2006 terni, convegno regionale, l'ablazione della fibrillazione atriale. il registro...

Stefano Nardi, MD, PhD

AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNIDIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE STRUTTURA COMPLESSA DI CARDIOLOGIA STRUTTURA COMPLESSA DI CARDIOLOGIA

UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE

L’ablazione transcatetere della Fibrillazione L’ablazione transcatetere della Fibrillazione Atriale. Il registro osservazionale Atriale. Il registro osservazionale T.E.R.N.I.T.E.R.N.I.

((TTerni erni EEvaluation of Pulmonavaluation of PulmonaRRy Vein y Vein IsolatioIsolatioNN with EnS with EnSIIte System)te System)

Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms

SUBSTRATO GANGLI VAGALI

meccanismi operativi

RF

TRIGGERS

ROTORI

triggers dalle Vene Polmonari

Haissaguerre, NEJM ‘’98

Firing VPSL

RF

Dominant source of triggers Dominant source of triggers

Role in the maintenanceRole in the maintenance• Firiing focali a scarica continua Firiing focali a scarica continua (Ja(Jaïïs)s)

• Firiing focali intermittenti Firiing focali intermittenti (O’Donnell, (O’Donnell, Kumagai, Oral)Kumagai, Oral)

• Rientro Rientro (Arora, Hocini, Wu, Mansour, Jais)(Arora, Hocini, Wu, Mansour, Jais)

HwangCirculation

2000

fibre critichefibre critiche

Sueda Sueda Ann Thorac Surg Ann Thorac Surg

19971997

Microcircuti Microcircuti di rientrodi rientro

Haissaguerre

NEJM 1998

triggers dell’FAtriggers dell’FA

Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms

Atrial Fibrillation ablationAtrial Fibrillation ablationPulmonary Vein isolation

Pulmonary vein anatomy the 1st challenge

Left common trunk 3 right lower veins

Normal

Pulmonary vein anatomy the 1st challenge

Hocini M, Card. Res ’02 Hocini M, Circulation ‘02

The Antral Zonethe 2nd challenge

The Antral Zonethe 2nd challenge

Atrial Fibrillation ablationAtrial Fibrillation ablationanalisi Vene Polmonarianalisi Vene Polmonari

Virtual geometry Virtual geometry reconstructionreconstruction

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

Esophageal contiguity with LA3D mapping system in AFib3D mapping system in AFib

Atrial Fibrillation approachAtrial Fibrillation approach

Ernst, JACC ‘03Ernst, JACC ‘03

Complete LesionsComplete LesionsA – 5% A – 5% B – 21% B – 21% C C – 50% – 50% D - 58-65% D - 58-65%OutcomeOutcome

• Complete lesion 74% Complete lesion 74% arrhythmia free w/o arrhythmia free w/o AADsAADs

• Incomplete lesion – Incomplete lesion – almost almost all recurrent all recurrent arrhythmiaarrhythmia

Limitation of CLAALimitation of CLAA

• SEVERAL GAPS can be found within the ablation lines (2-4mm) exploring the “encircling line”.

• Studi recenti hanno dimostrato che FASCI di MUSCOLATURA PARIETALE presenti nella TONACA MEDIA delle VP possono rappresentare una sorgente dominante d’innesco (TRIGGER) della FA nell’uomo

• Evidenza indiretta a favore della presenza di SORGENTI MULTIPLE nelle diverse VP e nel contesto della vena singola

Innesco Innesco

dell’FAdell’FA

Innesco Innesco

dell’FAdell’FA

Triggers dell’FA

Mantenimento Mantenimento dell’FAdell’FA

Mantenimento Mantenimento dell’FAdell’FA

Rimodellamento Rimodellamento atrialeatriale

Rimodellamento Rimodellamento atrialeatriale

Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture

Atrial Fibrillation ablationAtrial Fibrillation ablation

Atrial Fibrillation ablationAtrial Fibrillation ablationAnatomical considerations (fluoro)Anatomical considerations (fluoro)

Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncture (fluoro)transeptal puncture (fluoro)

Atrial Fibrillation ablationAtrial Fibrillation ablationTEE evaluationTEE evaluation

Inferomediale

Infero-laterale

VPIL

VPSL

VP

su

p.

lat.

VP

in

f.

lat.

VP

su

p.

set.

VP

in

f.

set.

Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction

CT/MRI Scanner

DICOM 3 Slice Data

Worstation

Segmented 3D ModelSegmentation Module

User Interface


Point-by-Point

Medium-Low


LSPV-LAA Junction

LA Medial-RPV Junction

RPV Carina


Baseline vs. Post RF Voltage Map

Baseline Voltage Map Post RF Voltage Map

Final Post RF Voltage Map + CT

CT Image Import

Geometry Acquisition

LA Chamber Geometry

Baseline Voltage Map

RF Lesion Tracking

Post RF Voltage Map

Contact with PV Mapping #6

Artifact from ABL Catheter in Contact with PV Map #6 at the LPV Carina

AF

RF Delivery at the LIPV-MV-LAA Junction

RF Delivery at the MV Isthmus

RF Delivery at the Posterior LIPV

Targeting the Inferior RIPV

Contact with PV Mapping Electrode #10 at the Inferior RIPV

AF

Navigating to Gaps at the Posterior LA

Navigate to the Gap at the Posterior RSPV

Monitor Catheter Stability During RF Delivery

Catheter Drifting into the RSPV During RF

Targeting PV Entrance at the RPV Carina

CS Pacing

Early Activity at Lasso 7-10 at the Posterior RIPV

Electrical Silence at RIPVPost RF at the RPV Carina

CS Pacing

LA Medial-RPV Junction

RPV Carena

LAA-LSPV Junction

LAA-LIPV Junction

LPV Carena

LAA-LSPV Junction

MV IsthmusLSPV-LAA Junction

potenziali VP pre-ablazione

Scomparsa potenziali elettrici

post-ablazione

Circumferential lesion pathway

PVPs

Atrial potentials

Lesion Validation (Preablation)Lesion Validation (Preablation)

Incomplete lesion

Lesion Validation Lesion Validation ((AblationAblation))

Complete lesion

Lesion Validation Lesion Validation ((AblationAblation))

Atrial potentials breakdown

PVPs disappearance

Lesion Validation Lesion Validation ((PVPs PVPs AbolitionAbolition))

0.1mV

0.05mV

Validazione delle lesioniValidazione delle lesioni ((abbattimento dei abbattimento dei potenzialipotenziali))

Circumferential lesion pathway

Type A AF (PV Tachycardia)

AF waves

Lesion Validation (Preablation)Lesion Validation (Preablation)

Incomplete lesion


Lesion Validation (Lesion Validation (AblationAblation))

Complete lesion

Lesion Validation (Lesion Validation (AblationAblation))

Atrial activity reduction


Abolition

Lesion ValidationLesion Validation Type A AF/PV Tachycardia AbolitionType A AF/PV Tachycardia Abolition

0.1mV

0.05mV

Validazione delle lesioniValidazione delle lesioni (abbattimento dei (abbattimento dei

potenziali)potenziali)

Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture

LPV Carina

REGISTRO OSSERVAZIONALE

T.E.R.N.I.

AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNIDIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE STRUTTURA COMPLESSA DI CARDIOLOGIA STRUTTURA COMPLESSA DI CARDIOLOGIA

UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE

Procedure (min): 14826 14424 151 29

Fluoroscopy (min): 5917 5816

6619 Mapping (min): 358

339 384 Nr. Pulses of RF:

7216 7017 7519

RESULTSRESULTS Global Pz.in SR Pz. in AF

TERNI RegistryTERNI Registry

629 VP treated (145 pts)

Acute Complete Acute Complete BlockBlock

558 VP (89%)558 VP (89%)

Incomplete Incomplete BlockBlock

71 VP (11%)71 VP (11%)

• 422 pts with symptomatic PaAF and PeAF referred to us between July ‘04 and September ’06. CA performed in

145/422 pts (34%).

TERNI registryTERNI registry

• At least one MONTHLY episode of Persistent symptomatic AF

• At least ONE WEEKLY episode of PaAF or PeAF

• At least Two or More AADs unable to control symptoms

• Age >75 yrs• Contraindications to ACT• Congestive HF• NYHA class III or IV• LVEF ≤35% • LA diameter ≥55mm• CARDIAC THROMBUS• Life expectancy <1 yr• CCH surgery <3 mo or

PROSTHETIC valves

Inclusion criteriaInclusion criteria Exclusion criteriaExclusion criteria

AFib PAROX. PERSIST. TOTALPatients 91 54 145 Age 62±13 67±8 64±15Sex (M/F) 61/26 37/21 98/47Duration 36±12N.episodes/mo 4±6LVEF (%) 55±6 51±9 53±9,7LA diameter 44±8 47±8 46±8CAD 15 21 36


• NO major complication (including death, stroke or other thromboembolic events) observed.

• MILD pericardial effusion observed in 4 pts.

• ANGIOGRAFIC analysis of all PVs performed post- procedure in all pts (no PV stenosis).

Clinical OUTCOME


• TELEMETRY MONITORING from 24 to 36 hr. • Eparin Na+ iv for 24 to 36 h.• ACT started 24 h post RFCA • ECHO pre-discharge.• Discharged with ACT (maintained for ≥ 6 mo)• Discharged with AADs (maintained for ≥ 6 mo) (35% with propafenone and 65% with flecainide)

Post-ablation MANAGEMENT


• After a mean FU Overall FREEDOM FROM AF (both PaAF and PeAF) was 60% (69% and 48%), w/o AADs and 72% (80% and 55%) with previous ineffective AADs.

Clinical OUTCOME

• The Kaplan-Meier statistical analysis probability of freedom from arrhythmia was maximal at 12 months


• Among UNIVARIATE predictors, the variables of age, sex, duration and frequency of AF, LVEF, LA size and structural heart disease, this approach revealed that an increased LA SIZE >50mm is an indipendet

predictor of AF recurrence

• NO major complication (including death, stroke or other thromboembolic events) observed.

• MILD pericardial effusion observed in 4 pts.

• ANGIOGRAFIC analysis of all PVs performed post- procedure in all pts (no PV stenosis).

Clinical OUTCOME


• TELEMETRY MONITORING from 24 to 36 hr. • Eparin Na+ iv for 24 to 36 h.• ACT started 24 h post RFCA • ECHO pre-discharge.• Discharged with ACT (maintained for ≥ 6 mo)• Discharged with AADs (maintained for ≥ 6 mo) (35% with propafenone and 65% with flecainide)

Post-ablation MANAGEMENT


• After a mean FU Overall FREEDOM FROM AF (both PaAF and PeAF) was 60% (69% and 48%), w/o AADs and 72% (80% and 55%) with previous ineffective AADs.

Clinical OUTCOME

• The Kaplan-Meier statistical analysis probability of freedom from arrhythmia was maximal at 12 months


• Among UNIVARIATE predictors, the variables of age, sex, duration and frequency of AF, LVEF, LA size and structural heart disease, this approach revealed that an increased LA SIZE >50mm is an indipendet

predictor of AF recurrence

different Technologiesdifferent Technologies

MappingMapping• Point by pointPoint by point

• LassoLasso• SpiralSpiral• BasketBasket

TrackingTracking• XrayXray

• CARTOCARTO• LocaLisaLocaLisa• NavXNavX• RPMRPM

• ICEICE

AblationAblation• ConventionalConventional

• 8 mm tip8 mm tip• Irrigated tipIrrigated tip• InvestigationalInvestigational(balloon, cryo...)(balloon, cryo...)

- Framework for ablationFramework for ablation

- Mapping guidanceMapping guidance

- Anatomic localizationAnatomic localization

- Tagging of ablation - Tagging of ablation sitessites

- Determine Determine catheter contactcatheter contact

- Improved Improved efficiency of efficiency of power deliverypower delivery

Atrial Fibrillation approachAtrial Fibrillation approach

• 422 pts with symptomatic PaAF and PeAF referred to us between July ‘04 and September ’06. CA performed in

145/422 pts (34%).


• At least one MONTHLY episode of Persistent symptomatic AF

• At least ONE WEEKLY episode of PaAF or PeAF

• At least Two or More AADs unable to control symptoms

• Age >75 yrs• Contraindications to ACT• Congestive HF• NYHA class III or IV• LVEF ≤35% • LA diameter ≥55mm• CARDIAC THROMBUS• Life expectancy <1 yr• CCH surgery <3 mo or

PROSTHETIC valves

Inclusion criteriaInclusion criteria Exclusion criteriaExclusion criteria

AFib PAROX. PERSIST. TOTALPatients 91 54 145 Age 62±13 67±8 64±15Sex (M/F) 61/26 37/21 98/47Duration 36±12N.episodes/mo 4±6LVEF (%) 55±6 51±9 53±9,7LA diameter 44±8 47±8 46±8CAD 15 21 36


evolution of 3D mapping systemAtrial Fibrillation approachAtrial Fibrillation approach

Procedure (min): 14826 14424 151 29

Fluoroscopy (min): 5917 5816

6619 Mapping (min): 358

339 384 Nr. Pulses of RF:

7216 7017 7519

RESULTSRESULTS Global Pz.in SR Pz. in AF


629 VP treated (145 pts)

Acute Complete Acute Complete BlockBlock

558 VP (89%)558 VP (89%)

Incomplete Incomplete BlockBlock

71 VP (11%)71 VP (11%)

2006 terni, convegno regionale, l'ablazione della fibrillazione atriale. il registro...

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