prevalence of atrial fibrillation - bryan health...a catheter-based curative approach to atrial...

10/9/2018

1

Robert Percell, MD, FACC

Cardiac Electrophysiologist,

Bryan Heart Institute

Lincoln, NE

Fluoroless Ablation… relinquishing an old habit

Prevalence of Atrial Fibrillation

3.1 Million + 1 Million

by 2020 <10%

Mission:

Provide better access to those eligible patients for ablation therapy.

Atrial Fibrillation is a Progressive Disease

of patients progress from

Paroxysmal to Persistent AF

within 1 year of diagnosis120%

Nieuwlaat R

Typical ProgressionTypical Progression

10/9/2018

2

Afib Management1

2

Ablation Procedure3

Latest Rhythm Control Strategies

10/9/2018

3

Rate vs. Rhythm Control

Timeline

AFFIRM Study

No survival

advantage of Rate vs.

Rhythm control

2002 2006 20142012

Class

III

Level C

2001

Class II

Level B

Ionescu

Mortality among

patients on rhythm

control gradually

decreased relative

to rate control

Class I

Level

A*

Ghanbari

NSR after RFCA is

associated with 60% reduction in

CV mortality

Society Guidelines for Afib: Ablation

*Class I Level A for PAF with no or minimal heart disease

2010

Wilber

RFCA is superior in

efficacy and safety to AAD

2004

Corley (AFFIRM

sub-analysis)

NSR associated

with 47% reduction

on risk of death

2003

DIAMOND

Study

NSR leads to

significant

reduction in

mortality

2002

10/9/2018

4

Progression of AF less likely with Rhythm Control Strategy

Efficacy of Catheter Ablation vs. AAD therapy

Catheter Ablation vs. AAD Therapy

10/9/2018

5

1. Bunch et al. Patients Treated With Catheter Ablation for Atrial Fibrillation Have Long-Term Rates of Death, Stroke and Dementia Similar to Patients Without Atrial Fibrillation. J Cardiovasc

Electrophysiol, Vol. 22, pp. 839-845, August 2011

RF Catheter Ablation Lowers the Risk of Death, Stroke and Dementia 1

Afib Management1

2

Ablation Procedure3

Latest Rhythm Control Strategies

1. Source: Adapted from Calkins H, Brugada J, Packer DL et al. (2007) HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for

personnel, policy, procedures and follow-up. A report of the HRS Task Force on Catheter and Surgical Ablation of Atrial Fibrillation developed in partnership with the EHRA and the ECAS; in collaboration with ACC, AHA, and the STS. Endorsed and approved by the governing bodies of the ACC, AHA, ECAS, EHRA, STS, and the HRS. Europace 9(6):335-379.

RF Catheter Ablation Involves Lesion Creation to Prevent Abnormal Activation

• RF catheter ablation uses high frequency

alternating current to eliminate or alter the

arrhythmogenic substrate

• An ablation catheter is used to apply RF to the

endocardium to produce continuous lesions (scars)

that prevent the abnormal electrical activation

contributing to AF

• The most common lesion sets include circling of the

pulmonary veins (PVs) called circumferential PV

isolation

1

10/9/2018

6

TactiCath® - Integration with the PRECISION

Mapping System allows the physician to select,

visualize, and manage ablation parameters

VS

CRYO - No mapping system used. Physician is

limited to only anatomical approach without ability

to diagnose/treat additional arrhythmias Heart

Wall

Last Week’s CaseLast Week’s Case

CTI

54 yo man w/ Persistent Atrial fibrillation, Symptomatic, s/p failed CV,

propafenone

PVI

THERMOCOOL® Catheters (including ThermoCool® SmartTouch® catheter) are approved for drug refractory recurrent symptomatic paroxysmal atrial fibrillation, when used with CARTO® Systems (excluding NAVISTAR®

RMT THERMOCOOL® Catheter) #021458

Left Atrium Pre PVI

10/9/2018

7



PVI with Roof and Posterior Floor Line



Left Atrium Post PVI



Left Atrium Pre Cryo PVI

10/9/2018

8



Left Atrium Post Cryo PVI



AVNRT Ablation

Pulmonary Vein Isolation History

First PVI in Humans 1994

• 12 hours

• 6 hours of X Ray Radiation• Swartz JF, Pellersels G, Silvers J, Patten L, Cervantez D. A catheter-based curative approach to atrial fibrillation in humans (abstract) Circulation. 1994;90:I-335.

•Popularized in 1998

• 6 hour procedure

• 4 hours of X Ray Radiation• Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339:659-

66.

10/9/2018

9

Radiation is NOT NOT NOT NOT your friend

•Discovered in 1896• Wilhelm Roentgen, a German professor of physics

•Harmful effects:• Deterministic

• Dose related effects

• Stochastic

• Dose independent

Harmful Effects of RadiationHarmful Effects of RadiationHarmful Effects of RadiationHarmful Effects of Radiation

• Local erythema

• Cataracts

• Skin desquamation

• Leukopenia

• Atrophy of the organs

• Birth defects

• Multiple organ and bone cancers.

Radiation Exposure

10/9/2018

10

Radiation Burns Post Ablation

Radiation Risks

• It is estimated that with a single dose of 100 mSv

• There is a 1% chance of developing a solid tumor or leukemia

• With a dose as low as 10 mSv

• There is a 0.1% chance of developing cancer.

• Typical EP procedures can deliver between 15–30 mSv and can be as high as 50 mSv in a single setting

• Many EP’s obtain pre procedure CT’s for PV anatomy

• Not to mention wearing 20 lb Lead aprons!

Radiation Free Ablation?

• Case Reports and series

• Pediatrics

• Pregnancy

• “Near Zero”

• Lowering fluoroscopic dose, frame rates, etc.

• Lone single randomized trial with PVI for AF

• Few patients

• All paroxysmal

• Experienced operators

10/9/2018

11

Patient Characteristics

Procedure Times

10/9/2018

12

Safety and Efficacy

Efficacy Results at 3 months

The Journal of Innovations in Cardiac Rhythm Management Zero

Fluoroscopy Radiofrequency Redo Ablation of Atrial Tachycardia after Pulmonary Vein Isolation: A Tale of Two Systems

10/9/2018

13

The Journal of Innovations in Cardiac Rhythm Management Zero Fluoroscopy Radiofrequency Redo Ablation of Atrial

Tachycardia after Pulmonary Vein Isolation: A Tale of Two Systems

Local Activation Time mapping

Sparkle Mapping

10/9/2018

14

SANS FLUORO Ablation numbers

2015 2016 2017 2018 (projected)

0

60

87

105

2

54 52

94

2

132

157

199

SANS FLUORO ABLATIONS

PVI SVT ALL

Future Directions

• Super Obese Patients

• 540 pound patient successful A Flutter ablation

• SANS FLUORO

• Lesion Size Index (LSI)

Questions?

prevalence of atrial fibrillation - bryan health...a catheter-based curative approach to atrial...

Documents