Transcript Section III: Catheter Ablation for the Treatment of AFib

Section III:
Catheter Ablation for the
Treatment of AFib
Section III. Catheter Ablation for
the Treatment of AFib
1. Left atrial (LA) and pulmonary vein (PV)
anatomy
2. Catheter ablation techniques
3. Technological issues
4. Success rates
5. Complication rates
6. Cost-effectiveness
7. Indications for catheter ablation
8. Centre experience
1. Left Atrial (LA) and
Pulmonary Vein (PV)
Anatomy
Macroscopic Anatomy of the Myocardial
Sleeves and the Pulmonary Veins and
Sleeves
PV
PV
PV
Non-uniform
PV sleeve
PV
Uniform PV
sleeve
Macroscopic Anatomy of the Myocardial
Sleeves and the Pulmonary Veins
Non-uniform
Uniform
sleeve
sleeve
Atrial-PV
border
reproduced with permission, Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
Microscopic Anatomy of Pulmonary
Veins
PERMISSION TO USE PHOTO BEING
REQUESTED
Myocardial sleeve
Myocardial sleeve
Myocardial sleeve
Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
Transverse Section Perpendicular to the
Axis of the Pulmonary Vein
PERMISSION TO USE PHOTO BEING
REQUESTED
Groups of
myocardial
cells in
different
orientations
Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
Length of Myocardial Sleeves in the 4
Pulmonary Veins
*
*
Length of myocardial sleeves (mm)
16
*p<0.01
*
14
*
*
12
10
8
6
4
2
0
LSPV
RSPV
LIPV
RIPV
Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
Schematic Representation of Superficial
Myocardial Fibres of the LA
SVC
LA
LSPV
LLPV
RA
RSPV
RIPV
IVC
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
Myocardial Fibre Orientation in the LA and
PV – Predominant Vertical Fibre Pattern
RSPV
LSPV
LIPV
RIPV
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
Myocardial Fibre Orientation in the LA and
PV – Predominant Horizontal Fibre Pattern
LSPV
RSPV
LMPV
RMPV
RIPV
LIPV
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
Myocardial Fibre Orientation in the LA and
PV – Predominant Oblique Fibre Pattern
SVC
LA
RSPV
LSPV
LIPV
RIPV
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
Myocardial Fibre Orientation in the LA
and PV – Mixed Fibre Pattern
SVC
LSPV
RSPV
LIPV
RIPV
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
PV-Left Atrial Connections
PERMISSION TO USE PHOTO BEING
REQUESTED
Pattern 1 – no connections
Pattern 2 – partial connections
Pattern 3 – good connections
Tan AY, et al. J Am Coll Cardiol (2006) 48: 132
Summary of Anatomical Changes in
Patients with AFib
• Atrial myocardium is more often present in the
PV of patients with AFib compared with patients
without AFib
• In the first group the atrial myocardium in the PV
is characterized by more severe discontinuity,
hypertrophy and fibrosis
• Muscular discontinuities and abrupt fibre
orientation change are present in more than
50% of PV-LA segments, creating significant
substrates for re-entry
• Adrenergic and cholinergic nerves have highest
densities within 5mm of the PV-LA junction but
are highly co-located
Tan AY, et al. J Am Coll Cardiol (2006) 48: 132
Hassink RJ, et al. J Am Coll Cardiol (2003) 42: 1108
Typical & Atypical Branching
Pattern of PV Anatomy
A
Typical
AFib
Control
N=16
N=18
D
Right Middle PV
AFib
Control
N=4
N=3
B
Short Common Left Trunk
C
N=7 (including 3 of D)
N=5 (including 2 of D)
E
Two Right Middle PVs
N=1
N=0
Long Common Left Trunk
N=2
N=2
F
Right Middle PV
and Right “upper” PV
N=1
N=1
adapted from Kato R et al. Circulation (2003) 107: 2004
Anatomy of the Pulmonary Veins
LA appendage
RSPV
LSPV
RIPV
LIPV
Right PV
Left PV
• Nuclear magnetic resonance image of the ostia of the right
and left superior and inferior PVs and the left atrial
appendage
reproduced with permission, Kato R, et al. Circulation (2003) 107: 2004
Anatomy of the Pulmonary Veins
PERMISSION TO USE PHOTO BEING
REQUESTED
LA longitudinal section
Transverse section from
above
Left pulmonary
veins
• Note the common opening of the LPV and separate
origins of the two RPV
Ho YS, et al. Heart (2001) 86: 265
Right Middle PV
PERMISSION TO USE PHOTO BEING
REQUESTED
• Nuclear magnetic
resonance image
showing a right PV with a
separate origin to the
right superior and inferior
PVs
RMPV
Kato R, et al. Circulation (2003) 107: 2004
Pulmonary Vein Geometry
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Posterior View
Inferior View
LAO 45°
Ostium of left lower PV
Magnetic Resonance Angiography
Fluoroangiography
Wittkampf FH, et al. Circulation (2003) 107: 21
Average Pulmonary Vein Ostium
Diameters
n
Maximum
(mm)
Minimum
(mm)
Ratio
Range
(mm)
Projected
(mm)
Left superior
38
18.7 ± 2.9
13.9 ± 3.7
1.4 ± 0.4
1.0-3.0
17.5 ± 2.9
Left inferior
38
15.9 ± 3.1
11.2 ± 3.1
1.5 ± 0.4
1.0-2.3
15.0 ± 2.7
Both left
76
Right superior
42
18.8 ± 2.7
16.0 ± 2.0
1.2 ± 0.1
1.0-1.5
17.5 ± 2.1
Right inferior
42
17.9 ± 2.9
15.1 ± 3.0
1.2 ± 0.2
1.0-1.7
16.9 ± 3.1
Both right
84
1.5 ± 0.4
1.2 ± 0.1
Left common
4
27.3 ± 6.2
18.7 ± 6.7
1.6 ± 0.5
1.0-2.2
26.5 ± 4.8
Right middle
4
7.6 ± 3.1
5.6 ± 2.1
1.4 ± 0.4
1.0-2.0
7.0 ± 1.9
Dimensions of PV ostia measured with MRA. The ratio between maximal and minimal ostium
diameters is a measure of the ovality of the PV ostia.
* Differences in ovality were only significant between right and left PV ostia (p<0.005)
Wittkampf, FH et al. Circulation (2003) 107: 21
Parasympathetic Ganglia
Fat pads
Distribution of Autonomic Nerves
at the PV-LA Junction
Anterior
junction
Adrenergic Nerve Density
Posterior
junction
AO
SVC
PA
RS
LS
Anterior
LA
Grade 2: 15-30 x 103 mm2/mm2
Grade 1: 0-15 x 103 mm2/mm2
Grade 4: 4.5-6.0 x 103 mm2/mm2
RI
IVC
VOM
Grade 3: 30-45 x 103 mm2/mm2
Cholinergic Nerve Density
Posterior
LA
LI
Grade 4: 45-60 x 103 mm2/mm2
Grade 3: 3.0-4.5 x 103 mm2/mm2
Grade 2: 1.5-3.0 x 103 mm2/mm2
Grade 1: 0-1.5 x 103 mm2/mm2
CS
S = Superior; I = Inferior; AS = Anterosuperior;
PI = Postinferior; AI = Anteroinferior; PS = Postsuperior
reproduced with permission, Tan AY, et al. J Am Coll Cardiol (2006) 48: 132
3. Catheter Ablation
Techniques
From the first procedures to
today
Landmarks in Catheter Ablation
Techniques and Success Rates
Technique
Maze reproduction
Publication date
Schwarz 1994
Right atrial linear lesions
Haïssaguerre 1994
Right and left atrial linear lesions
Haïssaguerre 1996
PV foci ablation
Jaïs / Haïssaguerre
1997/8
Ostial PV isolation
Haïssaguerre 2000
Circumferential PV ablation
Ablation of non-PV foci
Antral PV ablation
Double Lasso technique
CFAE sites ablation
Ostial or circumferential or antral PV
ablation plus extra lines (mitral isthmus,
posterior wall, roof)
Circumferential PV ablation with vagal
denervation
Pappone 2000
Lin 2003
Maroucche / Natale 2004
Ouyang / Kuck 2004
Nademanee 2004
Jaïs / Hocini 2004/5
Pappone 2004
1994: Reproduction of Cox Procedure
using Catheter Ablation by Schwarz
• Traditional Cox-Maze surgical procedure
RAA
LAA
LA
IVC
adapted from Cox JL, et al. J Thor Cardivasc Surg (1991) 101: 569
1994: Right Atrium Linear Lesions
• In the same year, Haïssaguerre placed three linear
lesions in the right atrium using radiofrequency energy
• 46-year old patient: AF-free with no AADs after 3-
months
SVC
1
2
3
T
Right
atrium
IVC
adapted from Haïssaguerre M, et al. J Cardiovasc Electrophysiol (1994) 5: 1045
1996: Technique Extended to Right and
Left Atrial Ablation
• In 1996 Haïssaguerre modified the procedure extending
linear lesions to the left atrium
• Aim was to isolate compartments of atrial tissue as in
the Cox procedure
1
1
2
2
3
3
4
4
adapted from Haïssaguerre M, et al. J Cardiovasc Electrophysiol (1996) 7: 1132
1998: Ablation of PV Foci
Spontaneous Initiation of Atrial Fibrillation
by Ectopic Beats Originating in the
Pulmonary Veins
Haïssaguerre, M, Jaïs, P, Shah, DC, et al.
N Engl J Med (1998) 339: 659
• Using multi-electrode catheter mapping Haïssaguerre
identified atrial foci triggering AFib in 45 patients
refractory to drug treatment
– Single focus in 29 patients (64%)
– 2 foci in 9 patients (20%)
– 3 to 4 foci in 7 patients (16%)
PV Foci Triggering Afib
• 94% of foci located inside PV (2-4 cm from ostium)
– 45% in LSPV, 25% in RSPV, 16% in LIPV, 9% in RIPV
Right Atrium
Left Atrium
Superior
vena cava
25%
45%
Pulmonary
Veins
Inferior
vena cava
Fossa
ovalis
9%
Coronary
sinus
16%
94%
reproduced with permission, Haïssaguerre M, et al. N Engl J Med (1998) 339: 659
Ectopic Beats Initiating AFib from Foci
in the RI and LS PVs
Ectopic beats (arrowed)
RIPV
LSPV
reproduced with permission, Haïssaguerre M, et al. N Engl J Med (1998) 339: 659
PV Foci Ablation: Results and
Conclusions
• Radiofrequency ablation of ectopic foci was associated
with a 62% success rate (absence of recurrence at 8 
6m follow-up)
Haïssaguerre M, et al. N Engl J Med (1998) 339: 659
2000: Ostial PV Isolation
Electrophysiological End Point for Catheter
Ablation of Atrial Fibrillation Initiated from
Multiple Venous Foci
Haïssaguerre, M, Jaïs, P, Shah, DC, et al.
Circulation (2000) 101: 1409--177
• Key study in 90 patients to investigate whether
complete isolation of PV ectopic foci correlates with
improved success
• End point was elimination of ectopy, spontaneous or
induced, and elimination of PV muscle conduction
Ostial PV Isolation
Atrial activation
preceding PVP
Discharges
from PV
Local PV activity
dissociated
distally at a slow
rate
reproduced with permission, Haïssaguerre M, et al. Circulation (2000) 101: 1409
Ostial PV Isolation: Results and
Conclusions
• Success, defined by elimination of AFib without
drugs, was correlated with the procedural end
point of abolition of distal PV potentials
– After a mean follow-up of 8+5 months, AFib was
completely eliminated in 64 patients (71%) without AADs
– Anticoagulants were interrupted in 52 cases
– The other 26 patients were prescribed a drug that was
ineffective before ablation, resulting in total elimination of
AFib in 12 of 26
• Recovery of local PV potential and the inability to
abolish it were significantly associated with AF
recurrences (90% success rate with versus 55%
without PV potential abolition)
Haïssaguerre M, et al. Circulation (2000) 101: 1409
2000: Circumferential PV ablation
Circumferential Radiofrequency Ablation
of Pulmonary Vein Ostia
A New Anatomic Approach for Curing Atrial Fibrillation
Pappone, C, Rosanio, S, Oreto, G, et al.
Circulation (2000) 102: 2619-28
• Anatomical approach guided by a non-fluoroscopic
mapping system to generate 3D electroanatomic maps
in 26 patients and to perform circular linear lesions
around the ostium of the PV
Circumferential PV ablation
Voltage maps
Pre-ablation
Post-ablation
• Color coding represents activation times. In all maps, earliest
activation (red) is located at pacing site. After ablation, conduction
delay is characterized by abrupt color change from shades of yellow
or green to blue or purple (latest activation)
reproduced with permission, Pappone C, et al. Circulation (2000) 102: 2619
Circumferential PV ablation : Results
and conclusions
• Among 14 patients with AFib at the beginning of the
procedure, 64% had sinus rhythm restoration during
ablation
• PV isolation was demonstrated in 76% of 104 PVs
treated
• After 9+3 months, 22 patients (85%) were free of
AFib (62% not on AADs), with no difference between
paroxysmal and permanent AFib
Pappone C, et al. Circulation (2000) 102: 2619
2003: Non-Pulmonary Vein Foci
Catheter Ablation of Paroxysmal Atrial
Fibrillation Initiated by Non-Pulmonary
Vein Ectopy
Lin, W-S, Tai, C-T, Hsieh, M-H, et al.
Circulation (2003) 107: 3176
• Most of the ectopic beats initiating paroxysmal AFib
(PAF) originate from the PV.
• Lin et al. investigated PAF originating from non-PV
areas
Non-Pulmonary Vein Foci
• Non-PV foci identified in 28% of patients:
– left atrial posterior free wall (LPFW), superior vena cava (SVC),
crista terminalis (CT) ligament of Marshall (LOM) coronary sinus
ostium (CSO), interatrial septum (IAS)
Patients
(n)
Age
(y)
History
(y)
Other SHD
(%)
LA size
(mm)
Multiple
AF Foci
(%)
Late
Recurrence
(%)
LPFW
27 (37%)
63 ± 14
5.2 ± 4.0
50
39.5 ± 5.9
100
56
SVC
27 (37%)
57 ± 12
4.7 ± 4.8
22
36.8 ± 5.1
44
26
CT
10 (14%)
63 ± 12
4.1 ± 3.2
0
29.7 ± 5.0
40
20
LOM
6 (8%)
66 ± 13
3.1 ± 2.5
50
41.3 ± 1.5
83
50
CSO
1 (1.4%)
67
1
0
--
0
0
IAS
1 (1.4%)
44
2
100
--
100
100
Group
SHD indicates structural heart disease
Lin W, et al. Circulation (2003) 107: 3176
Ablation of non-PV Ectopy
Ablation of ectopic triggers from the ligament of Marshall
Before
After
reproduced with permission, Lin W, et al. Circulation (2003) 107: 3176
Ablation of non-PV Ectopy: Results and
conclusions
• Catheter ablation eliminated AFib with acute
success rates of 63%, 96%, 100%, 50%, 100%,
and 0% in left atrial posterior free wall, superior
vena cava, crista terminalis, ligament of Marshall,
coronary sinus ostium, and interatrial septum,
respectively
• During a follow-up period of 22+11 months, 43
patients (63.2%) were off AADs without AFib
recurrence
Lin W, et al. Circulation (2003) 107: 3176
2004: PV Antrum Isolation
Pulmonary Vein Antrum Isolation:
Intracardiac Echocardiography-Guided
Technique
Verma, A, Marrouche, NF, and Natale, A
J Cardiovasc Electrophys (2004) 15: 1335-40
• Isolation of PVs guided by ICE and circular mapping
catheter in order to more precisely identify border of
the PV antrum and reduce risk of PV stenosis
PV Antrum Isolation
3D multi-slice images of PVs
Tubular ostium
defined by PV
angiography
Actual PV
antrum
extends more
posteriorly
Antral borders
defined by ICE
reproduced with permission, Verma A, et al. J Cardiovasc Electrophys (2004) 15: 1335
PV Antrum Ablation
Phased-Array Intracardiac
Echocardiography Monitoring During
Pulmonary Vein Isolation in Patients with
Atrial Fibrillation
Impact on Outcome and Complications
Marrouche, NF, Martin, DO, Wazni, O, et al.
Circulation (2003) 107: 2710
• 315 patients undergoing ostial isolation of all PVs
using either:
– Circular-mapping (CM) alone (group 1, n=56)
– CM and intracardiac echocardiography (ICE) (group 2,
n=107)
– CM and ICE with titration of RF energy based on
visualization of microbubbles (group 3, n=152)
PV Antrum Ablation: Results
Freedom from recurrent AF (%)
100
Group 1 (n=56)
Group 2 (n=107)
Group 3 (n=152)
90
80
70
60
Group 1 vs Group 3; p=0.009
Group 1 vs Group 2; p=0.08
Group 2 vs Group 3; p=0.08
50
40
0
30
150
270
390
510
630
750
870
Follow-up (days)
Marrouche NF, et al. Circulation (2003) 107: 2710
PV Antrum Ablation: Results
Intracardiac echocardiography improves the outcome
of cooled-tip PV isolation
Freedom from recurrent AF (%)
100
ICE (n=259)
No ICE (n=56)
90
80
70
60
50
p=0.01
40
0
30
150
270
390
510
630
750
870
Follow-up (days)
Marrouche NF, et al. Circulation (2003) 107: 2710
2004: Double LASSO® Catheter Ablation
Complete Isolation of Left Atrium
Surrounding the Pulmonary Veins
New Insights from the Double-Lasso Technique in Paroxysmal
Atrial Fibrillation
Ouyang, F, Bänsch, D, Ernst, S, et al.
Circulation (2004) 110: 2090
• Isolates pairs of pulmonary veins using two LASSO®
catheters
• Continuous circular lesions (CCLs) around PVs guided
by 3D mapping
2004: Double LASSO® Catheter Ablation
reproduced with permission, Ouyang F, et al. Circulation (2004) 110: 2090
Double LASSO® Catheter Ablation
• Automatic activity
and PV tachycardia
provide an
arrhythmogenic
substrate for AFib
• This activity could
be eliminated in
the majority of
patients by
isolating all PVs
with closed circular
lesions
reproduced with permission, Ouyang F, et al. Circulation (2004) 110: 2090
Double LASSO® Catheter Ablation:
Results and Conclusions
• During a mean follow-up of 6 months, recurrence
occurred in 10 patients. Nine patients underwent a
repeat procedure
• Conduction gaps in the left CCL in 9 patients and in the
right CCL in 2 patients were closed during the second
procedure
• No AFib recurred in 39 patients after PV isolation during
follow-up
• These results strongly support the hypothesis that it is
necessary to isolate all PVs to prevent recurrence and
stress the importance of the PV-LA junction in the
initiation and perpetuation of PAF
Ouyang F, et al. Circulation (2004) 110: 2090
2004: Complex Fractionated
Electrograms (CFAEs) Site Ablation
A New Approach for Catheter Ablation of
Atrial Fibrillation: Mapping of the
Electrophysiologic Substrate
Nademanee, K, McKenzie, J, Kosar, E, et al.
J Am Coll Cardiol (2004) 43: 2044
• Complex fractionated electrograms (CFAEs) recorded
during AFib used as target sites for ablation
• Based on CARTO™ System mapping, the biatrial replica
could be divided into distinct areas where RF energy
was delivered according to CFAE detection
2004: Complex Fractionated
Electrograms (CFAEs) Site Ablation
• Fractionated electrograms with continuous
prolonged activation complex over posterior septal
areas
reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
CFAEs Site Ablation
reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
CFAEs Site Ablation
reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
CFAEs Site Ablation: Results and
Conclusions
• Ablations of areas associated with CFAEs terminated
AFib in 115 of 121 patients (95%)
• After one-year, 110 (91%) patients were free of AFib
• Areas with CFAEs are ideal target sites for ablation of
AFib
Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
2004: Spectral Analysis to Guide
Catheter RF Ablation
A New Treatment for Atrial Fibrillation
Based on Spectral Analysis to Guide the
Catheter RF-Ablation
Pachon, JC, Pachon, EI, Pachon, JC, et al.
Europace (2004) 6: 590
• A new method for treating paroxysmal AFib by
targeting AFib “nests” of “fibrillar” myocardium – areas
of atrial substrate that can be identified by spectral
analysis through fast Fourier transforms (FFTs)
Spectral Analysis to Guide Catheter RF
Ablation
reproduced with permission, Pachon JC, et al. Europace (2004) 6: 590
Spectral Analysis to Guide Catheter RF
Ablation
• Six control and 34 drug-refractory paroxysmal or
persistent AFib patients were studied and treated
• RF was applied to all sites outside the pulmonary
veins presenting right-FFT-shift (AFib nests)
• RF-ablation of AF nests, decreasing the
fibrillar/compact myocardium ratio, eliminated 94%
of the paroxysmal AFib in patients at 9.9+5 months
of follow-up
• Paroxysmal AFib may be cured or controlled by
applying RF in several places outside the PV, thus
avoiding PV stenosis
Pachon JC, et al. Europace (2004) 6: 590
Identification of an Atrial Frequency
Gradient using Dominant Frequencies
Presence of Left-to-Right Atrial Frequency
Gradient in Paroxysmal but Not Persistent
Atrial Fibrillation in Humans
Lazar, S, Dixit, S, Marchlinski, FE, et al.
Circulation (2004) 110: 3181
• Investigated whether patients with AFib manifest a
left-to-right atrial frequency gradient
DF Atrial Gradients: Results and
Conclusions
• In patients with paroxysmal AFib there is a
significant left-to-right atrial DF gradient, with DF
highest at the PV/LA junction, intermediate at the
coronary sinus and lowest in the RA
• In patients with persistent AFib there are no
significant differences between DF recorded from
the LA/PV junction, CS, and RA
• These findings suggest that in induced paroxysmal
AFib, the posterior LA may serve an important role
in maintaining AFib
Lazar S, et al. Circulation (2004) 110: 3181
Ablation of Sites of Dominant
Frequency Activation using Spectral
Analysis
Spectral Analysis Identifies Sites of HighFrequency Activity Maintaining Atrial
Fibrillation in Humans
Sanders, P, Berenfeld, O, Hocini, M, et al.
Circulation (2005) 112: 789
• Electroanatomic mapping performed in 32 patients with
5-second electrograms obtained at each point to
determine the highest-amplitude frequency on spectral
analysis and to construct 3D dominant frequency (DF)
maps
• Ablation was performed with the operator blinded to
the DF maps to determine the effect of ablation at sites
with or without high-frequency DF sites
Ablation of Sites of Dominant
Frequency Activation using Spectral
Analysis
A: DF map in patient with
paroxysmal AFib (6 hours). Note
DF sites in each PV.
B: DF map in patient with
permanent AFib (24 months).
Maximal DF and atrial frequency
are higher than in patient in A. In
addition, many DF sites are
located outside PVs.
reproduced with permission, Sanders P, et al. Circulation (2005) 112: 789
Ablation of Sites of Dominant Frequency
Activation using Spectral Analysis
Greater clustering of DF sites seen in paroxysmal AFib
Paroxysmal AF
Permanent AF
Anterior
Anterior
MV
TV
MV
LAA
TV
LAA
RAA
RAA
SVC
CS
SVC
CS
IVC
Posterior
IVC
Posterior
adapted with permission, Sanders P, et al. Circulation (2005) 112: 789
Ablation of DF Sites using Spectral
Analysis: Results and Conclusions
• The spatial distribution of the DF sites was different
in patients with paroxysmal and permanent AFib
– In patients with paroxysmal AFib, the DF sources of activity
are often localized to the PVs. In contrast, patients with
permanent AFib demonstrate DF sites that are more often
localized to the atria, including RA sites
• Ablation at these DF sites resulted in a significant
slowing of the fibrillatory process and termination of
sustained AFib in 87% of patients with paroxysmal
AFib, confirming the role of localized sites of high
frequency in the maintenance of AF
• All patients with persisting AFib had additional DF
sites outside the ablated zones
Sanders P, et al. Circulation (2005) 112: 789
2004: Ostial or Circumferential or
Antral PV Ablation plus Extra Lines
• In addition to PV isolation, other investigators
have shown that extra ablation lines may further
improve results
- Mitral isthmus (Jaïs 2004)
- LA roof (Hocini 2005)
- Posterior wall
Jaïs P, et al. Circulation (2004) 110: 2996
2004: Ostial or Circumferential or
Antral PV Ablation plus Extra Lines
Technique and Results of Linear Ablation
at the Mitral Isthmus
Jaïs, P, Hocini, M, Hsu, L-F, et al.
Circulation (2004) 110: 2996
• Prospective, randomised study of mitral isthmus
ablation vs PV isolation alone
Linear Ablation at the Mitral Isthmus
Incomplete
block
Complete block
during CS
pacing
Completely
blocked mitral
isthmus
reproduced with permission, Jaïs P, et al. Circulation (2004) 110: 2996
Linear Ablation at the Mitral Isthmus
• Bidirectional isthmus block was confirmed by
demonstrating (1) a parallel corridor of double
potentials during CS pacing (2) an activation detour by
pacing either side of the line, and (3) differential
pacing techniques
• At 1 year after the last procedure, 87/100 patients with
mitral isthmus ablation and 69/100 without were
arrhythmia free without AADs
• Cardiac tamponade was noted in 4% of patients
Jaïs P, et al. Circulation (2004) 110: 2996
Linear Block at the Left Atrial Roof
Techniques, Evaluation, and Consequences
of Linear Block at the Left Atrial Roof in
Paroxysmal Atrial Fibrillation: A Prospective
Randomized Study
Hocini, M, Jaïs, P, Sanders, P, et al.
Circulation (2005) 112: 3688
• Prospective, randomised study of roofline ablation
vs PV isolation alone in 90 patients with
paroxysmal AFib
• Roofline ablation joining the 2 superior PVs
Linear Block at the Left
Atrial Roof
I
II
1
2
3
III
4
RSPV
Map
LSPV
1
RIPV
LIPV
V1
2
3
4
adapted with permission, Hocini M, et al. Circulation (2005) 112: 3688
Linear Block at the Left Atrial Roof
• Roofline ablation resulted in a significant increase in the
fibrillatory cycle length and non-inducibility of AFib
• At 15+4 months, 87% of the roofline group and 69%
with PV isolation alone were AFib-free without AADs
• Linear block of the LA roof may prolong the fibrillatory
cycle and terminate AFib, and may be associated with
better clinical outcome compared to PV isolation alone
Hocini M, et al. Circulation (2005) 112: 3688
2004: Adjunctive PV Denervation
during Circumferential PV Ablation
Pulmonary Vein Denervation Enhances
Long-Term Benefit After Circumferential
Ablation for Paroxysmal Atrial Fibrillation
Pappone, C, Santinelli, V, Manguso, F, et al.
Circulation (2004) 109: 327
• Ablation of all evoked vagal reflexes around all PV
ostia (complete vagal denervation)
2004: Adjunctive PV Denervation
during Circumferential PV Ablation
Vagal reflexes
evoked (blue
dots)
reproduced with permission, Pappone C, et al. Circulation (2004) 109: 327
Adjunctive PV denervation During
Circumferential PV Ablation
• Pre- and post-ablation voltage maps
vagal reflexes
abolished after
ablation
reproduced with permission, Pappone C, et al. Circulation (2004) 109: 327
Adjunctive PV Denervation During
Circumferential PV Ablation
Cumulative proportion
of patients
1.0
0.8
Vagal reflexes
No vagal reflexes
0.6
0.4
0.2
0
Log-rank p=0.0002
0
2
6
8
10
12
AFib Recurrence (months)
# at risk
Vagal reflexes
No vagal
reflexes
4
102
101
101
101
101
101
101
195
166
166
166
166
166
166
Pappone C, et al. Circulation (2004) 109: 327
Adjunctive PV Denervation: Results and
Conclusions
• In 297 patients undergoing circumferential PV
ablation for paroxysmal AFib complete vagal
denervation was achieved in 34.3% of cases
• Patients undergoing complete vagal denervation
were less likely to have recurrence of AFib
• Only the percentage area of left atrial isolation and
complete vagal denervation were predictors of AFib
recurrence
Pappone C, et al. Circulation (2004) 109: 327
A Combination of Techniques may be
used Depending on the Type of AFib
AFib
Trigger Ectopic Foci
PV & non-PV Foci
Ablation,
PV Isolation
Autonomic
Nervous
System
Vagal
Denervation
(parasympathetic
ganglia ablation)
Substrate Atrial tissue
CFAEs Ablation
Linear Lesions
(e.g. mitral isthmus,
roof)
Tailored Approach to Catheter
Ablation
A Tailored Approach to Catheter Ablation
of Paroxysmal Atrial Fibrillation
Oral, H, Chugh, A, Good, E, et al.
Circulation (2006) 113: 1824
• This study determined the feasibility of a tailored
catheter ablation strategy guided by the
electrophysiological characteristics of AFib, without
the use of a standardized lesion set (PV isolation
and/or encirclement with or without additional
ablation lines)
• Primary end point was absence of frequent atrial
ectopy and spontaneous AFib during isoproterenol
infusion and non-inducibility of AFib
Tailored Approach to Catheter
Ablation
• Tailored ablation - after encircling of the right-sided
pulmonary veins, left atrial ablation was performed to
target high-frequency and/or complex electrograms.
reproduced with permission, Oral H, et al. Circulation (2006) 113: 1824
Tailored Approach to Catheter Ablation:
Results and Conclusions
• During follow-up, left atrial flutter developed in
19% of patients and was still present in 10% at 12
weeks of follow-up
• A repeat ablation procedure was performed in 18%
of patients
• During a mean follow-up of 11+4 months, 77% of
patients were free from AFib and/or atrial flutter
without AADs
• Acute non-inducibility of AFib after ablation was
associated with a better clinical outcome than in
patients left with inducible AFib
Oral H, et al. Circulation (2006) 113: 1824
Tailored Approach to Catheter
Ablation
Long-term Evaluation of Atrial Fibrillation
Guided by Noninducibility
Jaïs, P, Hocini, M, Sanders, P, et al.
Heart Rhythm (2006) 3: 140
• Evaluated a step-wise approach to achieve non-
inducibility of AFib
• 74 patients with paroxysmal AFib underwent PV
isolation, if still inducible one or two additional
linear lesions were placed at the mitral isthmus or
LA roof
Tailored Approach
to Catheter Ablation
Step 1
Inducible or persisting
arrhythmia after step 1 ?
Yes
No: stop
Step 2
Inducible or persisting
arrhythmia after step 2 ?
Yes
or
No: stop
Step 3
adapted from Jaïs P, et al. Heart Rhythm (2006) 3: 140
Tailored Approach to Catheter Ablation:
Results and Conclusions
• In 42 patients (57%), PV isolation restored SR and
AFib was non-inducible
• In the remaining 32 patients, a single linear lesion
achieved non-inducibility in 20 patients
• An additional linear lesion was required in 12
patients, with 10 remaining non-inducible
• At 18+4 months follow-up, 91% of patients were
free from AFib without AADs
Jaïs P, et al. Heart Rhythm (2006) 3: 140
3. Technological Aspects
Technological Aspects of Catheter
Ablation
• Ablation catheters
• Energy sources
• Mapping catheters
• Electrophysiological mapping systems
• Cardiac imaging technologies
3. Technological Aspects
Ablation catheters and energy
sources
Ablation Catheters
• Non-irrigated tip catheters
– 4mm and 8mm
• Irrigated tip catheters
– open shower, chilled
• Balloon catheters
– ultrasound, laser
Ablation Catheters
• Irrigated RF catheters
– Permit use of higher radiofrequency energy
– Ablation temperatures reduced
– Char formation minimized
Light Ring Inflatable Balloon Catheter
Energy Sources
• Radiofrequency
– Most common source
• Cryoablation
• Ultrasound
• Laser
• Microwave
3. Technological Aspects
Mapping catheters
Special Mapping Catheters
• Circular multi-electrode mapping catheter
(LASSO® Catheter)
• Other multi-electrode mapping catheters
– BASKET, MESH, PENTARAY™ Catheter
Circular Mapping Catheter (LASSO®
Catheter)
Precise mapping of potentials and exit sites at PVs
Fully
Contracted
15 mm
Fully
Expanded
25 mm
RSPV mapping
10
9
1
8
2
3
7
6
5
4
LSPV mapping
1
2
3
4
10
9
5
8
7
6
High Density Multi-Electrode Mapping
Catheter (PENTARAY™ Catheter)
• 5 radiating spines (markers on spine A and B)
• 20 localized electrodes
• Central irrigation lumen
E
A
D
A
B
C
B
3. Technological Aspects
Electrophysiological mapping
systems
Electrophysiological Mapping Systems
• 3D-electroanatomic mapping
– CARTO™ System / CARTOMERGE™ Image Integration Software
Module
• Robotic magnetic navigation
– Stereotaxis
CARTO™ System
– Localization of catheter to within 1 mm
– Increase safety margin during ablation
Anatomic Maps Using CARTO™
System
• 3D-electroanatomic maps (CARTO™ System) showing
ablation points encircling PVs
Circumferential Electroanatomical
Ablation around PV Ostia
• 3D-electroanatomic maps (CARTO™ System) showing
pre- and post-ablation electrical activity
• Endpoint is complete electrical isolation of left atrium
Pre-ablation
Post-ablation
Point by point
RF lesions
Delayed
activation
reproduced with permission, Pappone C, et al. Circulation (2001) 104: 2539