Catheter Ablation – Top 5 New Things Clinicians Should Know

Suneet Mittal, MDDirector, Electrophysiology

Medical Director, Snyder Center for Atrial FibrillationValley Health System

www.valleymedicalgroup.com/EP

February 8, 2019@drsuneet

Suneet Mittal, MD

• Disclosure: Consultant to Abbott, Boston Scientific, Medtronic, SentreHeart

Case Presentation• 19-year old male complained of recurrent palpitations

– Twice yearly for past 4 years, worse during periods of emotional stress (e.g., exams)

– Last 15-20 minutes– Associated with near-syncope

• Cardiac evaluation unremarkable– ECG– Echocardiogram– 24-hour Holter

• Diagnosis: anxiety / panic attacks

ECG Monitoring Tools

Holter

HolterMonitoring(1-2 days)

Mobile Telemetry

Monitoring(Up to 30 days)

LeadBased

(e.g., multiple; Telesense)

Patch Based Biotelemetry – MCOT Patch

Lifewatch – ECG mini

Medicomp – TelePatch

Medtronic – SEEQ

Nuubo - nECG

Preventice – Body Guardian

Lead Based (2-Piece) Applied Cardiac Systems –

CORE

Biomedsys – TruVue

Infobionic – MoMe Kardia

Lifewatch – ACT Elite

Medicomp – Duet

Lead Based (1-Piece) Scottcare– TeleSense,

TeleSentry

Spectacor – Pocket ECG

TeleRhythmics – HeartrakTCAT

HolterMonitoring(1-2 weeks)

LeadBased

(e.g., CardioKey)(e.g., Zio) (e.g., ePatch)

Patch Based

GarmentBased

(e.g., nECG)

Mittal S et al. JACC 2011; 58: 1741-1749; Mittal S. CIR 2017; 25: 12-16; Lee RJ, Mittal S. Heart Rhythm 2018

(e.g., SEEQ, Body Guardian)

Patch Based

Implantable Loop Recorder(Up to 3 years)

Smartphone(e.g., Alivecor)

EventRecorder

Spot Single-Lead ECG

Check

Smartwatch(e.g., Kardiaband)

Embrace New Technology

• Cheap• Owned by the patient• Real time• Long term• High fidelity recordings• No intermediary between

patient and doctor

Diagnosis

Several months later, while running to catch a bus…SVT at 240 bpm!!!

Case Presentation• 68-year old male with hypertension and diabetes who was well

until 2 years ago when he developed atrial flutter in the setting of pneumonia– CHA2DS2-VASc score = 3– Echocardiogram = normal– Spontaneously converted to sinus

• Anticoagulation stopped after a month• He presented for a routine annual physical examination and

was found to have recurrent typical flutter– Echocardiogram = EF 45%

Audience Response

• In the first year following (chemical or electrical) cardioversion for typical atrial flutter, what proportion of patients would be expected to have recurrent atrial flutter?1. 10%2. 35%3. 65%4. 100%

Atrial Flutter: Universal Recurrence

Babaev A et al.Am J Cardiol 2003;

92: 1122-1124

Natural History of 53 Atrial Flutter Patients Following Restoration

of Sinus Rhythm

Treatment of Atrial Flutter

http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2015.08.856

Rate control

Treatment strategy

Rhythm control*

Beta blockers, diltiazem, or verapamil(Class I)

Amiodarone, dofetilide, or

sotalol (Class IIa)

Catheter ablation(Class I)

Atrial flutter

Flecainide or propafenone

(in the absence of SHD)†(Class IIb)

If ineffective

Options to consider

Audience Response

• The patient undergoes successful ablation of the cavotricuspid isthmus. He returns a month later and an ECG shows sinus rhythm. Should anticoagulation be continued?

1. Yes2. No

AF Following Flutter Ablation

Musat DL et al. EHRA 2018

At least 1 episode of AF occurred in most patients (84%), mostly commonly in first 6 months of CTI ablation

In about 60% of patients, all AF episodes are < 24 hours in duration.

Studies underway to determine

Anticoagulation management

AF progression

Role of concomitant AF ablation at time of CTI ablation

31 consecutive patients who underwent CTI ablation Paroxysmal or persistent atrial flutter No prior history of AF CHA2DS2-VASc score ≥ 2 Had a Medtronic LINQ™ ILR implanted

Catheter Ablation of Atrial FibrillationAsymptomatic Paroxysmal or Persistent AF

Class IIb

”A decision to perform AF ablation in an asymptomatic patient requires additional

discussion with the patient because the potential benefits of the procedure for the patient without

symptoms are uncertain.

HRS/EHRA/ECAS Recommendations Regarding Ablation Techniques

• Ablation strategies that target the PVs and/or PV antrum are the cornerstone of most AF ablation procedures

Catheter Ablation of Atrial Fibrillation

Heart Rhythm 2017;14: e-275-444

Balloons for PAF Ablation

Image from Dr. Dhiraj Gupta, UK

Balloons for PAF Ablation

Image from Dr. Dhiraj Gupta, UK

HRS/EHRA/ECAS Recommendations Regarding Ablation Techniques

• Ablation strategies that target the PVs and/or PV antrum are the cornerstone of most AF ablation procedures

• However, due to the high recurrence rate observed in patients with persistent and long standing persistent AF with PVI alone, continued efforts are underway to identify additive strategies to improve outcome

Additive Ablative StrategiesAnatomic

• Left atrial appendage• Fibrosis• Ganglionated plexi• Linear lesions

– Left atrial roof– Mitral isthmus

• Posterior left atrial wall– Endocardial– Epicardial

• Superior vena cava

Electrophysiologic• CFAEs• Non-PV triggers• Rotors• Spatiotemporal

electrogram dispersion

The aMaze Trial

Primary Effectiveness Endpoint

Freedom from episodes of AF > 30 seconds with no requirement for new Class I or III AAD therapy at 12 months post PVI, as measured by 24-hr Holter or symptomatic event monitoring

Primary SafetyEndpoint The incidence of significant LARIAT device or procedure-related

SAEs occurring within 30 days after the LAA ligation procedure

Cardiac MRI

Marrouche NF et al.JAMA 2014 311; 498-506

Cardiac MRI

Marrouche NF et al.JAMA 2014 311; 498-506

Case Presentation• 73-year old male with hypertension, diabetes, and coronary

artery disease (s/p infero-posterior MI; s/p CABG 2004• April 2013; NSVT; EF 29%; negative exercise stress test

– Single chamber ICD implanted for primary prevention of sudden death

• June 2017: VT storm– Amiodarone started and maintained at 200 mg daily

• March 2018: recurrent sustained VT

Audience Response

• What would you recommend next?

1. Increase dose of amiodarone2. Add a second antiarrhythmic drug, such

as mexilitene3. Catheter ablation4. Bilateral cervical sympathectomy

VT Ablation Better Than Drugs

Median non-invasive ablation

time was 15 minutes!!!