This document discusses challenges in atrial fibrillation ablation and how integrating new technologies can help address them. It describes how mapping systems, contact force sensing catheters, and intracardiac imaging have improved efficiency, safety and efficacy. A standardized clinical workflow is presented that utilizes these technologies to optimize lesion delivery, allow real-time monitoring and validation of results. This approach has led to significant reductions in procedure time, fluoroscopy use and repeat procedures while maintaining low complication rates.

1. DR JOSE OSORIO
The Evolution of Atrial Fibrillation Ablation:
Utilizing Current Technology to Improve
Efficiency, Safety and Efficacy

2. Atrial fibrillation Ablation
• Well-established option for AF
patients
• Technological evolution
– Ablation catheters
– Electroanatomical Mapping
Systems
• Increased procedural complexity
www.theafibclinic.com

3. • Safety
– Patients
– Physician and Staff
• Efficiency
– Long Procedure times
• Efficacy
– PV reconnection
– Repeat procedures
AFib Ablation
Challenges

4. AFib Ablation
My Journey
Procedure: ~ 150min
Fluoroscopy: ~ 40min
Ablations/day: 2-3
Recurrence: higher than current
No understanding of substrate
IV contrast
2010
~ 70min
1 second
5 or 6
Higher Success rates
Substrate data
No contrast used
Similar complication rates
2014

5. Using Technology to Address
AFib Ablation Challenges
2010
Mapping system:
• 3D reconstruction
Intracardiac Echo
2013
Univu
Visitag Module
2014
Contact Force
Sensing
Workflow
Integrating CF and
Visitag
Fluoroscopy Reduction
Clinical Afib Ablation Workflow
www.theafibclinic.com

6. Fluoroscopy Reduction
www.theafibclinic.com

7. Fluoroscopy Reduction
Fast Anatomical Mapping
www.theafibclinic.com

8. Fluoroscopy Reduction
Intracardiac Echo
www.theafibclinic.com

9. Fluoroscopy Reduction
Integrating EA Mapping and Imaging
• 1500 Afib ablations with low or zero fluoroscopy
– Very low complications: ~ 0.2% tamponade
• Reduced or eliminated fluoroscopy  Reduction in procedure times
• No change in complication rates
Procedure Time
(min)
Fluoroscopy Time
(sec)
Ablation Time (min)
Group 1 117 108 42
Group 2 94 47 38
Group 3 91 9 38
117 108
42
94
47 38
91
9
38
0
20
40
60
80
100
120
140
Time(minorsec)
PROCEDURAL, FLUOROSCOPY AND
TOTAL ABLATION TIME
2013-2014 Data
N= 598 patients
EA Mapping only
Fluoro integration Univu
Intracardiac Echo and Univu
www.theafibclinic.com

10. • Can we achieve it all?
• Clinical Workflow for Afib ablation with ST
catheter
– Biophysics of the Contact Force Catheters
– SmartTouch And Visitag Stability Module Integration
Safety, Efficiency and Efficacy
www.theafibclinic.com

11. Biophysics
If no Contact – Doesn’t Matter
Surrogate measures
of CF correlate very
poorly with CF
www.theafibclinic.com

12. Biophysics
In the Era of CF Catheters
What Ablation Settings should you use?
Increase in lesion
depth with force
Similar lesions
Different Power and Force
30 seconds ablation 30 seconds ablation
Nakagawa et alwww.theafibclinic.com

13. Biophysics
In the Era of CF Catheters
LesionSize(mm)
Time (sec)
Steady State = MAXIMUM Lesion Size
heat generated within lesion = heat
transferred away from lesion
~1/2 max lesion size created in
the first 5-10 seconds of energy
delivery
What Ablation Settings should you use?
Haines D. Biophysics of Radiofrequency
• Lesion size
• Power
• Force
• Time
• 40W w moderate CF for 30s
• ~9 mm depth
• ½ max in 5-10 seconds
www.theafibclinic.com

14. AF Ablation
Clinical Workflow
• Use well defined steps and settings
– Map  Ablation  Validation
– Increase reproducibility and efficiency
• Integration of new technologies
CARTO
VISITAG™
THERMOCOOL
SMARTTOUCH
®
94
35
78
27
SF Smart Touch
Procedure Time
(minutes)
Ablation Time
(minutes)www.theafibclinic.com

15. I - Determine your goals
• Visitag Setup to meet your ablation
strategy
Contact Force Catheter and
VISITAG™ - Stability Module Integration
Afib Ablation Workflow
Consistently perform similar ablation that can be
confirmed at the end of procedure
II - Real Time
• Maintain Contact Force
• Avoid long lesions – especially
posterior wall
III – Validation of lesion set
• Predefined goal achieved?
• Touch up
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16. • Goal
• Should NEVER be a VISITAG™
point
• Should simply be a representation
of procedure
CARTO VISITAG™ Module
Important Considerations
• Filters
• More filters  longer times to obtain
a tag
• Can be used during initial ablation
or to afterwards
• Choose based on your procedure
• Force over time - FOT
www.theafibclinic.com

17. 1. Contact Force
continuously monitored
2. Impedance Graph
3. Visitag color - 15 s red
4. Catheter moved every 15
-20s
Regardless of Visitag
Contact Force Catheter and
VISITAG™ - Stability Module Integration
Real-Time
www.theafibclinic.com

18. • Entrance/exit block
• Isuprel and
Adenosine
• Voltage Map
Validation
CARTO VISITAG™
Module Analysis
www.theafibclinic.com

19. FOT 80% at 5 grams FOT 80% at 10 gramsPost Ablation
• Analyze if adequate force was delivered at each point
• Choose your pre-defined FOT goal
• % of time that Force was above defined target
• Force below threshold tags disappear
Validation
Analysis of Lesion Set Post-Ablation
www.theafibclinic.com

20. • Target areas of low force  Reablation
• Achieve FOT at your pre-defined target
FOT 80% at 5 grams FOT 80% at 10 grams
After Touch Up
Post Isolation
Validation
Analysis of Lesion Set Post-Ablation
www.theafibclinic.com

21. FOT
50% at 10
grams
Post Isolation
Touching up
FOT
80% at 10
grams
FOT
80% at 10
grams
Areas of poor contact
Higher chances of
Return of conduction
Validation
Analysis of Lesion Set Post-Ablation
www.theafibclinic.com

22. • 232 consecutive index PAF ablations
• 12 re-ablations
• April 2014 and June 2016.
• PV isolation with workflow described
• Follow up:
• 3 and 12 months
• 4-day Holter at 6 and 12 months
• event monitoring as needed
• Success at 12 months:
• freedom from recurrence of AF, atrial tachyarrhythmia (AT), and
atrial flutter (AFL).
40826Efficiency and Predictability in Paroxysmal Atrial Fibrillation
Ablation with
Contact Force Catheter and Stability Module Integration
Europace 2017www.theafibclinic.com

23. Procedural Data
Procedural Efficiency Measure N Mean SD
Total Procedure Time (minutes) 222 82 32
Total Fluoroscopy Time (minutes) 229 0.2 0.4
Radiation Dose (mGy) 225 10 26
Ablation Time (minutes) 227 32 12
Left WACA Time to isolation (minutes) 185 4.3 3.2
Right WACA Time to isolation (minutes) 184 8.1 5.0
Europace 2017
Efficiency and Predictability in Paroxysmal Atrial Fibrillation
Ablation with
Contact Force Catheter and Stability Module Integration
www.theafibclinic.com

24. 84.8%
9.8%
5.4%
15.2%
(N=112)
Success
Afib Ablation Workflow
1 year Success Rates – Single Ablation
Europace 2017www.theafibclinic.com

25. Procedure
Time
(min.)
Ablation
Time
(min.)
Fluoroscop
y Time
(min.)
Fluoroscop
y Dose
(x10 mGy)
ThermoCool SF 92 36 1.5 25
SmartTouch 82 32 0.2 1
Cryoballoon 94 25 12.4 68
0
10
20
30
40
50
60
70
80
90
100
Europace 2017
A Comparison of Paroxysmal Atrial Fibrillation Ablation
Efficiency and Clinical Outcomes Across Technologies in a
High-Volume Center
www.theafibclinic.com

26. A Comparison of Paroxysmal Atrial Fibrillation Ablation
Efficiency and Clinical Outcomes Across Technologies in a
High-Volume Center
0.50
0.55
0.60
0.65
0.70
0.75
0.80
0.85
0.90
0.95
1.00
0 100 200 300 400 500 600 700
ProportionwithNoReablation
Days After First Ablation
Cryoballoon SmartTouch ThermoCool SFEuropace 2017www.theafibclinic.com

27. At the end of ablation:
• Complete lesion set with optimal CF
Validation
•Not just PVI
•Good ablation delivered?
•Transmural/long lasting lesions?
•PVI Standardized
•Consistent Results
•Safety, Efficacy and Efficiency
After Touch Up
FOT 85% 10g
Validation
Analysis of Lesion Set
www.theafibclinic.com

28. • Challenges in AF ablation
• Integration of technologies
• Standardized ablation
• Increases efficiency
• Validation of lesion set
• Reproducible AF Ablation
• Possible to achieve efficiency,
safety and efficacy
Conclusion
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