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AF Ablation: How has the Technique and Technology developed ?

AF Ablation: How has the Technique and Technology developed ?. Professeur Dipen Shah Responsable de l’Unité d’électrophysiologie, Hopital Cantonal de Geneve, Geneve. 7 th International Congress of Egyptian Cardiac Rhythm Association 15 th -17 th December 2010, Cairo.

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AF Ablation: How has the Technique and Technology developed ?

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  1. AF Ablation: How has the Technique and Technologydeveloped? Professeur Dipen Shah Responsable de l’Unité d’électrophysiologie, Hopital Cantonal de Geneve, Geneve 7th International Congress of Egyptian Cardiac Rhythm Association 15th-17th December 2010, Cairo

  2. Architecture of the junction between pulmonary veins and the left atrium:lessons for radiofrequency ablation 60y Male 60y Male 80y Female 25 year Male Left upper Left upper Left upper Left Right Left lower Left lower Left lower Common vein Isthmus between veins at veno-atrial junction Ho SY et al, Heart 2001

  3. PV Ablation Options • Sequential point by point ablation • Simple • Individual optimisation of lesion delivery possible • Obligatorily time consuming • Finite irreducible rate of gap occurrence • Circular lesion making devices • Unfamiliar, more complex design • Difficult to optimise contact/to generate consistent lesions • Still do not achieve rapid, one-shot • isolation

  4. Zheng et al, Journal of Interventional Cardiac Electrophysiology 5, 401–410, 2001

  5. Linear Ablation Technologies PV ablation times: segmental PVI: 35+15 min Hocini et al. and CPVA: 37+11 min Oral et al. PVAC: Boersma et al. 27+7 min, & Scharf et al. 32+12 min

  6. Multi-electrode PVAC • Incomplete circular form resulting in suboptimal circular mapping • Combination of bipolar and unipolar RF difficult to titrate • Noise does not allow electrogram monitoring during RF • Uniform contact essential for bipolar RF efficacy but unknown • No irrigation: uncertain protection from char/coagulum • Ablation times similar to segmental PVI: no single shot ablation

  7. Pre-Cryo Post-Cryo Cryoballoon Ablation LSPV Location of conduction recovery at redo Image courtesy V. Reddy

  8. Cryo-Balloon Pacing Catheter in SVC • Cryo-ablation in circulating blood: time consuming and probably smaller lesions • PV anatomy oval not circular: single-shot ablation not frequent • Inferior PVs difficult to isolate • Significant risk of phrenic palsy • No immunity from esophageal damage Cryoballoon Catheter at RSPV ostium Image courtesy V. Reddy

  9. Visually-Guided Ablation Aiming Beam “Static” Blood in LSPV LIPV LAA

  10. In Vivo Visually-Guided A.Flutter Ablation V.Reddy / P.Neuzil (manuscript in preparation)

  11. 30W p =0.031 100 80 60 40 3/10 20 Lesion Volume vs. Contact Force 0/10 0/10 0/10 0/10 0 2 10 20 30 40 50W 30W 2000 2000 p <0.01 p <0.01 50W p =0.0026 1542 1500 1500 100 80 (mm3) 1186 8/10 1052 1000 1000 7/10 60 906 6/10 773 683 5/10 632 40 500 500 445 431 20 271 0/10 0 2 10 20 30 40 2 10 20 30 40 2 10 20 30 40 Contact Force (g) Contact Sensing Incidence of Steam Pop (%) (%) Contact Force (g) Yokoyama K, Nakagawa H, Shah D et al Circ Arrhythmia EP 2008

  12. 12 % of ablations donewithlow contact forces (< 5 g) 35% 30% 25% 20% %age of ablations done with contact force < 5g 15% 10% 5% 0% 32% 12% 12% Source: K-H Kuck, presentation Boston AF 2010

  13. Sheath assisted Perforation w/o sheath with sheath * * grams LV RV time time w/o sheath Peak Df/dt: LV perforation 736 ± 368 g/sec with sheath LV perforation time: 0.8±0.5s with sheath vs 3.2±3 s w/o, p<0.0001 239± 178 g/sec p = 0.0013 Shah D et al, Europace 2010

  14. Perforating Force thru’ RF lesions 300±116g 172±79g n= 23 n= 21 p<0.002 Shah D et al, Europace 2010

  15. Remote Navigation Systems • Magnetic Navigation: Fixed Magnets (Stereotaxis) • Magnetic Navigation: Electro-Magnets (Magnetecs) • Robotic Navigation (Hansen Medical) Fixed Magnetic Nav Robotic Nav Electro-Magnetic Nav

  16. Arya et al, Europace 2010 e-pub

  17. robotic arm 3D mouse Sensei™ Robotic Catheter System

  18. Electromechanic Navigation Atrial fibrillation ablation • Wazni et al, JCE 2009 • 71 patients undergoing PV antral isolation • 5 vascular complications • 3 tamponade • 5 severe PV stenosis • 1 gastroparesis • 4/4 pts with esophageal ulceration at endoscopy on the post-ablation day • 1/4 pts developed esophageal fistula formation necessitating stenting • 34 of 40 pts off anti-arrhythmic drugs and „free from atrial arrhythmia“ 85% • 5 pts still on anti-arrhythmic medication • 2 pts with perforations/tamponade Saliba et al. JACC Vol. 51, No. 25, 2008:2407–11 Kuck KH, EHRA-Webinar AF ablation, March 2009

  19. Electro-mechanical Navigation • Point by point mapping and ablation: no reduction in procedure time • Extra –stiff sheath and poor contact force monitoring: higher risk of traumatic perforation and other complications • Single catheter control only • AF ablation poorly suited to automated, fully robotic procedure

  20. Technology for AF Ablation • New technology should simplify ablation • Shorten the procedure by reducing ablation times • Provide rapid and reliable endpoint verification • Result in durable, non-proarrhythmic lines of isolation • Should not increase complication risks Current standard of reference…

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