Substrate Ablation (CAFE)A Promising or Vanishing Technique

Substrate Ablation (CAFE)A Promising or Vanishing Technique

Walid I. Saliba, M.D.Walid I. Saliba, M.D.

Director, Atrial Fibrillation Center

Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine

THE CLEVELAND CLINIC FOUNDATION

Cleveland, Ohio

Director, Atrial Fibrillation Center

Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine

THE CLEVELAND CLINIC FOUNDATION

Cleveland, Ohio

Goal

To confuse you

Paroxysmal

Self terminating AF episodes

Permanent

Sinus cannot be maintained

Persistent

Sinus can be restored electrically

or chemically

“AF begets AF”Atrial remodeling:

↓Refractory Period ↓ Conduction velocity

Favors Arrhythmia

Trigger initiation

Substrate maintenance

Natural History of AF Dual Substrate Model

Ablation of Triggers

Modification of Substrate

Alternative Strategies

More Ablation

Where?

Why?

How much more?

CAFEDominant

FrequencyGanglionic PlexiStepwise/TailoredAF NestSVC / CS / Septum

/ CristaLAA, LoMFlutter? CTILines, circles …

Primary therapy

Adjunctive therapy to PVI

What are CAFÉ’s EGMs with CL < 120 ms

EGMs with continuous electrical activity

EGMs with low amplitude and more than 2 deflections

EGMs with CL shorter than in the CS or LAA

Mechanisms Underlying CAFE Pathological anisotropic conduction Slow conduction , Pivot and anchor points or Collision of

the wavelets (Alessie 1996)

Focal microreentry (Gardner/Alessie 1985)

Wave break and fibrillatory conduction at the Borderzone of the mother rotors and areas of dominant frequencies. (Kalifa et al Circ 2006)

Calcium transient triggering activities from hyperactive autonomic ganglionic plexi with shortening of the RP (Scherlag et al. 2004)

CAFÉ’s in Atrial Fibrillation Ablation

Stand Alone Targets ( Nademaneee)

Hybrid approach with PVI

Substrate-Guided Ablation: CAFÉ’s

Rationale Target key atrial regions responsible for perpetuating AF

rather than targeting the triggers in the PV’s

End Points Complete elimination of areas with CFAE’s Conversion of AF to SR

Nademanee et al, JACC 2004

Substrate-Guided Ablation: CFAE

Nademanee et al, JACC 2004

Fractionated electrograms composed of 2 deflections or more and continuous deflection of baseline

Atrial EGMs with very short CL <120 msec

Substrate-Guided Ablation: CFAE’s

60% patients had CFAEs clustered around PV’s 87% patients had CFAEs clustered around septum and

roof, close to PVs.Nademanee et al, JACC 2004

Median RF lesions: 64

Nademanee et al, JACC 2004

121 pts (51 PAF, 64 Chronic AF)

91% of pts free of arrhythmia

23% required a 2nd. Ablation13% on AAD

Substrate-Guided Ablation: CFAE’s Only

Ablation of CAFÉ’s as part of a stepwise approach to achieve conversion to SR

Rationale: Structures contributing to initiation and maintenance of

AF are sequentially targeted

With increasing ablation of left atrial structures, there is a cumulative increase in AFCL resulting in “AF termination” with each ablation step performed.

Stepwise Ablation ApproachHaissaguerre et al. JCE 2005

The Stepwise Ablation Approach

Lasso Guided PV Isolation

Roof Line Ablation

Ablation of CS & Complex LA activities

Mitral Isthmus Ablation

Right Atrial / SVC Ablation

Cardioversion

EGM Based Ablation

Haissaguerre et al. J CardiovascElectrophysiol2005;16:1125-37

• 87% (52) had AF termination during ablation (SR:7 ; AT:45)

• 60% success rate with a single procedure(40% required repeat ablation)

• 95% success rate with multiple procedures• Sinus rhythm at 11±6 months f/u ,without AAD’s • Good atrial transport function

Stepwise Ablation Approach

Haissaguerre et al., J C E, Vol. 16, pp. 1138 Nov 2005

60 pts with Non-PAF

Some Observations The greatest magnitude of prolongation of

fibrillatory cycle length occurred during ablation at the PV-LA junction (Antrum) Coronary sinus Anterior LA

Almost half of the residual atrial tahycardias originated these same sites.

Circulation.2007;115:2606

100 pts with Chronic AF RF ablation of CAFÉ’s in PV’s, LA and CS End point: All CAFÉ’s eliminated or AF termination

CAFÉ’sCFAEs EGM: • CL< 120 msec• CL < CL n CS• Fractionated and/or continuous electric activity

• 1 PV 46%• CS 55%• Septum/roof All

Results

33% in SR after a single ablation procedure

Repeat ablation in 44% CAFÉ’s in antrum, PV tachycardia, Macroreentrant

flutter and circuits……

57% in SR at ~1 year follow up.

“The modest efficacy attained in this study despite extensive ablation of left atrial and coronary sinus CFAEs suggests either that CFAEs do not accurately identify sites that are critical to the maintenance of chronic AF or that ablation of CFAEs is not sufficient to eliminate the driving mechanisms of chronic AF in a large proportion of patients.”

A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF

Oral et al. J Am Coll Cardiol 2009;53:782–9)

• Group A: • Termination with PVAI (n=19)

• Group B: • No Termination→Cardioversion (n=50)

• Group C: • No termination →CFAE* (n=50)

n=119

*LA and CS for up to 2 hrs additional ablation

CAFÉ: LA sites

A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF

Oral et al. J Am Coll Cardiol 2009;53:782–9)

• Group A: • Termination with PVAI (n=19)• Group B: • No Termination→Cardioversion (n=50)• Group C: • No termination →CFAE (n=50)

SR at 10 months

36%

34%

79%

P=0.84

Up to 2 h of additional ablation of CFAEs after PVAI does NOT appear to improve clinical outcomes in patients with

long-lasting persistent AF.

After a single Ablation

Repeat Ablation in 34 randomized patients.

Oral et al. J Am Coll Cardiol 2009;53:782–9)

• Group B: • No Termination→Cardioversion (n=50)• Group C: • No termination →CFAE (n=50)

SR at 9 months

68%

60%P=0. 4

No Difference even with repeat ablation

Methods 144 patients with permanent AF randomized to:

1. Group I: Pulmonary Vein Antrum Isolation .(PVAI) n=48

2. Group II: Hybrid approach. (CFAE’s + PVAI) n=49• Initial defragmentation: targeting bi-atrial and CS CFAE,

and started randomly in the right or left atrium followed by PVAI

3. Group III: Large area circumferential ablation. (LACA) n=47• Targeting voltage reduction using electroanatomic

mapping. (CARTO)

Elayi et al. ;Heart Rhythm. 2008 5(12):1665

PVAIN=48

Defragmentation ONLY

N=49

Defragmentation +PVAI N=49

P value

SR 3(6%)

0 (0%)

2(4%)

NS

AT 18 (38%)

1 (2%)

34(70%)

P<0.001

AF 27 (56%)

48(98%)

13(26%)

P=0.01

Acute Results Group I Group II

1. Defragmentation alone did not have a significant effect on AF organization.

2. Defragmentation as an adjunctive strategy to PVAI increases the rate of conversion from AF to organized arrhythmias.

Long Term Results

Group I PVAIn=48

Group II CFAE+PVAI

n=49

Mean follow-up (months) 11.4 ± 1.1 11.2 ± 1.2

Patients in sinus rhythm after a single procedure

42% 61%

Patients in sinus rhythm after two procedures and with AAD if needed

83% 94%

Better success rate when defragmentation was performed in conjunction with PVAI

LAA

Cristal Terminalis

CS Pre RF CS Post RF

LSPV

Presenting for Ablation

Post Antral Isolation

Post CS & LA-CAFEAT Ablation

Substrate vs. Trigger Ablation for Reduction of AF: An International, Multicenter, Randomized Trial (STAR-AF)

• Comparison of 3 strategies of AF ablation: • (n=100 pts, 35% persistent)

–CFE ablation alone–PVI ablation alone–PVI+CFE hybrid ablation

Verma et al, HRS LBT 2009

Fre

edom

fro

m A

F 74%

47%

29%

In high-burden paroxysmal/persistent AF, PVI+CAFE has the highest freedom from AF versus PVI or CAFE alone after one procedure.

CAFE alone has the lowest procedure success rates

with a higher incidence of repeat procedures

Outcomes of Different Ablation Approaches That Incorporated CFAE Ablation in Patients With Persistent AF

N AF CAFÉ only PVI only PVI + CAFÉ

Nademanee et al (2004) 121 P+C 91%

Oketani et al (2008) 410 P+C 81%

Verma et al (2007) 40 C 82%

Star AF (2009) 100 P+C 29% 47% 74%

Haissaguerre (2005) 60 C 95% *

Orale at al.(2009) 50 C 60%

Orale et al.(2006) 100 C 57%

Meulet et al.(2007) 96 C 67% 66%

Elayi et al. (2008) 97 C 83% 94%

After 1-2 ablations F/U ~1 year

60% 66% 83%

Does CAFÉ substrate modification offer additional success?

• Different techniques, Different Operators, Different Skills, Different interpretations, Different endpoints, different experiences, different follow up’s: – Can we generalize the information

– Can we trust the data: Is this Science?

• Significance of CAFÉ: Active vs Passive role?

• Is it just more Controlled Debulking? (CEDCA)

• I will let you draw your own conclusion

Conclusion

PV Antrum Isolation

Overlap of CFAE and PVI? Majority of ablated CFAE in tailored approach were in the LA

Extensive “fixed” PV antral isolation includes most areas of CAFÉ.

Is More ablation better?

• More Ablation: Potential for More atrial Flutter• More ablation: Compromise LA mechanical function• More ablation: Interatrial / intraatrial dyssynchrony• More ablation: More fluoro / More potential complications

Angioplasty in Acute MI

We were overzealous with the angiojet. Let us fly her to Boston for a body transplant

بكفيCAFE

OK, butwhat else

can we ablate?…

END