Arrow                                                            ...
RF Energy or Electrocautery For Transseptal Cathetherization          Circ AE 2008;1:169
Evaluating PV Anatomy
Area of Interest
Area of Interest
Area of Interest
Ablation Strategy: Avoid the PV’s
Ablation Strategy: Avoid the PV’s
Techniques Are ComplementaryLimitations of Esophageal Temperature Probe
Direct Visualization with ICE         Ablation Catheter on top of Esophagus
Mapping Facilitated by Circular CatheterLeft Pulmonary veins:   Right Pulmonary veins:   SVC:Low #’s are anterior    Low #...
Mapping Facilitated by Circular CatheterLeft Pulmonary veins:         Right Pulmonary veins:     SVC:Low #’s are anterior ...
PRESENTE
Randomized Trial Of PAFRefractory to 1 Antiarrhythmic            (multicenter)                              No redo”s     ...
Randomized Trial Of PAFRefractory to 1 Antiarrhythmic        (single center)                 Redo 23 patients             ...
Ablation in Persistent AF• Success rates are less• Redo’s are more common• (Complications are the same)
Long Standing Persistent AF             PVAI + Defragmentation + Pharmacologic                           ChallengeSuccess ...
Long Standing Persistent AF             PVAI + Defragmentation + Pharmacologic                           ChallengeSuccess ...
Ablation of Fractionated Electrograms(Consensus opinion: limited utility as stand-alone strategy, useful as               ...
Ablation of Long Standing      Persistent AFLinz et al. J CE 2010; published ahaed of print Sept 2010
Linz et al. J CE 2010; published ahaed of print Sept 2010
Ablation of Long Standing      Persistent AFLinz et al. J CE 2010; published ahaed of print Sept 2010
FUTURO
Left Atrial Appendage: An under-recognized source of AF triggers
Left Atrial Appendage: An under-recognized source of AF triggers        (isuprel induced)
LAA: segmental isolation similar to a PV
A       B    C
LAA dissociated firingA                            B
Left Atrial Appendage: An under-recognized source of AF triggers
Lateral Left Atrium    EHJ 2008;29, 356
Lateral Left Atrium    EHJ 2008;29, 356
Increasing Complexity of AF Ablation                                    Sinus Rhythm                                      ...
Challenge: Need for Redo Procedures  • 20-40% redo rates are needed  • Redo procedure are done mostly to    re-ablate prev...
Challenge: Life-threateningComplications Remain Present     JACC 2009;53:1798
Challenge: Life-threatening     Complications Remain PresentCould some complications be avoided with contact force        ...
Safety: steam pops            Incidence of Steam Pops in % at 40W*                                          P<0.01        ...
Safety: Esophageal injuryThis canine model demonstrates the striking role of contactforce in Eso injury during RF ablation...
Safety: Perforation Perforation Force [g]   350                         300                         250                   ...
Extreme Variability of Forces (when blinded to contact force data)          Source: D. Shah, HRS 2009
Summary• Surgical Maze remains the “best” single  procedure (and it is very far from perfect)• Present techniques are effe...
Summary• 2 major obstacles remain)  – Need for redo procedure to accomplish    permanent results (which hopefully will    ...
Gracias!
Termination during persistent AF                           HRJ 2010 ahead o                           print
Mechanism of AF   (from the perspective of an           ablationist)• AF is initiated by sites/regions of abnormal  automa...
AHA/ACC Proposed Clinical Algorithm(How to maintain sinus, sub-divided by underlying cardiac disease)                     ...
AHA/ACC Proposed Clinical Algorithm(How to maintain sinus, sub-divided by underlying cardiac disease)Ablation is an altern...
What should we call the procedure?• Initial concept: “Focal” ablation• Anatomic circumferential left atrial (PV) ablation ...
Surgical Ablation: “Maze”        Cox JL. Cox J Thoracic Card Surg 1991;101:406        and J Cardiovasc Electropysiol 2004;...
Relation Between LAAppendage and Left PVs                 Ho SY, et al                 Heart 2001;86:265         3
PV-Antrum and SVC Disconnection        SVC         RA        LA              MA
Pulmonary Vein Antrum
Titration of power  Microbubble formation
All relevant structures visualized
Identifying complications Thrombus in transseptal sheath                                  Marchlinski et al
Current Approach PVAI + Defragmentation + Pharmacologic ChallengePVAI+CFAE: 94% of patients in sinus after redo in 20% and...
Isoproterenol Induced CS Tachycardia                                       1007-1,02
Adenosine Induced Atrial fibrillation                                        1007-1,03
Recovery of PV Conduction With Isoproterenol
Recovery of PV Conduction With Isoproterenol
Pulmonary Vein Antrum Isolation                      2007
Pulmonary Vein Antrum Isolation                      2008
Advantages of extensive PVAI• Objective endpoint  – Practical: no arguments about how far from the    ostium, or about “fa...
Advantages of extensive PVAI• Objective endpoint  – Practical  – No arguments about:     • how far from the ostium     • “...
Advantages of extensive PVAI• Targets all triggers• Acknowledges the reality that there will be  some ablated sites that w...
Advantages of extensive PVAI• Achieves complete autonomic denervation  – 20 patients underwent identification of vagal    ...
The importance of AF termination      (after redo’s in 52%)     O’Neill et al. Eur Heart J 2009 (in print)
Haissaguerre: Stepwise approach in Persistents         (Predictors of termination) Duration in AF                       Cy...
Basic Rules• Minimize catheter manipulations  – If the catheter is in a place you will ablate, ablate  – If ablation is no...
Dr. javier sánchez a fib ablation leon october 2010
Dr. javier sánchez a fib ablation leon october 2010
Dr. javier sánchez a fib ablation leon october 2010
Dr. javier sánchez a fib ablation leon october 2010
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Dr. javier sánchez a fib ablation leon october 2010

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Transcript of "Dr. javier sánchez a fib ablation leon october 2010"

  1. 1. Ablacion de Venas Pulmonares: Pasado, Presente, y Futuro 9 de Octubre, 2010 Javier E. Sanchez MD Texas Cardiac Arrhythmia Institute St. Davids Medical Center Austin, Texas
  2. 2. Texas Cardiac Arrhythmia Institute at St. Davids Medical Center Austin, TexasElectrophysiologists Research Fellows/Nurses• David Burkhardt MD • Luigi DiBiasi MD • Prasant Mohanty MD• Shane M. Bailey MD • Yan Wang MD• Robert C. Canby MD • Deb Cardinal RN• Rodney P. Horton MD • Chantel Scallon RN • Barbara Thomas RN• G. Joseph Gallinghouse MD • Elva Brown RN• Andrea Natale MD • Jackie Kin RN• Larry Price DO • Karla Wolter RN • Wendy Brandhorst RN• Javier E. Sanchez MD • Maegen Lane RN• Jason D. Zagrodzky MD • Cindy Williams RN
  3. 3. G. Neal Kay
  4. 4. Meta• Proveer una perspectiva personal de como nuestro campo surgio, como ha evolucionado, y como progresara en el futuro cercano
  5. 5. PASADO
  6. 6. Surgical Cox Maze Procedure Cox JL. Cox J Thoracic Card Surg 1991;101:406 and J Cardiovasc Electropysiol 2004;2:250
  7. 7. Surgical Cox Maze Series• 276 patients (Sept 1987-June 2003)• Lone surgery on 160• Concomitant surgery on 113 – MV only 33 – CABG 40 – Ao V + CABG 2 – Others concomitant procedures on 38 J Thoracic and Cardiovasc Surg 2005;129:104
  8. 8. Success rate with Maze Procedure J Thoracic and Cardiovasc Surg 2005;129:104
  9. 9. Success according to duration of AF before surgery J Thoracic and Cardiovasc Surg 2005;129:104
  10. 10. Maze may not “cure” all Afib, but itdramatically decreases the incidence of strokes Prior stroke, No AC Risk factors, no AC Prior stroke, with AC Risk factors, with AC Lone AF, AC Maze, no AC J Thoracic and Cardiovasc Surg 1999;118:883
  11. 11. Catheter “Maze Procedure”The First Catheter Ablation Procedure for AF• J Swartz .Circulation 1994;90:I-335 – Patient with chronic AF, CHF, and a LA of 5.8 x 7.5 cm was treated with linear ablations in a pattern similar to the maze surgery. During procedure, arrhythmia progressively organized and eventually converted to sinus rhythm. – Later extended the series to 10 patients Never published as a full manuscript
  12. 12. Catheter Maze Procedure• Swartz, Kay, Packer 1995-1996 – 23/29 in sinus rhythm off antiarrhythmic therapy after 2 years of follow up (79% success) – Another 2 that previously had chronic AF, converted to PAF• Limitations – Procedure duration ~12 hrs – Many complications: VF, tamponades, 2 strokes, PV stenosis Never published as a full manuscript
  13. 13. Catheter Maze Procedure: First Published Series• Haissaguerre JCE1996;7:1132• 45 patients – 3 groups in base of RA ablation pattern – If AF after RA ablation, LA ablation offered • Linear ablation done first. If Atrial tachycardias noted they were mapped and ablated.
  14. 14. Catheter Maze Procedure:First Published Series: Haissaguerre , JCE1996;7:1132
  15. 15. Catheter Maze Procedure:First Published Series: Haissaguerre , JCE1996;7:1132 Focal ablation of atrial tachycardias done in the superior PV’s, the high crista and the CS os
  16. 16. Left Superior PVRight Anterior Oblique Left Anterior Oblique 3
  17. 17. Initial Linear Ablation System Designed for Catheter Maze Procedure Kay, Ellenbogen, Calkins
  18. 18. Initial Linear Ablation System Designed for Catheter Maze Procedure Kay, Ellenbogen, Calkins Am Heart J 1999; 83:227D
  19. 19. Initial Linear Ablation System Designed for Catheter Maze Procedure Kay, Ellenbogen, Calkins
  20. 20. Strategy• Patients with structural heart disease; with permanent or persistent atrial fibrillation – RA ablation – LA ablation – “Focal ablation” (which really meant PV ablation, although it wasn’t called that in initial protocol) Calkins et al. Am Heart Journal 1999;83:227D
  21. 21. Results• 49 Patients underwent RA linear ablation; in 7, SR obtained• 28 Patients underwent LA linear ablation – In 13, sinus rhythm was obtained; in 5, AF converted to paroxysmal – PV isolation performed in 19: • in 15, SR obtained; in 2, AF converted to paroxysmal; in 2, AF persisted • (overall 71% success rate) Calkins et al. Am Heart Journal 1999;83:227D
  22. 22. 62% Success Rate at 8 + 6 Months 25% 45% 9% 16% 94% (Haïssaguerre M et al. NEJM 1998; 339: 659-66)
  23. 23. Aislamiento de las Venas Pulmonares (Ablación en segmentos) • Resultados clínicos mas sostenidos • Menos estenosis de las VPs • Resultatado en FA crónica menos de 35%
  24. 24. Circulation 2000;101:1409-1417 3
  25. 25. Segmental Ostial AblationRAO LAO
  26. 26. Ablation at 2 segments around this vein achieves electrical isolation of the PV Circulation 2000;101:1409Recordings from inside the PV
  27. 27. Basket in Right Superior PVRight Anterior Oblique Left Anterior Oblique
  28. 28. Before Segmental Ostial Ablations Circulation 2003;108:590
  29. 29. After Segmental Ostial Ablations Circulation 2003;108:590
  30. 30. An uncommon case
  31. 31. Basket in Left Superior PVRight Anterior Oblique 3 Left Anterior Oblique
  32. 32. Basket in Left Inferior PVRight Anterior Oblique 3 Left Anterior Oblique
  33. 33. Basket in Right Superior PVRight Anterior Oblique 3 Left Anterior Oblique
  34. 34. Basket in Right Inferior PVRight Anterior Oblique 3 Left Anterior Oblique
  35. 35. Basket in SVCRight Anterior Oblique Left Anterior Oblique 3
  36. 36. Ablación Circular del Atrio Izquierdo (sin aislar las venas) Pappone et al., Circulation. 2001;104:2539
  37. 37. Registro (vs casos controles) Freedom from Atrial Fibrillation JACC 2003:42;185
  38. 38. Probabilidad de Eventos Adversos Decreased incidence of strokes, CHF admissions, and death Pappone et al. JACC 2003:42;185
  39. 39. Circular Ablation Vs Segmental Ostial Isolation Oral et al. Circulation 2003;108:2355
  40. 40. AF Catheter Ablation Strategies Exit (Os) FocalAntrumMore Proximal ablation: The PV Antrum
  41. 41. Atrial Esophageal Fistula Pappone et al. Circulation 2004;109:2724
  42. 42. Left atrial circular ablation achieving vein isolation with the use of Intracardiac echo (ICE) Intracardiac echocardiography (ICE) facilitated ablation in the atrium without ablation inside of the veins Circulation. 2003;107:2710
  43. 43. ICE guided ablation-The presence of microbubbles indicates excessive heating-Decreasing ablation power when microbubbles are seenincreases safety Circulation. 2003;107:2710 Circulation. 2003;107:2710
  44. 44. Improved safety and success with use of ICE Circulation. 2003;107:2710
  45. 45. Ablation of Fractionated Electrograms (Dr Nademanee) JACC 2004;43:2044 HRJ 2006;8:981
  46. 46. Lessons Learned
  47. 47. Right Atrium
  48. 48. Right Atrium
  49. 49. Considerations for AF Transseptals• For the lasso: anterior is better
  50. 50. Considerations for AF Transseptals• For the ablation a more inferior and posterior approach is better
  51. 51. PFO is Superior and Anterior to AF Transseptal Ideal SiteTo use the transseptal for the ablation prolongs total RF energy delivery andprocedure duration but does nor affect clinical result (JCE 2008;19:1236)For AF ablation I prefer to do 2 transseptals and not use the PFOAnother option is to use the PFO for the sheath that will have the circularmapping catheter
  52. 52. Transseptal Sheath not in PFO
  53. 53. Transseptals During Redo Procedures• Tend to be a little higher• Septum tends to be a little tougher – May costumize needle to resemble a BRK 1 – May use electrocautery or RF energy Europace 2008;10:276
  54. 54. Bending Needle to Resemble a BRK 1 Useful PACE 2007:30:1506
  55. 55. Transseptal Needles – BRK™ Series Direction Arrow ~70% Pediatric UseStopcock Valve ~30% May use stylet to avoid scratching the sheath
  56. 56. RF Energy or Electrocautery For Transseptal Cathetherization Circ AE 2008;1:169
  57. 57. Evaluating PV Anatomy
  58. 58. Area of Interest
  59. 59. Area of Interest
  60. 60. Area of Interest
  61. 61. Ablation Strategy: Avoid the PV’s
  62. 62. Ablation Strategy: Avoid the PV’s
  63. 63. Techniques Are ComplementaryLimitations of Esophageal Temperature Probe
  64. 64. Direct Visualization with ICE Ablation Catheter on top of Esophagus
  65. 65. Mapping Facilitated by Circular CatheterLeft Pulmonary veins: Right Pulmonary veins: SVC:Low #’s are anterior Low #’s are posterior Low #’s are posterior
  66. 66. Mapping Facilitated by Circular CatheterLeft Pulmonary veins: Right Pulmonary veins: SVC:Low #’s are anterior Low #’s are posterior Low #’s are posterior Recognize where far-field signals are
  67. 67. PRESENTE
  68. 68. Randomized Trial Of PAFRefractory to 1 Antiarrhythmic (multicenter) No redo”s Navistar Thermocool Study March 2009
  69. 69. Randomized Trial Of PAFRefractory to 1 Antiarrhythmic (single center) Redo 23 patients Jais et al. Circ 2008;118:2498
  70. 70. Ablation in Persistent AF• Success rates are less• Redo’s are more common• (Complications are the same)
  71. 71. Long Standing Persistent AF PVAI + Defragmentation + Pharmacologic ChallengeSuccess after 1 procedure: 11% 40% 61%Review: Cardiol Clin 2009; 27:163 Elayi et al. HRJ 2008; 5:1658
  72. 72. Long Standing Persistent AF PVAI + Defragmentation + Pharmacologic ChallengeSuccess after 1 procedure: 11% 40% 61% 94% of patients in sinus after redo in 20% and 14% on AADReview: Cardiol Clin 2009; 27:163 Elayi et al. HRJ 2008; 5:1658
  73. 73. Ablation of Fractionated Electrograms(Consensus opinion: limited utility as stand-alone strategy, useful as an add-on to PV isolation) PA AP Nademanee HRS Afib Summit 2007Common sites where fractionated electrograms are present
  74. 74. Ablation of Long Standing Persistent AFLinz et al. J CE 2010; published ahaed of print Sept 2010
  75. 75. Linz et al. J CE 2010; published ahaed of print Sept 2010
  76. 76. Ablation of Long Standing Persistent AFLinz et al. J CE 2010; published ahaed of print Sept 2010
  77. 77. FUTURO
  78. 78. Left Atrial Appendage: An under-recognized source of AF triggers
  79. 79. Left Atrial Appendage: An under-recognized source of AF triggers (isuprel induced)
  80. 80. LAA: segmental isolation similar to a PV
  81. 81. A B C
  82. 82. LAA dissociated firingA B
  83. 83. Left Atrial Appendage: An under-recognized source of AF triggers
  84. 84. Lateral Left Atrium EHJ 2008;29, 356
  85. 85. Lateral Left Atrium EHJ 2008;29, 356
  86. 86. Increasing Complexity of AF Ablation Sinus Rhythm Organized NonPV Atrial Arrhythmias Sources 86 Left Atrial Lines Atrial Fibrillation Isthmus/Roof/Antrum 82 4 PVs 70 3 PVs 50 2 PVs 1 PV RA Lines 11 1994 2002 Time
  87. 87. Challenge: Need for Redo Procedures • 20-40% redo rates are needed • Redo procedure are done mostly to re-ablate previously ablated sites. 1 Hindricks G et al, Late recurrent arrhythmias after ablation of atrial fibrillation: incidence, mechanisms, and treatment. Heart Rhythm 2004;1:676–683. 2 Callans DJ et al, Efficacy of repeat pulmonary vein isolation procedures in patients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol 2004;15:1050–1055.
  88. 88. Challenge: Life-threateningComplications Remain Present JACC 2009;53:1798
  89. 89. Challenge: Life-threatening Complications Remain PresentCould some complications be avoided with contact force feedback? JACC 2009;53:1798
  90. 90. Safety: steam pops Incidence of Steam Pops in % at 40W* P<0.01 % P=0.08 4/9 6/9 0/9 Low Force Moderate Force High force 10 g 25 g 70 gSteam pop occurred only with high contact force at 30 W in RVand moderate and high contact force at 40W and 50 W in LV. Nakagawa et al, 2008 HRS abstract (beating heart dog model in ventricles) * One ablation out of nine done at 50W
  91. 91. Safety: Esophageal injuryThis canine model demonstrates the striking role of contactforce in Eso injury during RF ablation in the LA close to Eso. Source: A. Ikeda, HRS 2008
  92. 92. Safety: Perforation Perforation Force [g] 350 300 250 200 RA lesion 150 RA tissue 100 50 0 5 1 2 7 4 6 3 e e e e e e e pl pl pl pl pl pl pl m m m m m m m Sa Sa Sa Sa Sa Sa SaPerforation with a typical ablation catheter through the healthy free walls of a pig heart required > 100 g of force. (less through recently ablated tissue) Shah et al, HRS 2008 abstract (ex vivo pig heart)
  93. 93. Extreme Variability of Forces (when blinded to contact force data) Source: D. Shah, HRS 2009
  94. 94. Summary• Surgical Maze remains the “best” single procedure (and it is very far from perfect)• Present techniques are effective and safe for the treatment of paroxysmal and recently persistent atrial fibrillation• Long-standing persistent atrial fibrillation remains a challenge
  95. 95. Summary• 2 major obstacles remain) – Need for redo procedure to accomplish permanent results (which hopefully will improve with contact force information in near future ) – Identification of sites other than the PV antral region
  96. 96. Gracias!
  97. 97. Termination during persistent AF HRJ 2010 ahead o print
  98. 98. Mechanism of AF (from the perspective of an ablationist)• AF is initiated by sites/regions of abnormal automaticity• AF is maintained by sites/regions with either abnormal automaticity or short refractory periods where local reentry occurs (the cardiac autonomic system may facilitate or cause some of these areas)
  99. 99. AHA/ACC Proposed Clinical Algorithm(How to maintain sinus, sub-divided by underlying cardiac disease) Circ 2006;114:700
  100. 100. AHA/ACC Proposed Clinical Algorithm(How to maintain sinus, sub-divided by underlying cardiac disease)Ablation is an alternative to initiation of amiodarone in all patientsexcept those with CHF Circ 2006;114:700
  101. 101. What should we call the procedure?• Initial concept: “Focal” ablation• Anatomic circumferential left atrial (PV) ablation – (Pappone et al)• Pulmonary vein antrum isolation – (Cleveland Clinic)• Ablation of fractionated electrograms – (Nadamanee)• Tailored approach – (Morady et al)• Stepwise ablation: “PVI” plus “linear” plus “defragmentation” plus “linear… – (Haissaguerre et al) Probably: “A Fib Ablation”
  102. 102. Surgical Ablation: “Maze” Cox JL. Cox J Thoracic Card Surg 1991;101:406 and J Cardiovasc Electropysiol 2004;2:250
  103. 103. Relation Between LAAppendage and Left PVs Ho SY, et al Heart 2001;86:265 3
  104. 104. PV-Antrum and SVC Disconnection SVC RA LA MA
  105. 105. Pulmonary Vein Antrum
  106. 106. Titration of power Microbubble formation
  107. 107. All relevant structures visualized
  108. 108. Identifying complications Thrombus in transseptal sheath Marchlinski et al
  109. 109. Current Approach PVAI + Defragmentation + Pharmacologic ChallengePVAI+CFAE: 94% of patients in sinus after redo in 20% and 14% on AAD Elayi et al. HRJ 2008; 5:1658
  110. 110. Isoproterenol Induced CS Tachycardia 1007-1,02
  111. 111. Adenosine Induced Atrial fibrillation 1007-1,03
  112. 112. Recovery of PV Conduction With Isoproterenol
  113. 113. Recovery of PV Conduction With Isoproterenol
  114. 114. Pulmonary Vein Antrum Isolation 2007
  115. 115. Pulmonary Vein Antrum Isolation 2008
  116. 116. Advantages of extensive PVAI• Objective endpoint – Practical: no arguments about how far from the ostium, or about “far-field” versus local, or about entrance or exit block – Reproducible results among various operators Verma et al. HRJ 2007;4:1177
  117. 117. Advantages of extensive PVAI• Objective endpoint – Practical – No arguments about: • how far from the ostium • “far-field” versus local electrograms • entrance or exit block – Reproducible results among various operators
  118. 118. Advantages of extensive PVAI• Targets all triggers• Acknowledges the reality that there will be some ablated sites that will regain conduction – If a trigger regains, it will probably remain isolated – If an ablation site that is part of a “line of block regains, neighboring sites are probably still enough to accomplish block
  119. 119. Advantages of extensive PVAI• Achieves complete autonomic denervation – 20 patients underwent identification of vagal sites, followed by PVAI by another operator • Post ablation vagal sites no longer present – 22 redo patients (another unrelated group) • Before ablations (in second procedure) 19/22 with no identifiable vagal sites Verma et al. HRJ 2007;4:1177
  120. 120. The importance of AF termination (after redo’s in 52%) O’Neill et al. Eur Heart J 2009 (in print)
  121. 121. Haissaguerre: Stepwise approach in Persistents (Predictors of termination) Duration in AF Cycle Length in LAA O’Neill et al. Eur Heart J 2009 (in print)
  122. 122. Basic Rules• Minimize catheter manipulations – If the catheter is in a place you will ablate, ablate – If ablation is not having the desired effect, ablate somewhere else• Recognize impossible manipulations – Going from left atrial appendage to the pulmonary veins – Going from one vein to another vein• Avoid dangerous manipulations – Never counterclock the circular catheter (always clock it) – Transseptal sheaths only go from 3 o’clock to 9 o’clock • (3-4-5-6-7-8-9; 9-8-7-6-5-4-3)
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