2008 roma, convegno updating in cardiologia. l'ablazione della fibrillazione atriale
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2008 roma, convegno updating in cardiologia. l'ablazione della fibrillazione atriale
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2008 roma, convegno updating in cardiologia. l'ablazione della fibrillazione atriale
- 1. Stefano Nardi, MD, PhD AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNI DIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACAUNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA La terapia ablativa dellaLa terapia ablativa della Fibrillazione AtrialeFibrillazione Atriale L’ entusiasmo dell’ elettrofisiologoL’ entusiasmo dell’ elettrofisiologo C O N V E G N O UPDATING DI CARDIOLOGIA 15 novembre 2008 Auditorium ex I Clinica Medica Policlinico Umberto I - ROMA
- 3. 9,6 13,4 15,3 18 25,7 28,9 49,8 0 10 20 30 40 50 60 SOLVD (II-III) V-HeFT (II-III) CHF-STAT (II-III) ATLAS (III) DIAMOND-CHF (II-III) GESICA (II-IV) CONSENSUS (IV) Prevalenza FA (% ) • All AFib affected pts have an increased Morbidity • The overall increased Mortality is 1,6-2,6% (Manitoba and Framingham Studies) • 5% year ischemic stroke • 1/6 Cerebro-Vascular Accident (CVA) • Framingham Study RHD 17 X rate of CVA Risk of Stroke increased with age (1,5% 50-59 yrs vs 23,5% at 80-89 yrs) MagnitudeMagnitude
- 4. FA CURA controllo clinico controllo FARipristino RS controllo clinico parossistica permanentepersistente Atrial FibrillationAtrial Fibrillation different strategiesdifferent strategies
- 5. L’importanza di seguire la giusta via
- 6. AFFIRM STAFSTAF PIAFPIAF HOT CAFÉHOT CAFÉ PAF-2PAF-2 RACERACE• Paroxysmal Atrial Fibirllation 2 (PAF2) Eur Heart J ’02 • Pharmacological Intervention in AF (PIAF) Lancet ’00. • Comparison of rate control and rhythm control in pts with AF (AFFIRM) NEJM ‘02. • Randomized trial of rate-control versus rhythm CTR in PeAF: the Strategies of Treatment of AF (STAF) study. JACC ‘03. • Effect of rate or rhythm control on QoL in PeAF: results from the Rate CTR vs ECV (RACE) Study. JACC ‘ 04. • How to treat C-AF (HOT-CAFÉ`) New DehliNew Dehli Atrial FibrillationAtrial Fibrillation Randomized TrialsRandomized Trials
- 7. - Strategies based to maintaining SR at 1 yrs FU without AADs is <30% (recurrence between 50-70%) .... Pooled (meta-analysis) data from PAF2, PIAF, STAF, AFFIRM e RACE - … however in most cases AADs based strategies are not able to prevent RECURRENCE of A Fib. • Global acute efficacy 40-50% (reduce in long term FU) 25% interruption of treatment ! • SIDE EFFECTS – Until 20% of cases (3-5% TdP)
- 8. • Arrhythmia-free survival after ECV in pts with PeAF Lower Curve Outcome after a single shock when no prophylactic AADs was given Upper curve Outcome with repeated ECV in conjunction with AADs prophylaxis Pooled (meta-analysis) data from PAF2, PIAF, STAF, AFFIRM e RACE
- 9. The original AFFIRM STUDY
- 10. One year later… AFFIRM revisited…AFFIRM revisited… AFFIRM revisited…AFFIRM revisited… AFFIRM revisited…AFFIRM revisited…
- 11. “l’importanza di usare gli STRUMENTI giusti
- 12. therapeutic Approachtherapeutic Approach Atrial FibrillationAtrial Fibrillation
- 13. Atrial FibrillationAtrial Fibrillation Therapeutic ApproachTherapeutic Approach
- 17. Action Potential, Ca++ and Contractility in AFib pts 1.1. Reduction in amplitude and increase in duration of APReduction in amplitude and increase in duration of AP ControlControl A FibA Fib AP (EAP (Emm)) [Ca[Ca2+2+ ]]ii ContractionContraction 2.2. Reduction in the upslope and downslop of the CaReduction in the upslope and downslop of the Ca++++ transienttransient 3. Parallel reduction in the upslope and downslop of the peak developed tension ContractionContraction [Ca2+]i[Ca2+]iAP (EmAP (Em))
- 18. Atrial Fibrillation histopathology • Karpawich (‘90) – Canine mod. – LA myofibril disarray was found after 4 months of AFib – Appearance of prominent cells in subendocardium, variable-sized mitochondria, and dystrophic calcification • Adomain (‘86) – Myofibril disarray was found in 75% of canine hearts after 3 months of pacing from AFib • Karpawich (‘99) – Pediatric Pts – Myofibril hypertrophy, intracellular vacuolation, degenerative fibrosis, and fatty deposits in the LA after more than 3 years of AFib
- 19. Left common trunk 3 right lower veins Normal Pulmonary vein anatomy TRIGGERTRIGGER
- 20. The Antral Zone Hocini M, Card. Res ’02, Circulation ‘02 SUBSTRATESUBSTRATE
- 21. Atrial Fibrillation ApproachAtrial Fibrillation Approach Anatomical considerationsAnatomical considerations
- 22. Atrial Fibrillation ablationAtrial Fibrillation ablation transeptal puncturetranseptal puncture
- 23. Atrial Fibrillation ablationAtrial Fibrillation ablation transeptal puncturetranseptal puncture
- 24. Atrial Fibrillation ablationAtrial Fibrillation ablation transeptal puncturetranseptal puncture
- 25. Atrial Fibrillation ablationAtrial Fibrillation ablation transeptal puncturetranseptal puncture
- 26. Atrial Fibrillation ablationAtrial Fibrillation ablation transeptal puncturetranseptal puncture
- 27. Atrial Fibrillation ablationAtrial Fibrillation ablation
- 28. Infero mediale Infero-laterale VPIL VPSL Atrial Fibrillation ablationAtrial Fibrillation ablation PVs anatomyPVs anatomy
- 29. Ma qual’è l’impatto delle nuove tecnologie ?
- 30. Atrial Fibrillation ablationAtrial Fibrillation ablation PVs activity mappingPVs activity mapping
- 31. Atrial Fibrillation ablationAtrial Fibrillation ablation virtual geometry reconstructionvirtual geometry reconstruction
- 32. Atrial Fibrillation ablationAtrial Fibrillation ablation virtual geometry reconstructionvirtual geometry reconstruction
- 33. Atrial Fibrillation ablationAtrial Fibrillation ablation virtual geometry reconstructionvirtual geometry reconstruction
- 34. Atrial Fibrillation ablationAtrial Fibrillation ablation virtual geometry reconstructionvirtual geometry reconstruction
- 35. Mandapati, Circulation `00Haissaguerre, NEJM ’98 SubstrateSubstrateTriggerTrigger Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
- 36. Atrial Fibrillation ablationAtrial Fibrillation ablation PVs trigger ablationPVs trigger ablation
- 38. Atrial Fibrillation ablationAtrial Fibrillation ablation virtual geometry reconstructionvirtual geometry reconstruction
- 39. Atrial Fibrillation ablationAtrial Fibrillation ablation 3D Mapping System3D Mapping System
- 40. Atrial Fibrillation ablationAtrial Fibrillation ablation 3D Mapping System3D Mapping System
- 41. Atrial Fibrillation ablationAtrial Fibrillation ablation Anatomical considerationsAnatomical considerations
- 42. Atrial Fibrillation ablationAtrial Fibrillation ablation Anatomical considerationsAnatomical considerations
- 43. Atrial Fibrillation ablationAtrial Fibrillation ablation Anatomical considerationsAnatomical considerations
- 44. Atrial Fibrillation ablationAtrial Fibrillation ablation during AF ablationduring AF ablation
- 45. Circumferential lesion pathway PVPs Atrial potentials Lesion Validation (Preablation)Lesion Validation (Preablation) Incomplete lesion Lesion ValidationLesion Validation ((AblationAblation)) Complete lesion Lesion ValidationLesion Validation ((AblationAblation)) Atrial potentials breakdown PVPs disappearance Lesion ValidationLesion Validation ((PVPsPVPs AbolitionAbolition)) ≤ 0.1mV ≤0.05mV Validazione delle lesioniValidazione delle lesioni ((abbattimento deiabbattimento dei potenzialipotenziali))
- 46. Atrial Fibrillation ablationAtrial Fibrillation ablation Vagal GangliaVagal Ganglia
- 47. Atrial Fibrillation ablationAtrial Fibrillation ablation Vagal GangliaVagal Ganglia
- 48. Atrial Fibrillation ablationAtrial Fibrillation ablation PVs analysisPVs analysis
- 49. Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
- 50. Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
- 51. Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
- 52. Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
- 53. 137 pz (età media: 62 a) FA parossistica o persistente Randomizzazione a tx antiaritmica da sola o in associazione ad ablazione transcatetere (ablazione circonferenziale, lesioni lineari in AD e AS) End-point: assenza di recidive aritmiche (>30 s) ad un f.u. di 1 anno Recidive aritmiche: 91.3% farmaci vs 44.1% farmaci + ablazione Complicanze maggiori: 4.4% (solo in relazione all’ablazione)
- 54. • Anatomia avversa e variabile per la realizzazione di un isolamento elettrico completo • Rischio di recidiva di conduzione attraverso una linea di blocco INCOMPLETA OSTACOLO CONSEGUENZA • Difficoltà alla realizzazione di lesioni transmurali all’orifizio delle VP • Rimodellamento elettrico • Volume consistente di tessuto aritmogeno tra l’orifizio della VP e la linea di blocco • Vulnerabilità all’innesco di FA in risposta a triggers non clinici (BESV da siti innocenti) Atrial Fibrillation ablationAtrial Fibrillation ablation PITFALLPITFALL
- 55. tipo di FAtipo di FA cardiopatia sottostantecardiopatia sottostante isolamento delle VPisolamento delle VP (ostiale, antrale, ecc)(ostiale, antrale, ecc) ablazione circonferenzialeablazione circonferenziale lesioni lineari aggiuntivelesioni lineari aggiuntive ablazione in aree aablazione in aree a conduzione rallentataconduzione rallentata effettivo isolamento VP Riduzione/modifica del substrato Δ tono autonomico creazione di barriere elettriche complete e non non inducibilità della FA recidive aritmicherecidive aritmiche sintomatiche/asintomatichesintomatiche/asintomatiche utilizzo terapia antiaritmicautilizzo terapia antiaritmica DisomogeneitàDisomogeneità delle popolazionidelle popolazioni arruolatearruolate Differenze dellaDifferenze della tecnica ablativatecnica ablativa End-pointEnd-point procedurali nonprocedurali non uniformiuniformi Metodologia delMetodologia del follow-upfollow-up
- 56. “l’importanza di TROVARE il bandolo della matassa
- 57. 181/777181/777 Laboratori in tutto il mondoLaboratori in tutto il mondo 8.7458.745 pz da 90 Laboratoripz da 90 Laboratori 10.19910.199 ATC x FA (90% in ASn)ATC x FA (90% in ASn) PERIODOPERIODO:: 1995 – 20021995 – 2002 SUCCESSO CLINICOSUCCESSO CLINICO:: 52% (52% (3,866 pts) senza f. antiaritmicisenza f. antiaritmici 75.9% (7408 pts) con f. antiaritmici75.9% (7408 pts) con f. antiaritmici Worldwide AFib SurveyWorldwide AFib Survey Cappato R, Circulation ‘04 Atrial Fibrillation ablationAtrial Fibrillation ablation
- 58. Who benefits from AF ablation ? Pts selectionPts selection
- 59. Ablazione dell’FAAblazione dell’FA Disertori M, et al. GIAC 2006Disertori M, et al. GIAC 2006 Linee Guida AIACLinee Guida AIAC
- 60. Ablazione dell’FAAblazione dell’FA Disertori M, et al. GIAC 2006Disertori M, et al. GIAC 2006 Linee Guida AIACLinee Guida AIAC
- 62. What is success? • Complete freedom of AF, off drug RX? • No symptoms, but drug Rx required? • Dramatic decrease in symptoms, but AADs still required? • QoL • How do we detect asymptomatic episodes? • Anticoagulation ………………...? QUESTIONSQUESTIONS
- 63. Mickelson S, JICE ‘05 Cappato R, Circulation ‘05 In US EP believe 29% of pts with AF are candidates for RFCA • Lower volume centres have lower success rates and higher complication rate Atrial Fibrillation ablationAtrial Fibrillation ablation
- 64. Scientific Paper • Results coud beResults coud be matched withmatched with hystoricalhystorical clinical dataclinical data Registry “Real life” results Clinical Practice Acceptance degree of randomized studies in clinical practice Prospectic data retrived of clinical aspects in pts already implanted with a PM Evaluation of clinical benefits due to specific PM functions (ex. Impact of special modality on several specific “end-point”) Hp, Control groups, economic evaluation CLINICAL Practice VS Registries Courtesy of Dr. Botto TherapyTherapy
- 66. “l’importanza di trovare le giuste “PROPORZIONI” Impact of AFib ablation
- 67. Atrial Fibrillation ablationAtrial Fibrillation ablation during AF ablationduring AF ablation
- 68. Atrial Fibrillation ablationAtrial Fibrillation ablation during AF ablationduring AF ablation
- 69. Atrial Fibrillation ablationAtrial Fibrillation ablation during AF ablationduring AF ablation
- 70. Esophageal contiguity with LA 3D mapping system in AFib3D mapping system in AFib
- 71. Atrial Fibrillation ablationAtrial Fibrillation ablation CCH ptsCCH pts
- 72. LA Medial- RPV Junction RPV Carena LAA-LSPV Junction LAA-LIPV Junction LPV Carena LAA-LSPV Junction MV IsthmusLSPV-LAA Junction PRE-ABLATION POST-ABLATION
- 73. Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
- 74. Seeking answers, butSeeking answers, but what about some questions?what about some questions? Who benefits from AF ablation ?
- 75. What we can do ?
- 76. Selezione dei pts che possono beneficiare dell’ablazione dell’FA: l’importanza di fare la SCELTA giusta
- 77. Atrial Fibrillation ablationAtrial Fibrillation ablation PVs potential ablationPVs potential ablation
- 78. Atrial Fibrillation ablationAtrial Fibrillation ablation virtual geometry reconstructionvirtual geometry reconstruction
- 79. Atrial Fibrillation ablationAtrial Fibrillation ablation 3D Mapping System3D Mapping System
- 80. Atrial Fibrillation ablationAtrial Fibrillation ablation Surface EKGSurface EKG
- 81. Atrial Fibrillation ablationAtrial Fibrillation ablation EGM 25 mmEGM 25 mm
- 82. Atrial Fibrillation ablationAtrial Fibrillation ablation EGM 50 mmEGM 50 mm
- 83. Atrial Fibrillation ablationAtrial Fibrillation ablation EGM 100 mmEGM 100 mm
- 84. Atrial Fibrillation ablationAtrial Fibrillation ablation EGM 200 mmEGM 200 mm
- 85. Who benefits from AFib ablation?
- 86. Atrial Fibrillation ablationAtrial Fibrillation ablation
- 87. Atrial Fibrillation ablationAtrial Fibrillation ablation Anatomical considerationsAnatomical considerations
- 88. Atrial Fibrillation ablationAtrial Fibrillation ablation virtual geometry reconstructionvirtual geometry reconstruction
Editor's Notes
- The prevailing opinion on the issue of why, how and when to maintain sinus rhythm in patients with Atrial Fibrillation has been recently questioned by three recently published trials comparing the two pharmacological strategies in atrial fibrillation: rhythm and rate control. The landmark AFFIRM study found a trend toward increased mortality in the arm of patients treated with antiarrhythmic drugs to restore and thereafter maintain SR; Indeed, subgroup analyses shows that the hypothesized advantage of rate controlling, is more pronounced in older patients, with ischemic heart disease and/or cardiac comorbidities. Thus, it can be speculated that this advantage in controlling heart rate may have resulted from antiarrhythmic drug toxicity and failure in patients with structural heart disease.
- Mr. Chairman and colleagues: Atrial Fibrillation (AF) is a hot topic and an “arrhythmia en vogue” these days for many reasons. The management of this extremely common and vexing heart rhythm disturbance, which is associated with a significant high risk of stroke, heart failure and death compared to normal sinus rhythm, has become more complex.
- (SLIDE 8) However, PVs anatomy and LA/PVs junction can be very changeable in morphology and anatomic variation, as you can see in this pictures (such as left or right common trunk, or numeber or anatomic variation in PVs numbers). At this purpose even if SOCA has clearly demonstrated to be very effective in AFib treatment, performing this procedure using the fluoroscopy technique alone could be technically challenging especially if LA three-dimensional (3D) geometry is particularly complex or atypical. A this purpose, the positioning of a circular mapping catheter or a repositioning after displacement could be imprecise under only fluoroscopic view and renders the creation of several lesions sometimes extremely difficult.
- From stable primary mother wave impulses spread away with fibrillatory conduction along well oriented fibers around PVs, as you can see in this slide. Thus, it is important, when delivering circular lesions, to seek for anatomical orientation of myocardial fibers, so as to disconnect more appropriately PVs from the LA.
- (SLIDE 3) However, at this purpose it’s clearly evident that pulmonary veins (PVs) can play a dominant role for initiation and maintenance AF, especially in Paroxismal AF or in mild or moderate LA enlargement, since Dr. Haissaguerre and colleagues firstly discovered that ectopic beats or rapidly firing foci, predominantly located in the muscle sleeves within pulmonary veins (PVs) or around the left atrium (LA) – PV junction, can start AF. PVs can play a dominant role as source of trigger and in the maintenance of AF and, defined the pivotal role played by PVs and considering the dominant role played by the excitable tissues located around the PVs ostia, the next step was limited the EP interactions between these areas and the remaining LA tissue.
- (SLIDE 3) However, at this purpose it’s clearly evident that pulmonary veins (PVs) can play a dominant role for initiation and maintenance AF, especially in Paroxismal AF or in mild or moderate LA enlargement, since Dr. Haissaguerre and colleagues firstly discovered that ectopic beats or rapidly firing foci, predominantly located in the muscle sleeves within pulmonary veins (PVs) or around the left atrium (LA) – PV junction, can start AF. PVs can play a dominant role as source of trigger and in the maintenance of AF and, defined the pivotal role played by PVs and considering the dominant role played by the excitable tissues located around the PVs ostia, the next step was limited the EP interactions between these areas and the remaining LA tissue.
- Similar to the previous slide, the altered strain patterns in the left ventricle can induce cellular and sub-cellular remodeling, as well as, fibrosis and calcification. Note: this occurs a distance from the pacing lead location.
- (SLIDE 8) However, PVs anatomy and LA/PVs junction can be very changeable in morphology and anatomic variation, as you can see in this pictures (such as left or right common trunk, or numeber or anatomic variation in PVs numbers). At this purpose even if SOCA has clearly demonstrated to be very effective in AFib treatment, performing this procedure using the fluoroscopy technique alone could be technically challenging especially if LA three-dimensional (3D) geometry is particularly complex or atypical. A this purpose, the positioning of a circular mapping catheter or a repositioning after displacement could be imprecise under only fluoroscopic view and renders the creation of several lesions sometimes extremely difficult.
- (SLIDE 12) Anatomo-patologic studies reveals a non-uniform distribution of the myocardial sleeves that extent from LA into PVs so that their disposition could not be circumferencial rather segmental. In this fashion to disconnect PVs from adiacent LA tissue and blocked the conduction, could not be necessary performed an encircling line around the PVs ostia as reported with CLAA.
- (SLIDE 7) This last one approach has the ambitious convincement that the electrical isolation of PVs from the LA have been showed to be reliable for eliminating AF in an high percentage of selected patients. At this purpose, even if SOCA has been guided by EP mapping, novel strategies have emerged over the last decade, mostly based on anatomic considerations that support the adjunctive role of a 3D mapping.
- AVI movie Here’s a quick illustration to show you how the chamber maps are built. At the start of an EnSite procedure, the catheter is inserted in the chamber and validated by the system. (click on map image) As a catheter is moved within the chamber, the system records three-dimensional points. The operator can also give certain points special emphasis (indicated by white squares)—these are called locked points, to help define key areas of the anatomy, such as the isthmus or crista. As seen in the published literature, chamber maps or geometries can be built in as little as five minutes. Thereafter, there is no need for fluoroscopy, since the system provides superior orientation to fluoroscopy through the 3D model and superior catheter orientation through the 3D catheter display. When the geometry is finished, event data can then be recorded.
- (SLIDE 7) This last one approach has the ambitious convincement that the electrical isolation of PVs from the LA have been showed to be reliable for eliminating AF in an high percentage of selected patients. At this purpose, even if SOCA has been guided by EP mapping, novel strategies have emerged over the last decade, mostly based on anatomic considerations that support the adjunctive role of a 3D mapping.
- (SLIDE 25 ) Because atrio-esophageal fistula is very rare but its occurrence is dramatic and devastating, we utilized lower RF energy applications when ablating particularly on the LA posterior wall, and to make the pulses on the posterior wall near to the roof of the LA, where the LA is not in direct contact with the esophagus. Anatomical-guided electrophysiological ablation procedures have been shown to be effective for curing AF.
- (SLIDE 7) This last one approach has the ambitious convincement that the electrical isolation of PVs from the LA have been showed to be reliable for eliminating AF in an high percentage of selected patients. At this purpose, even if SOCA has been guided by EP mapping, novel strategies have emerged over the last decade, mostly based on anatomic considerations that support the adjunctive role of a 3D mapping.
- (SLIDE 7) This last one approach has the ambitious convincement that the electrical isolation of PVs from the LA have been showed to be reliable for eliminating AF in an high percentage of selected patients. At this purpose, even if SOCA has been guided by EP mapping, novel strategies have emerged over the last decade, mostly based on anatomic considerations that support the adjunctive role of a 3D mapping.