Transcript New methods and technique in catheter ablation of atrial

New methods and techniques in
catheter ablation of atrial fibrillation
Yong-Mei Cha, MD
Mayo Clinic
NCF
Shenyang, 2014
©2012 MFMER | slide-1
Patient selection for cryoablation
• Patients with symptomatic AF
• FDA has approved cryoballoon catheter for patients with
paroxysmal AF
• Off-label use cryoballoon for patients with persistent AF
©2012 MFMER | slide-2
Cryoballoon ablation
Hypothermic
Zone
Ablation Zone
(sub-zero)
• Ablates at the point of balloon contact
• Ice formation and thawing
• Apoptosis
• Necrosis
©2012 MFMER | slide-3
How Arctic Front® Balloon Catheter
and AchieveTM Work
1. Access
targeted vein
2. Inflate and
position
3. Occlude and
ablate (4min)
4. Assess PV
isolation
4
©2012 MFMER | slide-4
LIPV cryo-balloon isolation
©2012 MFMER | slide-5
Before balloon inflation
©2012 MFMER | slide-6
Pre-cryo
Post-cryo
Adenosine
©2012 MFMER | slide-7
European Clinical Study Results
Neumann
Van Belle
Kojodjojo
Prospective study
Prospective study
Prospective study
PAF, n=293
Persistent , n=53
PAF, n=141
PAF, n=90
Persistent, n=34
PAF: 74% off AAD at 1y,
Persistent, 43%
73% off AAD at 1 year
77% off AAD at 13m
7.5% Phrenic nerve palsy;
all recovered at < 1 year
2.8% phrenic nerve
palsy; all resolved within
6 months
1.8% transient phrenic
nerve palsy
No PV stenosis
No PV stenosis
0.8% pericardial effusion
Neumann T, et al. J Am Coll Cardiol. 2008;52:273-278.
Van Belle Y, et al. Europace. 2008;10:1271-1276.
Kojodjojo P, et al. Heart. 2010;96:1379-1384.
©2012 MFMER | slide-8
KM free from AF
Free from AF (%)
100
75
50
Conventional
Cryo
25
0
0
3
6
9
12
15
18
Months
Months after ablation
Cryoablation
Radiofrequency ablation
0
90
53
6
79
42
12
69
33
18
26
12
Koiodioio Heart 2010
©2012 MFMER | slide-9
CARTO® SMARTTOUCH™ 3D Technology
• Catheter‐tissue contact is critical for effective lesion creation
• Ablating with consistent power, increase in contact force: Increases
lesion size, Increases incidence of steam pop/perforations
LOCATION SENSOR*
Detects micro-movement
of transmitter coil
TRANSMITTER COIL
Sends location reference signal
PRECISION SPRING*
Provides consistent
movement in response
to contact force
©2012 MFMER | slide-10
Below Threshold
<5g
Within Threshold
5-30g
Above Threshold
>30g
©2012 MFMER | slide-11
CARTO®SMARTTOUCH™ Technology
• Allows to monitor the stability,
consistency, and amount of contact
force on the tissue
• Based on user defined parameters,
display ablation data including:
Total Time
Impedance
Temperature
Power
Force Over Time (NEW)
Average Force (NEW)
Force Time Integral: is a
calculation of force and time,
in gram seconds
©2012 MFMER | slide-12
Minimal contact
and time
Increased
contact and time
Maximal contact
and time
©2012 MFMER | slide-13
Contact Force Sensing for Pulmonary Vein
Isolation in Paroxysmal AF
• Randomized study
CF group
• SmartTouch Thermocool n=30
Control group
• Thermocool n=30
• Complete PVI in all patients
• Fluoro time 20 min vs 27 min
• RF time 45 min vs 65 min
P=0.04
• AF recurrence
• Contact force 10.5%
• Noncontact force 35.9%
At risk
(no.)
CF
Control
Days
0
30
30
3-mo
30
30
6-mo
29
25
9-mo
28
22
12-mo
27
21
Marijon: JCE, 2014
©2012 MFMER | slide-14
nMARQ™ Multi-Ablation Technology
• Combining multi-ablation capability with
irrigation technology
• Uniform irrigation at the site of tissue
contact. Each nMARQ™ Catheter boasts
10 irrigation holes per electrode
completely surrounding the electrodes for
more efficient cooling
• Multi-electrode Mapping (MEM) allows you
to acquire multiple mapping points
simultaneously
• Ablate with any or all of the 10 catheter
electrodes
• The nMARQ™ Technology enables full
visualization of the catheter loop and
electrodes
©2012 MFMER | slide-15
Comparison of different ablation technologies
used for PVI in treatment of paroxysmal AF
Technology
Acute
success (%)
Procedure
time (min)
Fluoroscopy
n
time (min)
Conventional
RF ablation
97.6
165
24
2870
Cryoballoon
ablation
97.5
160
34
905
Visually guided
laser ablation
98.8
200
31
200
PVAC
100
133
30
89
nMARQ
catheter
100
110
23
25
Shin DI, Heart Rhythm. 2014
©2012 MFMER | slide-16
The Rhythmia™ Mapping System
• Highly accurate hybrid electroanatomical mapping system
provides an optimal blend of magnetic and impedance
technologies, accuracy ≤ 1-2mm
• Continuous mapping – No point-by-point acquisition
collecting thousands of points
• Eliminate need for time consuming manual annotations
• Superior resolution & signal quality
• Clearly assess gaps and lesions
©2012 MFMER | slide-17
IntellaMap Orion™ High-Resolution Mapping Catheter
• Open basket 64 low-noise
electrodes
• 2.5 mm inter-electrode spacing
192 intracardiac channels +
Surface ECG
• 8.5F, bi-directional steerability
• 8 smooth, flexible splines,
variable diameter (3-22mm) for
use in various anatomical
structures
• Flushing port designed to prevent
clot formation
• Potential lasso alternative during
PVI
©2012 MFMER | slide-18
Carto System
Rhythmia Medical System
• Physician accepts each point in manual
process
• 30 minutes: 276 usable points
• Proprietary algorithm sorts inputs from
64-pole basket in real time
• 10 minutes: 3,689 usable points
©2012 MFMER | slide-19
Find the gap
Source: Nakagawa H, Rapid high resolution electroanatomical mapping: evaluation
of a new system in a canine atrial linear lesion model. Circulation Arrhythmia Electrophysiology. 2012 Apr;5(2):417-24
©2012 MFMER | slide-20
Left Atrial Activation Map During AT
59M, Prior Ablation of AFx4
V3
Channel/gap
CS
Bip1-2
Double potential
Fractionated
Uni 1
Uni 2
©2012 MFMER | slide-21
Topera’s RhythmView™
3D Electrophysiological Mapping System
• Multi-polar FIRMap™ catheter
• Single beat mapping of the whole heart
chamber all at once
• Advanced signal processing algorithms
• Self referenced map
• Rapidly analyze of the arrhythmia
64 evenly-spaced electrodes
©2012 MFMER | slide-22
Treatment of Atrial Fibrillation by the Ablation of
Localized Sources: CONFIRM Trial
Right Atrial Rotor,
Left Atrial Focal Beat in AF
FIRM: Sinus Rhythm in 5.5 minutes
Narayan et al: JACC 60:628, 2012
©2012 MFMER | slide-23
Treatment of Atrial Fibrillation by the Ablation of
Localized Sources: CONFIRM Trial
Freedom from Atrial Fibrillation
• 92 patients with paroxysmal or
persistent AF
• AF termination 86% vs 20%
• After single procedure
• AF free 82% vs 45%
• Mean follow-up 9 months
P=0.016 1st ablation
P=0.006 all cases
Event-free survival
• Randomized to
• FIRM guided + conventional
• Conventional only
Entire Population
FIRM-blind
FIRM-guided
FIRM-blind, 1st ablation
FIRM-guided, 1st ablation
Population Off Anti-Arrhythmic Meds
P=0.015 1st ablation
P=0.003 all cases
Days
Narayan et al: JACC 60:628, 2012
©2012 MFMER | slide-24
Summary
•
Both cryoballoon and RF ablation are effective
technology for pulmonary vein isolation in patients with
symptomatic AF
•
RF ablation with contact force sensing and multielectrodes ablation may improve RF ablation outcome,
shorten procedure time and reduce complications
•
Newer 3D mapping system will increase mapping
efficiency (more accuracy, higher resolution/quality,
shorter time…) to facilitate ablative therapy
©2012 MFMER | slide-25
Mayo Clinic
©2012 MFMER | slide-26
CARTOUNIVU™ Module Concept
• Integration of Fluoroscopy images into the CARTO® 3 System
• Reducing fluoroscopy exposure
• Serve as virtual biplane fluoro monitor
• track vessel course during Complex EP procedures (AO root, congenital, CS)
• Assist in delineating PV Ostia
©2012 MFMER | slide-27
Pace Mapping Software (PASO)
1.
2.
3.
Objectively and efficiently compares the 12 lead PVC/VT ECG
morphology and the Pace Map
Calculates the correlation value
Displays appropriate tag and color to the map
Clinical VT
Pace Map (PM)
VT-PM Matching
©2012 MFMER | slide-28
RVOT Pace Mapping (PaSo)
QRS
match 64%
©2012 MFMER | slide-29
LVOT Left Aortic Cusp Pace Mapping (PaSo)
QRS
match 98%
©2012 MFMER | slide-30
Acute Termination of Human AF by Identification and Catheter
Ablation of Localized Rotors and Sources: 1st Multicenter
Experience of Focal Impulse and Rotor Modulation Ablation
2 Rotors and
1 Focal Source in AF
FIRM at Rotors, Focal Beat
(<10 min) Terminates AF
Shivkumar et al: JCE 23(12):1277, 2012
©2012 MFMER | slide-31