Transcript AF ablation

AF ablation with 3D mapping:
our technique and results
Dr Dhiraj Gupta MRCP MD DM
Liverpool Heart and Chest Hospital
Northern UK AF experts Best Practice meeting
Langdale Hotel, Cumbria 5 Feb 2010
Schema
Our approach to AF ablation at LHCH
Our reasons for each step
Our in-lab and follow-up results
Our approach in a nutshell
• PVAI with Wide area circumferential ablation
• CT image integration using CARTO
• Individualised lesion set prescription
• Aim to ablate out of AF, ideally to SR
• Procedure duration limit of 5 hours
CT image registration
• Critical part of the process
• 2 steps
• Single point Landmark registration
• Surface Registration with Fast Anatomical Mapping
• Takes 5-10 minutes
CT image segmentation
Fast Anatomical Map creation
Image Surface registration
Why the individualised approach?
• Heterogeneity amongst AF population
• Trigger removal vs Substrate Modification
• Aim to achieve high single procedure success rates
• Incremental risk with multiple procedures
• That’s what the patient wants
• That’s what the health economists want!
Patient selection criteria
• Patients not offered Catheter ablation if
• Very long standing Persistent AF (>3 years)
• Very large LA (>5.5 cm)
• Morbid Obesity (BMI >40), Sleep Apnea
• Significant RA dilatation (>LA)
• Patients not offered first redo at least for 6 months
• Not offered Second redo if still in PsAF
Not all AF patients are the same
• True PAF
• Short lived episodes, short history, normal sized LA
• Sustained PAF: 2 or more of the following
•
AF episodes>24 hours, History of AF > 5 years, LA size
>4.5 cm, Age >65 years, Documented flutter, High AF
burden (most days)
• Persistent AF
• Long standing Persistent AF (>12 months)
Minimum RF Lesion set
• True PAF
• PVAI using WACA
• Sustained PAF
•
+ LA roof line + RA flutter line
• Persistent AF
• + LA floor line + Mitral isthmus line
• Long standing Persistent AF
•
+ Epicardial CS ablation+ CAFÉ ablation
Paroxysmal PAF
Sustained PAF
Persistent AF
Long standing Persistent AF
Surgical Maze for ‘Permanent AF’
•Still the Gold
standard in terms of
results
•96% free of AF at 5
years*
* SM Prasad et al, J Thorac Cardiovasc Surg 2003; 126: 1822-27
Results with ‘Catheter Maze’
N
Redo
AAD therapy
Results
Complications
Haissaguerre
JCE 2005
60
1/2
Stopped at
ablation
95% at 11
months
2 Tamponades
Oral
NEJM 2006
77
1/3
Amio 6/52 pre & 77% at 1
3/12 post
year
0
Postch
Circ 2008
88
1/2
Stopped at
ablation
81% at 20
months
2 Tamponades
1 TIA
Lo
JCE 2009
87
1/4
AAD for 2/12
post
79% at 21
months
1 Tamponade
Why CT image integration?
• Forewarned is forearmed: PV anatomical variations
• Common Left Pulmonary Vein
• Additional pulmonary vein(s)
• Important anatomical information
• thickness of the LAA ridge, intervenous carina
• extent of the PV antra
• length of the mitral isthmus
Why CT image integration?
• Dramatically reduces procedural fluoro times:
•
<10 minutes for PAF cases
• 10-20 minutes for PsAF cases
• Decreases fatigue
• Removes ‘the fear of the unknown’…..
• Demystifies AF ablation for the nurses/ radiographers!
Why CARTO rather than ESI?
• Unmatched catheter stability
• no catheter ‘dive’ with onset of RF delivery
• Allows linear lesions
• No need for stable intracardiac reference
• Ability to perform activation mapping if needed
• Great CT image integration software
Advances with CARTO-3
• Hybrid of impedance and magnetic catheter location
• Ability to see all catheters
• Ability to create fast anatomical maps
• Makes CT image integration easier
• More streamlined patient set-up
Why WACA?
• PV ostial/ antral triggers
• Substrate modification by Atrial debulking
• Less risk of PV stenosis
• Quicker than segmental PVI
• Easy to anchor linear lesions on either side
• ‘Et tu, Bordeaux?!’
Why our RF settings?
• Continuous RF: 35 W, 50°C, 10 ml/ min flow
• Quicker signal obliteration than 30/25 W
• Short procedure time (20-30’ per WACA)
• Prevents peri-lesion edema (?
reconnection risk)
• RF controlled by Foot pedal
• Frees up a cardiac physiologist
• Imposes discipline on use of X-ray pedal!
Our results
131 consecutive pts. between Jan 08-July 09
Individualised ablation strategy
• True PAF (n=45)
• PVAI using WACA
• Sustained PAF (n=31)
• + LA roof line+ RA flutter line
• Ps AF (n=22)
• + LA floor line+ Mitral isthmus line
• Long standing Ps AF (n=33)
•
+ Epicardial CS ablation+ CAFÉ ablation
In-lab results
• All patients received prescribed minimum lesion set
• Mean Procedure time 173 min (98-300)
• Fluoroscopy times
• Mean 26.5 min (13-58) (as pre-CARTO 3 era)
• Now with CARTO-3 (n=36): Mean 14 min (6-21)
• Complications
• 1 tamponade (PVI group), 1 AV fistula
Our follow-up strategy
• Antiarrhythmic drug therapy for 2-3 months
• Early post-op arrhythmias
• DC CV if sustained and poorly tolerated (n=1)
• No redo ablation procedure for at least 6 months
• Mean follow up 11.3 months (6-24)
Our Clinical Results
• Definition of Procedural Success:
• No symptoms beyond 3 months, AND
• Absence of AF/AT on 24 hour Holter at 6 mo
• Single procedure success rates at 6 months
• PAF 84%
• PsAF 86%
• Sustained PAF 77% (p=0.05)
• Long standing PsAF 64% (p<0.001)
Conclusions
• Single procedure success should be the goal
• Most patients need substrate modification in addition
to trigger removal
• This needs application of linear lesions
• 3D mapping guided ablation the gold standard
Acknowledgements to Dr Richard Schilling, my mentor and guide
Thank You
www.heartrhythmspecialist.co.uk