gerhard hindricks university of...

Gerhard Hindricks

Fire or Ice

Radiofrequency or cryo ablation

University of Leipzig

- Heart Center -

Dept. of Electrophysiology

IDSS Tel Aviv 2015

Presenter Disclosure Information

Gerhard Hindricks/Department of Electrophysiology has received scientific grants

and research grants through the University Leipzig / Heart Center from German

Heart Foundation, ProCordis Foundation, St. Jude Medical, Biotronik, Boston

Scientific, and Volkswagen Foundation.

No personal financial relation to disclose.

• point-by-point RF ablation is standard of care for

AV-nodal reentrant tachycardia

tachycardia due to accessory pathway

ectopic atrial tachycardia

typical and atypical atrial flutter

ventricular arrhythmia

• RF ablation is the most frequent technology for

catheter ablation of atrial fibrillation

Current role of point-by-point RF ablation

Fire or Ice for AF ablation

Cryo-Balloon Cardiofocus Mesh-Ablator Ablation

Frontiers

PV-devices and alternative energy sources

HIFU

40% silent

stroke

10% PVI

rate

complications

incl. death

highly

complex,

no benefits ?


• Conceptual aspects and ablation strategies

• Procedural aspects (duration, fluoro time ...)

• Safety and Efficacy

• Development of future technologies

PV ablation devices and energy: What counts ?


PV devices: One size fits all ?


• 14 pat. with AF ablation devices (cryo, laser, HIFU)

• 3D voltage map before and after ablation

Reddy et al.; Heart Rhythm 2008

• level of PV isolation was

– distal within the PV antrum (segmental position)

– AF substrate within the PV antrum untreated

PV devices: Level of PV isolation


• Conceptual aspects and ablation strategies

• Procedural aspects (duration, fluoro time ...)

• Safety and Efficacy

• Development of future technologies

PV ablation devices and energy: What counts ?


• PV-isolation

• activation maps

• entrainment maps

• substrate maps

• CFAE maps

• rotor maps

• HD maps

Ablation strategies to approach AF: Changing paradigms

• distal PVI

• - no

• - no

• - no

• - no

• - no

• - no


New technologies will furhter improve RF ablation



Carto 1

Substrate-based AF ablation strategies

Rolf S et al.; Circulation AE 2014, in press


MRT around fossa ovalis


Assumption one:

• Cryo balloon ablation ablation is as effective as

radiofrequency ablation......

• This has never been shown by means of a

prospective randomized study performed in centers

that are experienced in the use of point-by-point RF

ablation......even not for paroxysmal atrial fibrillation.

For substrate driven AF, cryo ablation is absolutely

ineffective.


Non-randomized comparison of Cryo vs RF-ablation

Mubnai G et al., Am J Cardiol 2014


Pokushalov I et al., JCE 2013

Randomized comparison of Cryo vs RF re-ablations


Randomized comparison of Cryo vs RF re-ablations

Pokushalov I et al., JCE 2013


Assumption two:

• Cryo balloon ablation ablation is as safe or even

safer as compared radiofrequency ablation......

• No data support this assumption. Reported data

indicate that complication rates may be higher as

compared RF ablation. Let´s look to the data.....


Cryo ablation and complicatons: the reality

Packer et al., JACC 2013


Schmidt B et al., JCE 2014

Cryo ablation and complicatons: the reality


Assumption three:

• Atrio-esophageal fistula does not occur after cryo

ablation.

• Unfortunately this is not true. Severe esophageal

injury as well as perforation with atrio-esophagal

fistula has been reported.


Assumption four:

• Cryo balloon ablation ablation is faster than

radiofrequency ablation......

Schmidt B et al., JCE 2014

n= 2850 905


Cryo-energy versus RF energy

• Prospective randomized studies have compared the

efficacy and safety of cryo-energy and

radiofrequency energy in the setting of

- typical atrial flutter (3 studies)

- AV-nodal reentrant tachycardia (2 studies)

• all studies confirmed superiority of radiofrequency

energy as compared to cryo energy.

• Key finding: higher recurrence rate with cryo,

same complication rate!


Cryoenergy versus RF energy


Catheter ablation at Heart Center Leipzig


Cryoballoon versus RF energy

• Cryo RF

all types of AF no yes

individualized ablation no yes

antral ablation no yes

mapping capabilities no yes

concomitant flutter ablation

right atrium no yes

left atrium no yes

non fluoroscopic navigation no yes


Workflow for FIRM ablation

Sommer et al.; JCE 2015


LA map – geometry and voltage

MRI-guided AF ablation

• Why did cryo ablation not evolve as a key ablation strategy in

true high volume ablation centers?

• Because it is less effective, takes longer, and is more

expensive as compared to RF ablation.

• Point-by-point RF ablation does

• enable individualized treatment of anatomy and substrate

• enable safer and more efficacious lesion deployment

• enable innovative 3D/4D catheter navigation

• lead to procedures with

• with procedure duration < 120 min

• with fluoroscopy time < 10 min

• with clinical efficacy > 80% in PAF

Should cryo ablation be first line treatment for PAF?


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