atrial fibrillation talk

1. Atrial Fibrillation: EmergingAtrial Fibrillation: Emerging
ConceptsConcepts
New Treatment Paradigms
John Hakim, MD, FACC

3. The hallmark of AF is chaotic atrial impulsesThe hallmark of AF is chaotic atrial impulses
leading to irregularly irregular ventricularleading to irregularly irregular ventricular
contraction, usually with incessant tachycardiacontraction, usually with incessant tachycardia

6. OVERVIEWOVERVIEW
Atrial fibrillation is a progressive diseaseAtrial fibrillation is a progressive disease
Atrial fibrillation has hemodynamic and myocardialAtrial fibrillation has hemodynamic and myocardial
consequences (i.e., reduced cardiac output and heart failure)consequences (i.e., reduced cardiac output and heart failure)
There is significant morbidity and mortality consequencesThere is significant morbidity and mortality consequences
--increased hospitalizationsincreased hospitalizations
--reduced quality of lifereduced quality of life
-increased risk of thromboembolism and stroke-increased risk of thromboembolism and stroke (accounts for 75,000(accounts for 75,000
strokes per year in the United States alone)strokes per year in the United States alone)
--decreased survivaldecreased survival (AF is associated with increased mortality, but(AF is associated with increased mortality, but
whether it is the cause or an innocent bystanderwhether it is the cause or an innocent bystander
is not well established)is not well established)1-81-8
Atrial fibrillation can be a treatable disorder, especially with earlyAtrial fibrillation can be a treatable disorder, especially with early
interventionintervention
What’s new in atrial fibrillation treatmen.tWhat’s new in atrial fibrillation treatmen.t
1
Benjamim EJ, et al. Impact of AF on the risk of death: The Framinham Heart Study. Circulation. 1998; 98: 946-52.
2
Gajewski J, et al. Mortality in an insured population with AF. JAMA. 1981; 245: 1540-44.
3
Krahn AD, et al. The natural history of AF. Am J Med. 1995; 98: 476-84.
4
Flegel KM, et al. Risk of stroke in non-rheumatic AF. Lancet. 1987; 1: 526-9.
5
Kulbertus HE, et al. AF in elderly, ambulatory patients. AF; 1982: 148-57.
6
Lake FR, et al. AF and mortality in an elderly population. Aus N Z J Med. 1989; 19: 321-6.
7
Kannel WB, et al. Epidemiologic features of chronic AF: the Framingham Study. NEJM 1982; 306: 1018-22.
8
Kitchin AH, et al. Longitudinal survey of ischemic heart disease in randomly selected older population. Br Heart J 1977; 39: 889-93.

7. Classification and Patterns of AFClassification and Patterns of AF
ParoxysmalParoxysmal: terminates spontaneously, typically: terminates spontaneously, typically
duration is <7 days (most<24 hours). May beduration is <7 days (most<24 hours). May be
recurrent.recurrent.
PersistentPersistent: medication or electrical intervention is: medication or electrical intervention is
required to restore sinus rhythm; does not self-required to restore sinus rhythm; does not self-
terminate. Typically lasts > 7 days. May beterminate. Typically lasts > 7 days. May be
recurrent.recurrent.
PermanentPermanent: sinus rhythm cannot be restored or: sinus rhythm cannot be restored or
maintained despite interventionmaintained despite intervention
*** Evaluate for thrombotic risk each of these*** Evaluate for thrombotic risk each of these
situations.*****situations.*****

8. Causes of Atrial FibrillationCauses of Atrial Fibrillation
HypertensionHypertension
Heart attacks/ CADHeart attacks/ CAD
Valvular Heart DiseaseValvular Heart Disease
Congenital heart defectsCongenital heart defects
Hyperthyroid or other metabolicHyperthyroid or other metabolic
imbalanceimbalance
Exposure to stimulants such asExposure to stimulants such as
medications, caffeine or tobacco, or tomedications, caffeine or tobacco, or to
alcohol (holliday heart)alcohol (holliday heart)
Sick sinus syndrome — improperSick sinus syndrome — improper
functioning of the heart's naturalfunctioning of the heart's natural
pacemakerpacemaker
Emphysema or other lung diseasesEmphysema or other lung diseases
CABG/ Previous heart surgeryCABG/ Previous heart surgery
Viral infections /PericarditisViral infections /Pericarditis
Stress due to pneumonia, surgery orStress due to pneumonia, surgery or
other illnesses (Cathecholamines)other illnesses (Cathecholamines)
Pulmonary EmbolusPulmonary Embolus
PneumoniaPneumonia
Sleep ApneaSleep Apnea
PericarditisPericarditis
Lone A fib (younger people)Lone A fib (younger people)
Left ventricular HypertrophyLeft ventricular Hypertrophy
CardiomyopathyCardiomyopathy
CHF –Systolic or DiastolicCHF –Systolic or Diastolic
Idiopathic – mostly in younger people –Idiopathic – mostly in younger people –
Lone Atrial FibLone Atrial Fib
Familial Predisposition.Familial Predisposition.
glucocorticoidsglucocorticoids

9. Risk Factors for AF: DiabetesRisk Factors for AF: Diabetes
AF was 44% more prevalent and 38% more likely to develop whenAF was 44% more prevalent and 38% more likely to develop when
diabetes was present in an adult populationdiabetes was present in an adult population
Prevalence and incidence of AF in 17,372 patients with diabetes and inPrevalence and incidence of AF in 17,372 patients with diabetes and in
the same amount of age- and sex-matched controls without type 2the same amount of age- and sex-matched controls without type 2
diabetes included in a Kaiser Permanente diabetes registry. Thediabetes included in a Kaiser Permanente diabetes registry. The
researchers followed patients without AF for the comparison of AFresearchers followed patients without AF for the comparison of AF
incidence while controlling for known risk factors.incidence while controlling for known risk factors.
Prevalence for AF was significantly higher among patients withPrevalence for AF was significantly higher among patients with
diabetes compared with those without (3.6% vs. 2.5%;diabetes compared with those without (3.6% vs. 2.5%; PP<.0001).<.0001).
Over 7.2 years, patients with diabetes without AF at baselineOver 7.2 years, patients with diabetes without AF at baseline
developed AF at an age- and sex-adjusted rate of 9.1 per 1,000 person-developed AF at an age- and sex-adjusted rate of 9.1 per 1,000 person-
years vs. 6.6 per 1,000 person-years for patients without diabetes.years vs. 6.6 per 1,000 person-years for patients without diabetes.
Diabetes was associated with a 26% increased risk for AF amongDiabetes was associated with a 26% increased risk for AF among
women after adjusting for other risk factors (HR=1.26; 95% CI, 1.08-women after adjusting for other risk factors (HR=1.26; 95% CI, 1.08-
1.46). Diabetes was not a statistically significant risk factor among men.1.46). Diabetes was not a statistically significant risk factor among men.
Men had a higher prevalence of AF in all age groups regardless ofMen had a higher prevalence of AF in all age groups regardless of
diabetesdiabetes

15. Original Article
Effect of Clopidogrel Added to Aspirin in Patients
with Atrial Fibrillation --- ACTIVE TRIAL
N Engl J Med Volume 360(20):2066-2078 May 14, 2009
• A randomized trial enrolled 7554 patients with AF who were at
increased risk of stroke but not candidates for vitamin K
antagonists
• Participants were assigned to aspirin or aspirin plus clopidogrel
• At a median of 3.6 years, the risk of major vascular events
decreased significantly with clopidogrel, primarily because of
reduced risk of stroke
• The risk of major bleeding increased significantly with
clopidogrel

16. Cumulative Incidence of Trial Outcomes, According to Treatment Group
The ACTIVE Investigators. N Engl J Med 2009;360:2066-2078

17. The ACTIVE InvestigatorsThe ACTIVE Investigators
In patients with atrial fibrillation forIn patients with atrial fibrillation for
whom vitaminwhom vitaminK–antagonist therapyK–antagonist therapy
was unsuitable, the addition ofwas unsuitable, the addition of
clopidogrelclopidogrelto aspirin reduced the riskto aspirin reduced the risk
of major vascular events, especiallyof major vascular events, especially
stroke, and increased the risk of majorstroke, and increased the risk of major
hemorrhage.hemorrhage.

18. Cumulative Hazard Rates for the Primary Outcome of Stroke or Systemic Embolism,
According to Treatment Group
Connolly SJ et al. N Engl J Med 2009;361:1139-1151

19. Dabigatran versus Warfarin in Patients withDabigatran versus Warfarin in Patients with
Atrial Fibrillation (NEJM 9/7/2009)Atrial Fibrillation (NEJM 9/7/2009)
In patients with AF, dabigatranIn patients with AF, dabigatrangiven at a dose of 110given at a dose of 110
mg was associated with rates of strokemg was associated with rates of stroke and systemicand systemic
embolism that were similar to those associatedembolism that were similar to those associated withwith
warfarin, as well as lower rates of major hemorrhage.warfarin, as well as lower rates of major hemorrhage.
DabigatranDabigatranadministered at a dose of 150 mg, asadministered at a dose of 150 mg, as
compared with warfarin,compared with warfarin,was associated with lowerwas associated with lower
rates of stroke and systemic embolismrates of stroke and systemic embolism but similarbut similar
rates of major hemorrhagerates of major hemorrhage

21. If clinicians do not try to maintain normal sinus rhythm in the present, it becomes
more difficult over time. Patients converted to normal sinus rhythm within 3
months have a 69% chance of remaining in sinus rhythm at 6 months compared to
only 27% if they are allowed to remain in AF for > 12 months.2
2
Dittrich HC, et al. Am J Cardiol 1989; 63: 193-7.

22. Therapeutic Goals in the Treatment of AF
•Prevent Stroke/TE
•Prevention of CHF
•Relief of symptoms
•Improved quality of life
•Reduction in cost of care
to medical system

24. Atrial Fibrillation: A UnifyingAtrial Fibrillation: A Unifying
TheoryTheory
Focal triggering initiationFocal triggering initiation
Multiple wavelets for AF maintenanceMultiple wavelets for AF maintenance
Parasympathetic effects on atrial substrateParasympathetic effects on atrial substrate
Varying importance among population of lone,Varying importance among population of lone,
vagally-mediated, PAF, persistent , andvagally-mediated, PAF, persistent , and
permanent atrial fibrillation.permanent atrial fibrillation.

25. Electrophysiologic mechanisms of AFElectrophysiologic mechanisms of AF
AUTONOMIC INFLUENCE WAVELETS AND ROTORS
PV AND LA TRIGGERS
FOCAL TRIGGERS LEADING
TO INITIATION OF REENTRY
AND WAVELETS

26. Substrate Evolution Hints at a Patient-Substrate Evolution Hints at a Patient-
Tailored approachTailored approach
-The role of pulmonary veins in
the perpetuation and initiation
of paroxysmal AF have been
demonstrated; hence the
effectiveness of pulmonary vein
isolation techniques in this
cohort of patients.
-As atrial fibrillation progresses
to persistent and permanent,
the role of “muscle, scar, and
fibrosis”, that is structural
disease, becomes more
prominent, hence a hybrid
approach is more effective both
targeting the substrate and the
triggers
Fisher JD, et al. PACE 2006; 29: 523.
Wyse DG, Gersh BJ. Circ 2004; 109: 3089.

27. Benefits of rhythm control include: decreasedBenefits of rhythm control include: decreased
hospitalizations, improved cardiac function, improvedhospitalizations, improved cardiac function, improved
exercise tolerance, and improvement in quality of lifeexercise tolerance, and improvement in quality of life
Consequences of failure to maintain sinus rhythm: atrialConsequences of failure to maintain sinus rhythm: atrial
remodeling and permanent atrial fibrillationremodeling and permanent atrial fibrillation
The goals of antiarrhythmic therapy to maintain normal sinusThe goals of antiarrhythmic therapy to maintain normal sinus
rhythm should be:rhythm should be:
1. To reduce the frequency, severity, and duration of AF1. To reduce the frequency, severity, and duration of AF
to a degree acceptable to the patientto a degree acceptable to the patient
2. To do so with the lowest likelihood of adverse effects2. To do so with the lowest likelihood of adverse effects
Rate versus Rhythm controlRate versus Rhythm control

28. So the Question in atrialSo the Question in atrial
fibrillation, which is better:fibrillation, which is better:
rate control or rhythmrate control or rhythm
control?control?
First answered in 2002First answered in 2002

29. A Comparison of Rate
Control and Rhythm Control
in Patients with Atrial
Fibrillation
The Atrial Fibrillation Follow-up
Investigation of Rhythm Management
(AFFIRM) Investigators
NEJM 347:1825-1833347:1825-1833 December 5, 2002December 5, 2002

30. There are two approaches to the treatment of AF:
one is cardioversion and treatment with antiarrhythmic drugs
to maintain sinus rhythm, and the other is the use of rate-
controlling drugs, allowing AF to persist. In both approaches,
the use of anticoagulant drugs is recommended.
AFFIRM was a randomized, multicenter comparison of
these two treatment strategies in patients with AF and a high
risk of stroke or death. The primary end point was overall
mortality.
Results A total of 4060 patients (mean [±SD] age,
69.7±9.0 years) were enrolled in the study; 70.8 percent had a
history of hypertension, and 38.2 percent had coronary artery
disease. Of the 3311 patients with echocardiograms, the left
atrium was enlarged in 64.7 percent and left ventricular
function was depressed in 26.0 percentgroup of high-risk
patients.
AFFIRM Trial

31. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N
Engl J Med 2002;347:1825-1833
Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control Group

32. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N
Engl J Med 2002;347:1825-1833
Hazard Ratios for Death in Prespecified Subgroups

33. Result of AFFIRM TrialResult of AFFIRM Trial
. There were 356 deaths among the patients assignedto rhythm-
control therapy and 310 deaths among those assignedto rate-
control therapy (mortality at five years, 23.8 percentand 21.3
percent, respectively; hazard ratio, 1.15 [95 percentconfidence
interval, 0.99 to 1.34]; P=0.08). More patients inthe rhythm-control
group than in the rate-control group werehospitalized, and there
were more adverse drug effects in therhythm-control group as well.
In both groups, the majority ofstrokes occurred after warfarin had
been stopped or when theinternational normalized ratio was
subtherapeutic.
Conclusions Management of AF with the rhythm-
controlstrategy offers no survival advantage over
the rate-controlstrategy, and there are potential
advantages, such as a lowerrisk of adverse drug effects, with the
rate-control strategy.Anticoagulation should be continued in this
(NEJM 2002)

35. Which Strategy is Better inWhich Strategy is Better in
Heart Failure Patients?Heart Failure Patients?
Rhythm Control versus Rate Control for AtrialRhythm Control versus Rate Control for Atrial
Fibrillation and Heart Failure TrialFibrillation and Heart Failure Trial
NEJM 358:2667-2677NEJM 358:2667-2677 June 19, 2008June 19, 2008

36. Rhythm Control versus Rate Control for Atrial Fibrillation and Heart FailureRhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure
(AF- CHF TRIAL)(AF- CHF TRIAL)
NEJM 2008; 358: 2667-2677NEJM 2008; 358: 2667-2677
Common practice is to restore and maintain sinus rhythm in patients
with AF and heart failure. This approach is based in part on data
indicating that AF is a predictor of death in patients with heart failure
and suggesting that the suppression of AF may favorably affect the
outcome.
Methods A multicenter, randomized trial comparing the maintenance
of sinus rhythm (rhythm control) with control of the ventricular rate
(rate control) in patients with EF 35% or less, symptoms of
congestive heart failure, and a history of AF. The primary outcome
was the time to death from cardiovascular causes. as compared with a
rate-control strategy

37. RESULTS of AF CHFRESULTS of AF CHF
ResultsResults A total of 1376 patients were enrolled (682 in the rhythm-A total of 1376 patients were enrolled (682 in the rhythm-
controlcontrolgroup and 694 in the rate-control group) and weregroup and 694 in the rate-control group) and were
followed forfollowed fora mean of 37 months. Of these patients, 182 (27%)a mean of 37 months. Of these patients, 182 (27%)
in the rhythm-controlin the rhythm-controlgroup died from cardiovascular causes, asgroup died from cardiovascular causes, as
compared with 175compared with 175(25%) in the rate-control group (hazard ratio(25%) in the rate-control group (hazard ratio
in the rhythm-controlin the rhythm-controlgroup, 1.06; 95% confidence interval, 0.86group, 1.06; 95% confidence interval, 0.86
to 1.30; P=0.59 byto 1.30; P=0.59 bythe log-rank test).the log-rank test).
Secondary outcomes also did not differ significantly between the two treatmentSecondary outcomes also did not differ significantly between the two treatment
strategies:strategies:
– All-cause death: 32% and 33%, P = 0.73All-cause death: 32% and 33%, P = 0.73
– Stroke: 3% and 4%, P = 0.32Stroke: 3% and 4%, P = 0.32
– Worsening heart failure: 28% and 31%, P = 0.17Worsening heart failure: 28% and 31%, P = 0.17
– Composite of CV death, stroke, worsening heart failure: 43% and 46%, P =Composite of CV death, stroke, worsening heart failure: 43% and 46%, P =
0.200.20
There were also no significantThere were also no significant differences favoring either strategydifferences favoring either strategy
in any predefined subgroup.in any predefined subgroup.

38. AF CHF resultsAF CHF results
ConclusionsConclusions In patients with AF andIn patients with AF and
congestivecongestiveheart failure, a routineheart failure, a routine
strategy of rhythm control does notstrategy of rhythm control does not
reduce the rate of cardiovascular death.reduce the rate of cardiovascular death.
Comment:Comment: The investigators caution that, "OurThe investigators caution that, "Our
results cannot be generalized to patients with heartresults cannot be generalized to patients with heart
failure and preserved left ventricular function.“failure and preserved left ventricular function.“
NEJM 358:2667-2677NEJM 358:2667-2677 June 19, 2008June 19, 2008

40. Why hasn’t rhythm controlWhy hasn’t rhythm control
worked in trials?worked in trials?
Drugs used in trials don’t guarantee rhythm controlDrugs used in trials don’t guarantee rhythm control
Toxicity of Anti arrythmic drugs contribute to lack ofToxicity of Anti arrythmic drugs contribute to lack of
benefit of rhythm control groups.benefit of rhythm control groups.
AF may be a marker of poor prognosis, in whichAF may be a marker of poor prognosis, in whichthethe
primary problem is poor ventricular function,primary problem is poor ventricular function,
neurohormonalneurohormonalactivation, or inflammation, with noactivation, or inflammation, with no
independent effect of atrialindependent effect of atrialfibrillation on outcome.fibrillation on outcome.

41. IF Drugs Don’t work, WillIF Drugs Don’t work, Will
Ablation?Ablation?
AF AblationAF Ablation
– eliminates confoundingeliminates confoundingcontributions of lowcontributions of low
efficacy and high toxicity associated withefficacy and high toxicity associated with
antiarrhythmic drug therapyantiarrhythmic drug therapy
– may better determine the desirabilitymay better determine the desirabilityofof
maintaining sinus rhythm in patients with atrialmaintaining sinus rhythm in patients with atrial
fibrillation.fibrillation.
– Clinical Trials are in progress comparing catheterClinical Trials are in progress comparing catheter
ablation of atrialablation of atrialfibrillation to conventionalfibrillation to conventional
antiarrhythmic drugantiarrhythmic drugtherapy.therapy.
– AF Ablation has yet to be proven to be better thanAF Ablation has yet to be proven to be better than
rate control.rate control.

42. Rate versus Rhythm ControlRate versus Rhythm Control

45. DigoxinDigoxin
Described by WilliamDescribed by WilliamWithering, 1785 to treat rapid heart rateWithering, 1785 to treat rapid heart rate
and CHFand CHF
decreases conduction ofdecreases conduction of electrical impulseselectrical impulses through thethrough the
AV nodeAV node, making it a commonly used, making it a commonly used antiarrhythmic agentantiarrhythmic agent inin
controlling thecontrolling the heart rateheart rate duringduring atrial fibrillationatrial fibrillation oror
atrial flutteratrial flutter..
An increase ofAn increase of forceforce ofof contractioncontraction via inhibition of the Navia inhibition of the Na++
/K/K++
ATPase pumpATPase pump

46. Quinidine- OLD schoolQuinidine- OLD school
seen as too dangerous nowseen as too dangerous now
A stereoisomer of quinine initially derived from the bark of theA stereoisomer of quinine initially derived from the bark of the
cinchona tree has been used for decades for AF. Chinchona iscinchona tree has been used for decades for AF. Chinchona is
an evergreen native to the mountainous areas of Central andan evergreen native to the mountainous areas of Central and
South America. Quinine is the base flavor in most bitters andSouth America. Quinine is the base flavor in most bitters and
contributes the bitter essence to tonic water.contributes the bitter essence to tonic water.
Discovered by a Danish Merchant seaman with AF who tookDiscovered by a Danish Merchant seaman with AF who took
quinine for malaria prophylaxis during trips to India. He notedquinine for malaria prophylaxis during trips to India. He noted
his pulse was regular while in India but irregular at home.his pulse was regular while in India but irregular at home.
Chichonism describes tinnitus and hearing loss with quinidineChichonism describes tinnitus and hearing loss with quinidine
excess. excess.
Quinidine can cause thrombocytopenia, granulomatousQuinidine can cause thrombocytopenia, granulomatous
hepatitis, myasthenia gravis, and torsades de pointes and forhepatitis, myasthenia gravis, and torsades de pointes and for
that reason is not used much today. Torsades can occur afterthat reason is not used much today. Torsades can occur after
the first dose.the first dose.

47. Drugs used for atrial fibDrugs used for atrial fib
FlecanideFlecanide
DofetilideDofetilide
PropafenonePropafenone
SotololSotolol
AmiodaroneAmiodarone

53. What is the Future of A FibWhat is the Future of A Fib
Advances in AnticoagulationAdvances in Anticoagulation
New Drugs: Substantial resources areNew Drugs: Substantial resources are
being invested in the developmentbeing invested in the development ofof
new drugs that promise to be morenew drugs that promise to be more
efficacious and safer forefficacious and safer foruse in patientsuse in patients
with atrial fibrillationwith atrial fibrillation
Advances in AblationAdvances in Ablation

55. Things that Havent workedThings that Havent worked
in Atrial Fibin Atrial Fib
DronedaroneDronedarone: a novel antiarrhythmic drug with: a novel antiarrhythmic drug with
electrophysiologicalelectrophysiologicalproperties that are similar to those ofproperties that are similar to those of
amiodarone, but it doesamiodarone, but it doesnot contain iodine and thus does notnot contain iodine and thus does not
cause iodine-related adversecause iodine-related adverse reactions. In patients with severereactions. In patients with severe
heart failure and left ventricularheart failure and left ventricular systolic dysfunction, treatmentsystolic dysfunction, treatment
with dronedarone was associatedwith dronedarone was associated with increased early mortalitywith increased early mortality
related to the worsening of heartrelated to the worsening of heartfailure NEJM358: 2725-2727failure NEJM358: 2725-2727
June 19, 2008June 19, 2008
Atrial Defibrillators – Convert the Atrial Fib, but not toleratedAtrial Defibrillators – Convert the Atrial Fib, but not tolerated
by patients.by patients.

58. Indications for Catheter ablation ofIndications for Catheter ablation of
Atrial fibrillationAtrial fibrillation

59. Left Atrial Circumferential Ablation
(1) PV isolation for trigger initiation of AF
(2) Ablation of areas of potential reentry rotors/wavelets
(4) Vagal denervation altering electrophysiologic substrate
(3) Transect the vein of Marshall
VOM

62. HIFUHIFU (High-(High-
frequencyfrequency
Ultrasound) :Ultrasound) :
noncontact techniquenoncontact technique
with tissue heatingwith tissue heating
CryoablationCryoablation: tissue: tissue
contact and freezingcontact and freezing
LaserLaser (infrared):(infrared):
tissue contact and heatingtissue contact and heating
Balloon Catheter Technology in AFBalloon Catheter Technology in AF
AblationAblation

63. Catheter ablationCatheter ablation
*Ablation strategies
target the PVs and or
PV antrum.
*Complete electrical
isolation should be the
goal.

64. Image Integration and Image-GuidedImage Integration and Image-Guided
Mapping and AblationMapping and Ablation
3-Dimensional Electroanatomical Mapping (EAM)3-Dimensional Electroanatomical Mapping (EAM)
systems are used to construct image of the left atriumsystems are used to construct image of the left atrium
This image is merged into a LA CT or MRI scanThis image is merged into a LA CT or MRI scan
Using intracardiac ultrasound, the antrum of theUsing intracardiac ultrasound, the antrum of the
pulmonary veins can be reliably determinedpulmonary veins can be reliably determined
The location and delivery of radiofrequency energyThe location and delivery of radiofrequency energy
can be monitored and tracked with the 3-D EAMcan be monitored and tracked with the 3-D EAM
systemsystem

65. Common Lesion Sets used in AFCommon Lesion Sets used in AF
AblationAblation

69. ICE IMAGES

71. NON-PULMONARY VEIN TRIGGERS OF
AFIB