Atrial Fibrillation Ablation

1,208 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,208
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
85
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • Olshansky via Medtronic (modified) ____ Demonstrates the anatomy of the left atrium, especially of the pulmonary veins. These can be sites of origin of not only left atrial tachycardias, but also of AF.
  • Image taken from Mike’s AF brochure… 010620
  • Olshansky via Medtronic (modified) ____ Demonstrates the anatomy of the left atrium, especially of the pulmonary veins. These can be sites of origin of not only left atrial tachycardias, but also of AF.
  • Electrophysiological Breakthroughs From the Left Atrium to the Pulmonary Veins Michel Haïssaguerre, MD; Dipen C. Shah, MD; Pierre Jaïs, MD; Mélèze Hocini, MD; Teiichi Yamane, MD; Isabel Deisenhofer, MD; Michel Chauvin, MD; Stéphane Garrigue, MD; Jacques Clémenty, MD
  • Facilitate safe and rapid transeptal LA access Visual guidance for placement of diagnostic loop catheter at PV ostium Optimization of RF energy delivery via “bubble” monitoring Doppler flow assessment of PV flow to assess for stenosis Visualization of PV ostial size, anatomic abnormalities, pericardial effusion, thrombus
  • An 8 Fr model also was announced in June 2004 (?release date?)
  • Intracardiac echo facilitates PV isolation by: 1. Rendering transseptal access easier and safer. 2. Helping in proper placement of the circular mapping catheter at the vein ostium. 3. Optimizing power titration during radiofrequency energy delivery through detection of bubbles at the catheter-tissue interface. Prompt detection of dense bubbles (type 2 bubbles) could also prevent impedance rise and avoid the milieu for thrombus formation. In addition, monitoring PV flow velocity offers the potential to prevent excessive swelling at the PV ostium, which could lead to chronic PV stenosis. In this respect, ablation at the PV ostium should be aborted when the PV diastolic flow velocity exceeds 1 m/s.
  • Radiofrequency energy was delivered using a power controlled cooled-tip ablation catheter (50 Watt generator; EPT, Sunnyvale, CA, USA). Energy delivery was titrated to the maximum value within 45-60 s. Energy delivery was terminated after 45-60 s. Figure 2a Correct placement of the circular mapping catheter at the ostium of the LUPV is confirmed via ICE imaging. The bubbles seen near the ablation catheter, and the absence of bubbles elsewhere in the LA, indicate appropriate lesion formation. Figure 2b Shower of dense bubbles (type 2) well back into the LA indicates tissue over-heating.
  • Atrial Fibrillation Ablation

    1. 1. Atrial Fibrillation Ablation Cardiology Symposium December 6, 2004 Paul R. Steiner, M.D. Cardiac Electrophysiology
    2. 2. Case Background: <ul><li>46 yr old athletic woman (cyclist, runner) </li></ul><ul><li>3 yr h/o increasingly frequent rapid palpitations paroxysmal AF </li></ul><ul><ul><li>Often immediately following exercise </li></ul></ul><ul><ul><li>More recently may occur randomly </li></ul></ul><ul><li>No other medical conditions </li></ul>
    3. 3. Initial Evaluation: <ul><ul><li>ECG : Sinus bradycardia at rest 54 bpm, normal morphology </li></ul></ul><ul><ul><li>Labs : T4, TSH, lytes, etc. are WNL </li></ul></ul><ul><ul><li>Echo : Structurally normal heart </li></ul></ul><ul><ul><li>Holter : Frequent APCs, occas PVCs; salvos of AT and AF, some that are associated w/ symptoms on the patient log. </li></ul></ul><ul><ul><ul><li>Heart rate range (in sinus) : 46 – 138 bpm </li></ul></ul></ul>
    4. 4. Treatment History: <ul><ul><li>Rate control strategy: </li></ul></ul><ul><ul><ul><ul><li>Digoxin </li></ul></ul></ul></ul><ul><ul><ul><ul><li>β – blockers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CCBs </li></ul></ul></ul></ul><ul><ul><li>Rhythm control strategy: </li></ul></ul><ul><ul><ul><ul><li>Propafenone (Rhythmol) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flecainide </li></ul></ul></ul></ul>What next?
    5. 5. Question: <ul><li>What would you do next to effectively treat her life-style altering paroxysmal AF? </li></ul><ul><li>[ A ] Trial of a class IA drug ( ex . quinidine). </li></ul><ul><li>[ B ] Amiodarone treatment (with regular careful monitoring). </li></ul><ul><li>[ C ] Referral for AV junction ablation and high-quality pacemaker </li></ul><ul><li>[ D ] Refer for atrial defibrillator implant </li></ul><ul><li>[ E ] Refer for catheter ablation of AF </li></ul>
    6. 6. Atrial Fibrillation Ablation (What we did…) <ul><li>FOR WHOM? ( Paroxysmal or Persistent ) </li></ul><ul><li>AF w/ “ significant symptoms ” associated </li></ul><ul><li>Refractory to AADs </li></ul><ul><li>Absence of severe structural heart dz. </li></ul>[ E ]
    7. 7. Left Atrium Posterior Basal View R. superior pulmonary vein R. inferior pulmonary vein Coronary sinus L. inferior pulmonary vein L. atrium L. superior pulmonary vein L. auricle L. pulmonary artery R. pulmonary artery Netter F. Atlas of Human Anatomy. 1989;Plate 202.
    8. 8. Nathan, Circ Res, 1969? Left Atrium, Posterior Wall Variable Anatomy (Common) RIPV RSPV LIPV LSPV IVC SVC LAA RAA
    9. 9. Left Atrium, Posterior Wall
    10. 10. Atrial Fibrillation Initiation Mechanism – PV Triggers
    11. 11. Nathan, Circ Res, 1969? Left Atrium, Posterior Wall Pulmonary Vein Isolation
    12. 12. Mediastinum Axial Superior View Netter F. Atlas of Human Anatomy. 1989;Plate 230. Esophagus Right Pulmonary Veins Left Pulmonary Veins Aorta Azygous Vein Left Atrium Right Atrium
    13. 13. T8 Axial View Courtesy of M. Ramsey, PhD, CEO CardioCommand Right PVs Left PVs Esophagus Aorta Left Ventricle
    14. 14. Atrial Fibrillation Ablation Technique <ul><li>Combined Modality Imaging </li></ul><ul><li>Fluoroscopy (biplane, for rapid 3-D estimates) </li></ul><ul><li>High resolution gated CT or MRI </li></ul><ul><li>3-D electroanatomic mapping </li></ul><ul><li>Intracardiac echo </li></ul><ul><li>In the future: </li></ul><ul><li>Multi-modality image co-registration combining real-time anatomy and function… </li></ul>Current
    15. 15. Left Atrium (LA) and Pulmonary Vein Anatomy 3-D CT Reconstruction ( Extreme PA Cranial View ) LA Roof Esophagus Left PVs Right PVs LA Appendage
    16. 16. Side-by-Side Geometry Electroanatomic Map & 3-D CT: Cranial View ESI Nav-X 3-D Geometry 3-D CT via CardEP ( Cranial View ) LA Roof Esophagus Left PVs Right PVs LAA
    17. 17. Side-by-Side Geometry RF catheter pointing away from esophagus ESI Nav-X 3-D Geometry 3-D CT via CardEP
    18. 18. Pulmonary Vein Isolation Segmental Approach Haïssaguerre, M. et al., Circulation. 2000;102:2463–2465. Going… Going… Gone !
    19. 19. LA Mapping and Catheter Ablation Visualization : Intracardiac Ultrasound <ul><li>Facilitate transeptal access to LA </li></ul><ul><li>Visual guidance of catheters at PV ostium </li></ul><ul><li>RF energy delivery titration via “bubble” monitoring </li></ul><ul><li>Doppler PV flow ( assess for size and stenosis ) </li></ul><ul><li>Direct visualization of: </li></ul><ul><ul><ul><ul><li>PV ostial size </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anatomic abnormalities </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pericardial effusion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thrombus </li></ul></ul></ul></ul>
    20. 20. Left Atrial Mapping and Catheter Ablation Visualization : Intracardiac Ultrasound Transeptal Access to LA Tenting of the intra-atrial septum during transeptal catheterization AcuNav 10 Fr Phased Array Diagnostic Ultrasound Catheter (by Acuson)
    21. 21. Left Atrial Mapping and Catheter Ablation Visualization : Intracardiac Ultrasound Optimizing Catheter Placement at PV Os
    22. 22. Caution STOP ! Marrouche N and Natale A. Electromedica 70 (2002) no. 1
    23. 23. PV Isolation by RF Lesion Before …
    24. 24. Electronically Isolated PV After …
    25. 25. SUMMARY Atrial Fibrillation Ablation <ul><li>FOR WHOM? ( Paroxysmal or Persistent ) </li></ul><ul><li>AF w/ “ significant symptoms ” associated </li></ul><ul><li>Refractory to AADs </li></ul><ul><li>Absence of severe structural heart dz </li></ul><ul><li>HOW? </li></ul><ul><li>Electrical isolation of pulmonary veins </li></ul><ul><li>Atrial tissue substrate modification </li></ul><ul><li>Accomplished via catheter ablation combined w/ multiple imaging modalities </li></ul>

    ×