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Ablation of Persistent and Long Lasting Persistent Atrial Fibrillation

Ablation of Persistent and Long Lasting Persistent Atrial Fibrillation. John R Onufer MD FHRS . New Classification of Atrial Fibrillation. Paroxysmal (that which terminates spontaneously)

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Ablation of Persistent and Long Lasting Persistent Atrial Fibrillation

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  1. Ablation of Persistent and Long Lasting Persistent Atrial Fibrillation John R Onufer MD FHRS

  2. New Classification of Atrial Fibrillation • Paroxysmal (that which terminates spontaneously) • Persistent Sustained > 7 days, or lasting < 7 days but requires pharmacologic or electrical cardioversion treatment • Long lasting persistent: That which may last longer than 7 days but plans to convert to nsr • Permanent No longer plan to return to NSR • (chronic afib is no longer a term)

  3. Stepwise approach • 1. PV isolation: PV isolation alone is a 50-20% Success (afib <1 year associated with higher success) • 2. Linear lesions with pv isolation (Willems: 69 vs 20% mean fu 487 days) • Roof between lspv and rspv • LIPV to Mitral annulus • TV-IVC

  4. Stepwise approach • 3. CFAEs: Definition variable • 120 msec. but not clearly associated with areas of scar. • Variable results • 4. Non Pulmonary Foci; • Ligament of Marshall • SVC • Mitral annulus • CS • Crista terminalis • LA posterior wall • LA appendage

  5. Bordeaux experience • 38% Drug free success at 20 months • 81% if perform multiple procedures • Termination of afib during ablation for persistent and long standing persistent afib predictive of higher success rate. • Critical to confirm pv isolation and Integrety of lines after conversion to nsr • 86% terminate to atach or aflutter (focal, macro reentrant, localized reentry)

  6. Cost of More Extensive procedures • Higher complication rate • Longer procedure times • Higher rate of post procedure atrial tachycardias • Longer fluro times

  7. Patient Selection • Higher rates of recurrance: • LA size greater than 4.3 cm • Pulmonary disease • Duration of afib • Valvular heart disease

  8. Hybrid Afib ablation

  9. HrsGuidelines • Careful identification of the PV ostia is mandatory to avoid ablation within the PVs. • If a focal trigger is identified outside a PV at the time of an AF ablation procedure, ablation of that focal trigger should be considered. • If additional linear lesions are applied, operators should consider using mapping and pacing maneuvers to assess for line completeness. • Ablation of the cavotricuspid isthmus is recommended in patients with a history of typical atrial flutter or inducible cavotricuspid isthmus dependent atrial flutter.

  10. HRS Guidelines • If patients with long standing persistent AF are approached, operators should consider more extensive ablations based on linear lesions or complex fractionated electrograms • It is recommended that RF power be reduced when creating lesions along the posterior wall near the esophagus

  11. Summary:Ablation of Long lasting persistent atrial fibrillation • 1. Remains a challenge • 2. There is no uniform procedure • PV antral isolation superior to pv wide area encircling lesions with voltage abatement • CFAE ablation alone inferior to PVAI and linear lesions • No incremental benefit to right atrial CFAE ablation (routinely) • CFAE ablation may or may not provide incremental benefit when added to PVAI. • 3. Risk/Benefit for any patient has to be carefully considered • 4. Long term outcomes need to be evaluated in randomized trials

  12. Thank you

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