hrs/ehra/ecas consens us statement on catheter and surgical ablation of atrial fibrillation

HRS/EHRA/ECAS ConsensHRS/EHRA/ECAS Consensus us

Statement on Catheter and Surgical Statement on Catheter and Surgical

Ablation of Atrial Fibrillation Ablation of Atrial Fibrillation

Asklepios Klink St. Georg, HamburgAsklepios Klink St. Georg, Hamburg

K.R. Julian ChunK.R. Julian Chun

ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation

Fuster et al. Circulation 2006;114: 257-354

Verma A et al. (Circulation 2005;112:1214–1231)

Catheter ablatioCatheter ablation of atrial fibrillationn of atrial fibrillation

SUCCESS RATES

Verma A et al. (Circulation 2005;112:1214–1231)


COMPLICATIONS – LARGE Centers

Pooled data complication rate: 2.8%

COMPLICATIONS - World Wide Survey

Cappato et al. Circulation 2005; 111; 1100-1105


%n=

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

2.262.44

2.662.94

3.33

3.80

4.34

4.78

5.165.42

5.61

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0

Year

Ad

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s w

ith

atr

ial f

ibr i

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[m

il lio

ns ]

2.08

Go et al, JAMA 2001;285:2370

Prevalence Atrial FibrillationPrevalence Atrial Fibrillation

Heart Rhythm. 2007 Jun;4(6):816-61.


HRS/EHRA/ECAS ConsensHRS/EHRA/ECAS Consensus Statementus Statement

Paroxysmal AF: AF (≥2 episodes) that terminates spontaneously within 7 days

Persistent AF: >7 days or cardioversion

Longstanding persistent AF: >12 months continuous AF

Permanent AF: AF has been accepted

Definitions Atrial Fibrillation (AF)



Mechanisms of Atrial FibrillationMechanisms of Atrial Fibrillation



AF Ablation Strategies


AF Ablation StrategiesAF Ablation Strategies

CFAE Definition

Haissaguerre et al. JCE 2005

Procedural EProcedural Endpointndpoint

• Wide area circumferential lesions (CCL)Wide area circumferential lesions (CCL)

• Online Lasso recordings to prove PVIOnline Lasso recordings to prove PVI

Ouyang et al. 2004 Circulation Heart Rhythm. 2007

#4#7

#1#9

#9#1

#7#4

Lateral PVs

Ouyang F et al. (Circulation 2004;110:2090–2096)

LSPV

Map CS

His LIPV

LSPV

LIPV

LAA

Pulmonary Vein IsolationPulmonary Vein Isolation

• It is important to recognize that catheter It is important to recognize that catheter ablation of AF is a demanding technical ablation of AF is a demanding technical procedure that may result in complicationsprocedure that may result in complications

• Patients should only undergo AF ablation Patients should only undergo AF ablation after carefully weighing the risks and after carefully weighing the risks and benefits of the procedurebenefits of the procedure


Indications for AF Catheter Ablation



• Symptomatic AF refractory ≥ 1 AAD Symptomatic AF refractory ≥ 1 AAD (Class I, III)(Class I, III)

• AF ablation as first line therapy (rare AF ablation as first line therapy (rare clinical situations)clinical situations)

• Selected pts with heart failure and/or Selected pts with heart failure and/or reduced EFreduced EF


Indications for AF Catheter Ablation


• Cardiac tamponade (<6%)Cardiac tamponade (<6%)

• Pulmonary vein stenosis (0-38%)Pulmonary vein stenosis (0-38%)

• Atrio-Esophageal fistula (<0.25%)Atrio-Esophageal fistula (<0.25%)

• Phrenic nerve injury (<0.48%)Phrenic nerve injury (<0.48%)

• Thromembolism (0-7%)Thromembolism (0-7%)

• Post procedural arrhythmias (5-25%)Post procedural arrhythmias (5-25%)

• Vascular complications (0-13%)Vascular complications (0-13%)

• Radiation exposureRadiation exposure


Complications in AF Ablation


• Heparin Heparin Target ACT 300 to 400s Target ACT 300 to 400s

• Careful identification of PV ostia is mandatoryCareful identification of PV ostia is mandatory

• If additional lesions are applied, line completeness If additional lesions are applied, line completeness should be demonstrated should be demonstrated

• RAI block only in pts with typical or inducible AFLRAI block only in pts with typical or inducible AFL

• Non PV triggers should be targeted if possibleNon PV triggers should be targeted if possible

• If pts with longstanding persistent AF are If pts with longstanding persistent AF are approached, ostial PVI may not be sufficentapproached, ostial PVI may not be sufficent


Technique / Lab Managements


• F/U visits; 3 months, 9 months and then every 6 F/U visits; 3 months, 9 months and then every 6 months for at least 2 yearsmonths for at least 2 years

• Event monitor in pts who complain of Event monitor in pts who complain of palpitationspalpitations

• AF/AFL/AT >30s are treatment failuresAF/AFL/AT >30s are treatment failures

• 24h HOLTER is acceptable for minimal 24h HOLTER is acceptable for minimal monitoring for pts in clinical trials and is monitoring for pts in clinical trials and is recommended at 3 to 6 months intervals for 1 to recommended at 3 to 6 months intervals for 1 to 2 years2 years


Minimal Monitoring

• 1. Procedure:1. Procedure: Wide area circumferential Wide area circumferential PVI of ipsilateral PVsPVI of ipsilateral PVs

• 2. Procedure:2. Procedure: Re-check PV conduction: Re-check PV conduction: Gap closureGap closure

– Clinical AT Clinical AT Ablation Ablation

• 3. Procedure:3. Procedure: CFAE identification and CFAE identification and ablation (LA, CS, RA)ablation (LA, CS, RA)

– Clinical AT Clinical AT Ablation Ablation

Hamburg AF Ablation Approach

• Catheter ablation of AF is...Catheter ablation of AF is...

– performed throughout the worldperformed throughout the world

– associated with high success ratesassociated with high success rates

– significant complicationssignificant complications

• PV isolation is cornerstone of AF ablationPV isolation is cornerstone of AF ablation


Conclusion

hrs/ehra/ecas consens us statement on catheter and surgical ablation of atrial fibrillation

Documents

catheter ablation of

dayspersistent af

circulationheart rhythm

iiiaf ablation

primary endpointno af

symptomatic af refractory

atrial fibrillationfuster

atrial fibrillation