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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. Left atrial (LA) and pulmonary vein (PV) anatomy Catheter ablation techniques Technological issues Success rates Complication rates Cost-effectiveness

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Section III: Catheter Ablation for the Treatment of AFib

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  1. Section III:Catheter Ablation for the Treatment of AFib

  2. Section III. Catheter Ablation for the Treatment of AFib • Left atrial (LA) and pulmonary vein (PV) anatomy • Catheter ablation techniques • Technological issues • Success rates • Complication rates • Cost-effectiveness • Indications for catheter ablation • Centre experience

  3. 1. Left Atrial (LA) and Pulmonary Vein (PV) Anatomy

  4. Macroscopic Anatomy of the Myocardial Sleeves and the Pulmonary Veins and Sleeves PV PV PV Non-uniform PV sleeve PV Uniform PV sleeve

  5. Macroscopic Anatomy of the Myocardial Sleeves and the Pulmonary Veins Uniform sleeve Non-uniform sleeve Atrial-PV border reproduced with permission, Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888

  6. 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

  7. 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

  8. Length of Myocardial Sleeves in the 4 Pulmonary Veins * 16 * *p<0.01 14 * * * 12 10 Length of myocardialsleeves (mm) 8 6 4 2 0 LSPV RSPV LIPV RIPV Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888

  9. Schematic Representation of Superficial Myocardial Fibres of the LA SVC RA LA RSPV LSPV LLPV RIPV IVC adapted from Nathan H & Eliakim M Circulation (1966) 34: 412

  10. 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

  11. 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

  12. Myocardial Fibre Orientation in the LA and PV – Predominant Oblique Fibre Pattern SVC LA RSPV LSPV RIPV LIPV adapted from Nathan H & Eliakim M Circulation (1966) 34: 412

  13. Myocardial Fibre Orientation in the LAand PV – Mixed Fibre Pattern SVC LSPV RSPV RIPV LIPV adapted from Nathan H & Eliakim M Circulation (1966) 34: 412

  14. 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

  15. 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

  16. Typical & Atypical Branching Pattern of PV Anatomy A B C Typical Short Common Left Trunk Long Common Left Trunk AFibControl N=16N=18 N=7 (including 3 of D)N=5 (including 2 of D) N=2N=2 Right Middle PV Two Right Middle PVs Right Middle PVand Right “upper” PV D E F AFibControl N=4N=3 N=1 N=0 N=1N=1 adapted from Kato R et al. Circulation (2003) 107: 2004

  17. Anatomy of the Pulmonary Veins LA appendage RSPV LSPV RIPV LIPV Left PV Right 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

  18. Anatomy of the Pulmonary Veins PERMISSION TO USE PHOTO BEING REQUESTED Transverse section from above LA longitudinal section 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

  19. 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

  20. Pulmonary Vein Geometry PERMISSION TO USE PHOTO BEING REQUESTED Posterior View Inferior View LAO 45° Ostium of left lower PV Fluoroangiography Magnetic Resonance Angiography Wittkampf FH, et al. Circulation (2003) 107: 21

  21. Average Pulmonary Vein Ostium Diameters Maximum(mm) Minimum(mm) Range(mm) Projected(mm) n Ratio Dimensions of PV ostia measured with MRA. The ratio between maximal and minimal ostiumdiameters 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

  22. Parasympathetic Ganglia Fat pads

  23. Distribution of Autonomic Nerves at the PV-LA Junction Anteriorjunction Posteriorjunction AO SVC PA RS LS AnteriorLA PosteriorLA RI LI IVC VOM 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

  24. 3. Catheter Ablation Techniques From the first procedures to today

  25. Landmarks in Catheter Ablation Techniques and Success Rates Technique Publication date

  26. 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

  27. 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 3 Right atrium 2 T IVC adapted from Haïssaguerre M,et al. J Cardiovasc Electrophysiol (1994) 5: 1045

  28. 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 2 3 4 1 2 3 4 adapted from Haïssaguerre M, et al. J Cardiovasc Electrophysiol (1996) 7: 1132

  29. 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%)

  30. 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 Superiorvena cava Septum 25% 45% PulmonaryVeins Fossaovalis Inferiorvena cava 9% 16% Coronarysinus 94% reproduced with permission, Haïssaguerre M, et al.N Engl J Med (1998) 339: 659

  31. 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

  32. PV Foci Ablation: Results and Conclusions • Radiofrequency ablation of ectopic foci was associated witha 62% success rate (absence of recurrence at 8  6m follow-up) Haïssaguerre M, et al.N Engl J Med (1998) 339: 659

  33. 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

  34. Ostial PV Isolation Discharges from PV Atrial activation preceding PVP Local PV activity dissociated distally at a slow rate reproduced with permission, Haïssaguerre M, et al. Circulation (2000) 101: 1409

  35. 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

  36. 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

  37. Circumferential PV ablation Voltage maps Post-ablation Pre-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

  38. 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

  39. 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

  40. 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) MultipleAF Foci(%) LateRecurrence(%) Patients(n) Age(y) History(y) Other SHD(%) LA size(mm) Group SHD indicates structural heart disease Lin W, et al. Circulation (2003) 107: 3176

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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)

  46. Group 1 (n=56) Group 2 (n=107) Group 3 (n=152) Group 1 vs Group 3; p=0.009 Group 1 vs Group 2; p=0.08 Group 2 vs Group 3; p=0.08 PV Antrum Ablation: Results 100 90 80 70 Freedom from recurrent AF (%) 60 50 40 0 30 150 270 390 510 630 750 870 Follow-up (days) Marrouche NF, et al. Circulation (2003) 107: 2710

  47. PV Antrum Ablation: Results • Intracardiac echocardiography improves the outcomeof cooled-tip PV isolation 100 ICE (n=259) No ICE (n=56) 90 80 70 Freedom from recurrent AF (%) 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

  48. 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

  49. 2004: Double LASSO® Catheter Ablation reproduced with permission, Ouyang F, et al. Circulation (2004) 110: 2090

  50. 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

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