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Arrhythmia Alliance Regional Update Oct 2010

EP SpR

Ian Lines

AF AblationPlymouth

David Tomlinson

Guy Haywood

Haïssaguerre M et al NEJM 1998 339:659-666

TRIGGER

ROTORS

Jaliffe J. Cardiovasc Res (2002) 54 (2): 204-216

PARASYMPATHETIC GANGLIA

Courtesy of Professor Antonio Raviele, Mestre, Italy

PO, S. S., NAKAGAWA, H. and JACKMAN, W. M. (2009), Localization of Left Atrial Ganglionated Plexi in Patients with Atrial Fibrillation. Journal of Cardiovascular Electrophysiology, 20: 1186–1189

Focal activation Multiple Wavelets

PVs

LA

IVC IVC

RA

SVC SVC

PVs

LA

RA

Adapted from ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation J Am Coll Cardiol (2006) 48: 854

Initiated by focal triggers and maintained by substrate mediated factors that become more prevalent as AFib progresses

Kato T, et al. Circ J (2004) 68: 568

Transformation of paroxysmal AFib to persistent AFib:5.5% patients per year

Ratio in s

inus r

hyth

m

0

1.0

0.8

0.6

0.4

0.2

Follow-up (years)

0 30

Without structural heart disease

With structural heart disease

252015105

Paroxysmal AF onset

Resulting Prevalence –Presentation of AFib in EuroHeart Survey

40

30

10

0Paroxysmal AFib

% p

atients

Persistent AFib Permanent AFib

20

50

60

36

2836

EuroHeart Survey 2005

5,333 patients enrolled with AFib on ECG or Holterrecording during the qualifying admission/consultation, or in the preceding 12 months

Nieuwlaat R, et al. Eur Heart J (2005) 26: 2422

Percutaneous Intra-operative

Pulmonary Vein Isolation

Arctic Front®

CARTO

CARTOMERGE

T-VAC™

Selective venography

Percutaneous AF Ablation TechniquesUsed in Plymouth

Electrical Isolation of a Pulmonary Vein

Atrial p waveStill enteringPulmonary V

Pulmonary V‘Fenced off’from rest of Atrium

When isolatedP waves can’t get inPV triggers can’t get out

Isolated Pulmonary Vein Potential

A trigger fires in the pulmonary veinbut does not get out in to the atriumand Sinus Rhythm continues undisturbed

Randomised controlled trial over one year- 70 patients / AF frequency > 3 mths / no previous AA drugs

- PVI ablation(s) (n = 33) versus AA drugs (n = 37)

End-points: PVI AADs p

Recurrence of AF (>1) 13% 63% < 0.00

Hospitalisations 9% 54% < 0.001

Quality of life (6 mths) better worse

Quantifying the effectiveness of AF Ablation

Efficacy of catheter ablation in patients with AF

Calkins H et al. Circ Arrhythm Electrophysiol 2009;2:349-

361

Copyright © American Heart Association

Treatment of atrial fibrillation with antiarrhythmicdrugs or radiofrequency ablation: two systematic literature reviews and meta-analyses

International

success rate from

single procedure =

72% (freedom from AF on or

off drugs)

72 Patients

Minimum 6 month Follow-Up Data on 31

CLASS 1 2 3 4 % SUCCESS

PAF 18 10 4 3 1 78%

PeAF 13 6 3 1 3 69%

TOTAL 31 16 7 4 4 73%

Single operator data – GAH

1995-2002 (N = 8,745) Patient N %Death 4 0.05

Tamponade 107 1.22

Stroke 47 0.66

PV Stenosis (symptomatic) 41 0.57

Permanent diaphragmatic paralysis

10 0.11

International data - 2010 updateOverall – serious complication rate 4.5%Death 0.15%

Point by point ablation (up to 2009) – no

deaths, no long term adverse outcomes, no

tamponade, no strokes with detectable long

term disability

Duty Cycled RF (from 2009) - Complications: 1 patient with seizures following barbiturate withdrawal post procedure – full recovery, Tamponade 0, Stroke 0, Death 0

Comparison complication rates for AF management on long term antiarrhythmic drugsMajor complications 30%, Death 2.8%

10

8

6

4

2

0

Prevale

nce (

%)

50-59 60-69 70-79 80-89

12

8.8

4.8

1.80.5

Wolf PA, et al. Stroke (1991) 22: 983

Framingham study

Torbay dataClin Med 2009; 3: 219-23

Age distribution of patients

with Atrial Fibrillation

• Linear RF Ablation Catheter• 6 Platinum electrodes• Deflectable curve

In Vitro testing of linear ablation lesion

TVAC

•Targeting of Complex Fractionated Atrial Electrograms in addition to WACA & linear lesions

Tsai W J Card Electrophysiol 2010: 21-6

TVAC

Hunter R et al. Heart 2010; 96:1372-8

74% PVI + CFAEs v. 45% PVI only @ 1 year Verma STAR-AF EHJ 2010; 31: 1344-56

With substrate modification

Without substrate modification

80% PAF asymptomatic 69% Persistent AF asymptomatic 23% Persistent AF no better 25% “Re-do rate” No long-term procedural complications:

One severe contrast reaction before resulting in cardiac arrest and admission to ITU for 24 hours

Two groin haematoma One pericardial effusion – no drainage required Un-explained general weakness with full recovery - ?

related to GA

Ablation Frontiers2009

0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 proj

No

. o

f P

roc

ed

ure

s

Year

AF Ablations Plymouth

DRT

GAH

After correction for co-morbiditiesestimated 1.5 fold excess mortalityattributable to AF

Prognostic Impact

589 ablated vs 582 AAD for rhythm control

Non-randomised Pappone C, JACC 2003

CABANA study – randomized mortality trialDue to start reporting 2012 – full results 2015Non randomised report AHA 2011 –Stroke reduction with AF Ablation

AV node Ablation

Ablate and Pace - Palliative

Ablate and Pace OutcomesWood MA Meta analysis Circulation 2000 101 1138-44

Reviewed AF prevention Trials including DAPPAF, ASPECT, OASES, ADOPT, ATTEST

Conclusion: ‘ At present, permanent pacing to prevent AF is not indicated’

Role of Permanent Pacing to PreventAtrial Fibrillation (AHA Advisory Statement)Circulation 2005; 111:240-243

UltraCinch

UltraWand

European Society ofCardiology Guidelines2010 Camm J et al.

European Heart Journal(2010) 31, 2369–2429www.escardio.org

Symptomatic Paroxysmal or Pesistent AF

Failure to respond to one or more antiarrhythmicdrugs (Flecainide, Sotalol, Propafenone, Amiodarone, Disopyramide, Dronedarone)

Absence of severe co-morbidities or significant structural heart disease

Age < 70

LA diameter < 55 mm

AF duration < 5 years

Oral H, Morady F. Heart Rhythm 2006; 3: 615-618

• Atrial fibrillation ablation is an established technique with overall effectiveness in PAF of approximately 80%

• Efficacy is lower the longer the duration of persistent AF but in selected cases is 65 – 75%

• New technologies are developing and showing promise

• The technique should be reserved for patients with drug refractory symptoms sufficiently severe to adversely affect quality of life