minglong chen, md division of cardiology nanjing medical university hospital, mainland china
DESCRIPTION
CPVI Plus Electr ophysiological S ubs t rate Ab lation of the Le ft Atrium during S inus R hythm ( STABLE-SR ) for the Treatment of Persistent AF. Minglong Chen, MD Division of Cardiology Nanjing Medical University Hospital, Mainland China. Background. - PowerPoint PPT PresentationTRANSCRIPT
CPVI Plus Electrophysiological Substrate Ablation of the Left
Atrium during Sinus Rhythm (STABLE-SR)
for the Treatment of Persistent AF
Minglong Chen, MD
Division of Cardiology
Nanjing Medical University Hospital, Mainland China
Background
Circumferential PV Isolation (CPVI)
Effective in curing PAF
(The success rate in single procedure was 75.6%, 6M Follow up )
Ouyang, et al . Circulation 2004; 110: 2090-2096.
Efficacy of PVI for persistent AF
Author Year Pts(N) Age(Yr)LA size
(mm)
Follow-up
(months)
Primary
Success(%)
Kanagaratnam 2001 71 57±12 42±8 29±9 21
Lim 2006 51 59±10 45±6 17±9 22
Yamada 2007 14 56±9 39±4 —— 21
Anthony G, et al. Heart Rhythm 2010;7:835-846.
Single Procedure
Limited success rate in persistent AF
Per-AF requiring aggressive ablation strategies
Linear ablation
CTI
LA Roof
Posterior Mitral/MI
Coronary Sinus
CFE ablation
Aggressive ablation strategy
Efficacy of aggressive ablation for per-AF
Anthony G, et al. Heart Rhythm 2010;7:835-846.
“CPVI + Lines + CFE”
Author Year Pts(N) Age(Yr)LA size
(mm)
Follow-up
(months)
Primary
Success(%)
Estner 2008 35 57±9 49±6 19±12 51
Li 2008 92 59±6 42±5 12±11 58
Elayi 2008 49 59±12 46±6 16±1 61
Oral 2009 50 62±8 46±6 10±3 36
RASTA Study
Randomized Controlled Trial 1 year Follow-up
Evaluate the single procedure efficacy of Per-AF
Per-AF (n=156)
Group2 (n=50)
Group3 (n=51)
Group1 (n=55)
PVI PVI+Lines PVI+CFE
PVI PVI+Lines PVI+CFE
*P=0.04
*P=0.004
RASTA Study
Primary Study End Point: Freedom from AF/AT off AADs
29%???
Oral H, et al. J Am Coll Cardiol 2009; 53: 782-9
Does linear ablation and defragmentation really improve the success rate of persistent AF?
----Follow-up results and EP findings in the redo procedures from
169 consecutive patients
Roof-line-1
Roof-line-2
Posterior mitral line-1
Posterior mitral line-2
Posterior mitral line-3
Posterior mitral line-4
The Study Results
169 consecutive Per-AF patients
2007.5~2010.7
Mean age: 56y
Mean LAD: 42mm
Mean AF duration: 24m
15±8 months Follow up
169 pts
SR: 84 pts (50%)
AT: 51 pts (30%)
AF: 34 pts (20%)
AT ablation: 46pts
Macro-AT: 36 Focal-AT: 45
81 ATs
Proarrhythmic effects of linear lesions
Mechanism of AT after AF ablation
Macro-reentrant
Mechanism of AT after AF ablation
Macro-reentrant
Proarrhythmic effects of linear lesions
Mechanism of AT after AF ablation
Ju W, Chen ML, et al. PACE 2011;34(8):919-26.
Focal
Proarrhythmic effects of linear lesions
CFE ablation
Proarrhythmic effects of empiric CFE ablation
Localized reentry as a novel type of the proarrhythmic effects of linear lesion in the left atrium
----Ju et al. PACE. 2011;34:919-926
The ideal ablation strategy of persistent AF
still remains a matter of debate…Veenhuyzen GD, et al. PACE 2009 Mar;32(3):393-8.
Comparison of Left Atrial Electrophysiologic Abnormalities
during Sinus Rhythm in Patients with Paroxysmal, Persiste
nt and Long-Standing Atrial Fibrillation
Par-AF: 30 ptsPer-AF: 22 ptsLS-AF: 28 ptsControl: 20 pts with LAP
Mapping Methods
• A-Focus high density mapping during sinus rhythm
• Mapping was done after CPVI, Per-AF and LS-AF need cardioversion
• NavX: interior and exterior projection, interpolaration were set at 5 mm
• LA voltage, activation time and complex electrograms were analyzed
Comparison of the LA activation time among different populations
The correlation of LA activation time with overall mean bipolar voltage, left atrium diameter , low voltage index and percentage of complex electrograms
Definition of Complex Electrocardiogram
Distinct deflections ≥ 3
Electrocardiogram duration≥ 50 ms
> 50ms
A: Comparison of the percentage of complex electrograms in LA. B: Comparison of the mean bipolar voltage of complex electrograms. C: Comparison of the duration of complex electrograms.
Study Findings
• With AF progression there was a lower mean bipolar voltage, higher low voltage index and more prevalent and larger LVZ area in LA
• With AF progression there was also conduction abnormalities characterized by prolonged LA activation time and more proportion of complex electrogram
• The cutoff value to define low voltage zone (0.1~0.4mV) and the transitional zone (0.4~1.3mV) was defined
New ablation strategy
Novel ablation strategy for Per-AF
CPVI
Cavotricuspid isthmus ablation
LA high density electroanatomic mapping
Substrate modification
Check linear lesions to achieve bidirectional block
To double check PV being isolated
Cardioversion
AF = atrial fibrillation; CPVI = circumferential pulmonary vein isolation; CTI = cavotricuspid isthmus; DC = direct current; SR = sinus rhythm; LA = left atrium; HDM = high density mapping; LVZ = low voltage zone; TZ = transitional zone
AF = atrial fibrillation; CPVI = circumferential pulmonary vein isolation; CTI = cavotricuspid isthmus; DC = direct current; SR = sinus rhythm; LA = left atrium; HDM = high density mapping; LVZ = low voltage zone; TZ = transitional zone
Pilot Study of Circumferential Pulmonary Vein Isolation Plus Electrophysiological Substrate Ablation in the Left Atrium During Sinus Rhythm (STABLE-SR) in the
Treatment of Chronic Atrial FibrillationClinicalTrials.gov Identifier: NCT 01716143
Representation of substrate-based ablation during SR in the LA besides CPVI
Example of relatively “healthy” LA and does not need additional ablation
No LVZ was found in the LA body
No LVZ was found in the LA body
No CFE was found in TZ
No CFE was found in TZ
Example of diffused LVZ and SR-CFEs within TZ
Color bar setting: 0.1~0.4 mV
Color bar setting: 0.1~0.4 mV
Color bar setting: 0.4~1.3 mV
Color bar setting: 0.4~1.3 mV
Lesion deployed based on HDM mapping results
Continuous ablation of the site with CFE till the voltage was < 0.1 mV
The circular catheter was dislodged from the PVsThe circular catheter was dislodged from the PVs
Example of HDM after CPVI
Notice the distribution of LVZ and TZ with CFEs
Lesion deployment according to HDM results
Homogenization of LVZ, modification of the TZ sites with CFEs and joining these areas to the right lesion ring and the anterior mitral annulus actually create a narrow band of conduction block in the left anterior septal wall.
Pacing from the LAA to check the conduction block
ResultsBaseline Patient Characteristics (N=68)
Number of patients 68
Age, yrs 52.5 ± 10.5
Male, n 61 (89.7)
AF duration, months 19.5 ± 21.6
Hypertension, n 38 (55.9)
Structural heart disease, n 6 (8.8)
LA diameter, mm 40.9 ± 4.1
LVEF, % 63.0 ± 5.3
CHADS2 score 1.0 ± 0.8
Results
Percentage of patients with LA substrates at different regions
75 enrolled pts
CPVI + CTI ablation
Failed ( 9.3% )SR ( 90.7% )
cv
68 7
Aggressive ablation
STABLE - SR
Distribution of LVZ and TZ of 57 Regions and the Corresponding Ablation Strategies
Region Number Linear ablation LVZ homogenization
Roof 16 16 0
Anterior 19 7 12
Posterior 17 2 15
Lateral 1 1 0
Septum 4 1 3
Left atrial appendage 0 0 0
• Freedom of ATa off AADs after a single-ablation procedure: 53 of
68 (77.9%)
• Types of recurrent arrhythmia• PAF in 12 of 68 (17.6%)
• persistent AF in 2 of 68 (2.9%)
• AT in 1 of 68 (1.5%)
• Arrhythmia recurred within the first year after ablation in 6 of 68
(8.8%) patients. Nine (13.2%) patients had recurrences after 12
months after ablation.
ResultsFollow-up (21.5 ± 7.8 months)
68 pts
Ata Free (53) Ata occurrence (15)
PAF (12) PeAF (2) AT (1)
• Total procedure: 212 ± 34 minutes
• Total fluoroscopy time: 31 ± 7 minutes
• Adverse Events 2 (2.9%) femoral hematomas
Results
Comparative Study of STABLE-SR vs. STEPWISE in the Treatment of Chronic Atrial Fibrillation
ClinicalTrials.gov Identifier: NCT 01761188
Randomized
Comparative
Multicenter
Single blind
Prospective
Launched in June 6, 2013
Conclusion
Aggressive ablation strategy is “a knife with two blades”
linear ablation and CFE ablation should be highly selective,
but not empirical and extensive
CPVI plus substrate based ablation (LVZ ablation and co
mplex electrgram modification) might be a more electroph
ysiological individualized ablation strategy for chronic AF
patients
“Nanjing Approach”