Section III:Catheter Ablation for the Treatment of AFib
Section III. Catheter Ablation for the Treatment of AFib
1. Left atrial (LA) and pulmonary vein (PV) anatomy
2. Catheter ablation techniques
3. Technological issues
4. Success rates
5. Complication rates
6. Cost-effectiveness
7. Indications for catheter ablation
8. Centre experience
1. Left Atrial (LA) and Pulmonary Vein (PV) Anatomy
Macroscopic Anatomy of the Myocardial Sleeves and the Pulmonary Veins and Sleeves
Uniform PV sleeve
Non-uniform PV sleeve
PV
PV
PV
PV
Macroscopic Anatomy of the Myocardial Sleeves and the Pulmonary Veins
reproduced with permission, Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
Non-uniform
sleeve
Uniform
sleeve
Atrial-PV border
Microscopic Anatomy of Pulmonary Veins
Myocardial sleeve
Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
Myocardial sleeve
Myocardial sleeve
PERMISSION TO USE PHOTO BEING REQUESTED
Transverse Section Perpendicular to the Axis of the Pulmonary Vein
Groups of myocardial
cells in different
orientations
Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
PERMISSION TO USE PHOTO BEING REQUESTED
Length of Myocardial Sleeves in the 4 Pulmonary Veins
Saito T, et al. J Cardiovasc Electrophysiol (2000) 11: 888
Len
gth
of
myocard
ial sle
eves (
mm
)
LSPV RSPV LIPV RIPV
*p<0.01
0
2
4
8
12
16
14
10
6
* **
*
*
Schematic Representation of Superficial Myocardial Fibres of the LA
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
LSPV
LLPV
LARA
SVC
RSPV
RIPV
IVC
Myocardial Fibre Orientation in the LA and PV – Predominant Vertical Fibre Pattern
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
LIPV
LSPV
RSPV
RIPV
Myocardial Fibre Orientation in the LA and PV – Predominant Horizontal Fibre Pattern
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
LSPV
LMPV
LIPVRIPV
RMPV
RSPV
Myocardial Fibre Orientation in the LA and PV – Predominant Oblique Fibre Pattern
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
LA
LSPV
SVC
LIPV
RSPV
RIPV
Myocardial Fibre Orientation in the LAand PV – Mixed Fibre Pattern
adapted from Nathan H & Eliakim M Circulation (1966) 34: 412
LIPV
LSPV
SVC
RSPV
RIPV
PV-Left Atrial Connections
Pattern 1 – no connections
Pattern 2 – partial connections
Pattern 3 – good connections
Tan AY, et al. J Am Coll Cardiol (2006) 48: 132
PERMISSION TO USE PHOTO BEING REQUESTED
Summary of Anatomical Changes in Patients with AFib
Tan AY, et al. J Am Coll Cardiol (2006) 48: 132Hassink RJ, et al. J Am Coll Cardiol (2003) 42: 1108
•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
Typical & Atypical Branching Pattern of PV Anatomy
Typical Short Common Left Trunk Long Common Left Trunk
Right Middle PV Two Right Middle PVs Right Middle PVand Right “upper” PVD E F
A B C
N=16N=18
N=7 (including 3 of D)N=5 (including 2 of D)
N=2N=2
N=4N=3
N=1 N=0
N=1N=1
AFibControl
AFibControl
adapted from Kato R et al. Circulation (2003) 107: 2004
Anatomy of the Pulmonary Veins
reproduced with permission, Kato R, et al. Circulation (2003) 107: 2004
RIPV
RSPV
LSPV
LIPV
LA appendage
Right PV Left PV
• Nuclear magnetic resonance image of the ostia of the right and left superior and inferior PVs and the left atrial appendage
Anatomy of the Pulmonary Veins
Ho YS, et al. Heart (2001) 86: 265
• Note the common opening of the LPV and separate origins of the two RPV
Left pulmonary veins
LA longitudinal section Transverse section from above
PERMISSION TO USE PHOTO BEING REQUESTED
Right Middle PV
Kato R, et al. Circulation (2003) 107: 2004
RMPV
• Nuclear magnetic resonance image showing a right PV with a separate origin to the right superior and inferior PVs
PERMISSION TO USE PHOTO BEING REQUESTED
Wittkampf FH, et al. Circulation (2003) 107: 21
Pulmonary Vein Geometry
Posterior View Inferior View LAO 45°
Ostium of left lower PV
Magnetic Resonance Angiography Fluoroangiography
PERMISSION TO USE PHOTO BEING REQUESTED
Left superior 38 18.7 ± 2.9 13.9 ± 3.7 1.4 ± 0.4 1.0-3.0 17.5 ± 2.9
Left inferior 38 15.9 ± 3.1 11.2 ± 3.1 1.5 ± 0.4 1.0-2.3 15.0 ± 2.7
Both left 76 1.5 ± 0.4
Right superior 42 18.8 ± 2.7 16.0 ± 2.0 1.2 ± 0.1 1.0-1.5 17.5 ± 2.1
Right inferior 42 17.9 ± 2.9 15.1 ± 3.0 1.2 ± 0.2 1.0-1.7 16.9 ± 3.1
Both right 84 1.2 ± 0.1
Left common 4 27.3 ± 6.2 18.7 ± 6.7 1.6 ± 0.5 1.0-2.2 26.5 ± 4.8
Right middle 4 7.6 ± 3.1 5.6 ± 2.1 1.4 ± 0.4 1.0-2.0 7.0 ± 1.9
nMaximum
(mm)Projected
(mm)Minimum
(mm) RatioRange(mm)
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)
Average Pulmonary Vein Ostium Diameters
Wittkampf, FH et al. Circulation (2003) 107: 21
Parasympathetic Ganglia
Fat pads
Distribution of Autonomic Nerves at the PV-LA Junction
AnteriorLA
VOM
LIRI
LS RSPA
AO SVC
IVC
CS
PosteriorLA
Adrenergic Nerve Density
Grade 4: 45-60 x 103 m2/mm2
Grade 3: 30-45 x 103 m2/mm2
Grade 2: 15-30 x 103 m2/mm2
Grade 1: 0-15 x 103 m2/mm2
Cholinergic Nerve Density
Grade 4: 4.5-6.0 x 103 m2/mm2
Grade 3: 3.0-4.5 x 103 m2/mm2
Grade 2: 1.5-3.0 x 103 m2/mm2
Grade 1: 0-1.5 x 103 m2/mm2
Anteriorjunction
Posteriorjunction
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
3. Catheter Ablation Techniques
From the first procedures to today
Maze reproduction Schwarz 1994
Right atrial linear lesions Haïssaguerre 1994
Right and left atrial linear lesions Haïssaguerre 1996
PV foci ablation Jaïs / Haïssaguerre 1997/8
Ostial PV isolation Haïssaguerre 2000
Circumferential PV ablation Pappone 2000
Ablation of non-PV foci Lin 2003
Antral PV ablation Maroucche / Natale 2004
Double Lasso technique Ouyang / Kuck 2004
CFAE sites ablation Nademanee 2004
Ostial or circumferential or antral PV ablation plus extra lines (mitral isthmus, posterior wall, roof)
Jaïs / Hocini 2004/5
Circumferential PV ablation with vagal denervation
Pappone 2004
Technique Publication date
Landmarks in Catheter Ablation Techniques and Success Rates
1994: Reproduction of Cox Procedure using Catheter Ablation by Schwarz
• Traditional Cox-Maze surgical procedure
adapted from Cox JL, et al. J Thor Cardivasc Surg (1991) 101: 569
RAALAA
LA
IVC
1994: Right Atrium Linear Lesions
adapted from Haïssaguerre M, et al. J Cardiovasc Electrophysiol (1994) 5: 1045
• 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
Right atrium
SVC
IVC
1
2
3
T
1996: Technique Extended to Right and Left Atrial Ablation
adapted from Haïssaguerre M, et al. J Cardiovasc Electrophysiol (1996) 7: 1132
• 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 41 2 3 4
1998: Ablation of PV Foci
• 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%)
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
PV Foci Triggering Afib
reproduced with permission, Haïssaguerre M, et al. N Engl J Med (1998) 339: 659
Superiorvena cava
Inferiorvena cava
Fossaovalis
Septum
Coronarysinus
94%
25% 45%
9% 16%
PulmonaryVeins
Right Atrium Left Atrium
• 94% of foci located inside PV (2-4 cm from ostium)– 45% in LSPV, 25% in RSPV, 16% in LIPV, 9% in RIPV
Ectopic Beats Initiating AFib from Foci in the RI and LS PVs
reproduced with permission, Haïssaguerre M, et al. N Engl J Med (1998) 339: 659
Ectopic beats (arrowed)
RIPV
LSPV
PV Foci Ablation: Results and Conclusions
• Radiofrequency ablation of ectopic foci was associated with a 62% success rate (absence of recurrence at 8 6m follow-up)
Haïssaguerre M, et al. N Engl J Med (1998) 339: 659
2000: Ostial PV Isolation
• 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
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
Ostial PV Isolation
reproduced with permission, Haïssaguerre M, et al. Circulation (2000) 101: 1409
Atrial activation preceding PVP
Discharges from PV
Local PV activity dissociated
distally at a slow rate
Ostial PV Isolation: Results and Conclusions
Haïssaguerre M, et al. Circulation (2000) 101: 1409
•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)
2000: Circumferential PV ablation
• 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
Circumferential Radiofrequency Ablation of Pulmonary Vein OstiaA New Anatomic Approach for Curing Atrial Fibrillation
Pappone, C, Rosanio, S, Oreto, G, et al.Circulation (2000) 102: 2619-28
Circumferential PV ablation
reproduced with permission, Pappone C, et al. Circulation (2000) 102: 2619
• 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)
Pre-ablation Post-ablationVoltage maps
Circumferential PV ablation : Results and conclusions
Pappone C, et al. Circulation (2000) 102: 2619
• 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
2003: Non-Pulmonary Vein Foci
•Most of the ectopic beats initiating paroxysmal AFib (PAF) originate from the PV.
•Lin et al. investigated PAF originating from non-PV areas
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
LPFW 27 (37%) 63 ± 14 5.2 ± 4.0 50 39.5 ± 5.9 100 56
SVC 27 (37%) 57 ± 12 4.7 ± 4.8 22 36.8 ± 5.1 44 26
CT 10 (14%) 63 ± 12 4.1 ± 3.2 0 29.7 ± 5.0 40 20
LOM 6 (8%) 66 ± 13 3.1 ± 2.5 50 41.3 ± 1.5 83 50
CSO 1 (1.4%) 67 1 0 - - 0 0
IAS 1 (1.4%) 44 2 100 - - 100 100
Patients(n)
Age(y)
LateRecurrence
(%)History
(y)LA size(mm)
MultipleAF Foci
(%)Group
SHD indicates structural heart disease
Other SHD(%)
Non-Pulmonary Vein Foci
Lin W, et al. Circulation (2003) 107: 3176
•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)
Ablation of non-PV Ectopy
reproduced with permission, Lin W, et al. Circulation (2003) 107: 3176
Ablation of ectopic triggers from the ligament of Marshall
Before After
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
2004: PV Antrum Isolation
• 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
Pulmonary Vein Antrum Isolation: Intracardiac Echocardiography-Guided Technique
Verma, A, Marrouche, NF, and Natale, AJ Cardiovasc Electrophys (2004) 15: 1335-40
PV Antrum Isolation
3D multi-slice images of PVs
reproduced with permission, Verma A, et al. J Cardiovasc Electrophys (2004) 15: 1335
Tubular ostium defined by PV angiography
Actual PV antrum extends more posteriorly
Antral borders defined by ICE
PV Antrum Ablation
•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)
Phased-Array Intracardiac Echocardiography Monitoring During Pulmonary Vein Isolation in Patients with Atrial FibrillationImpact on Outcome and Complications
Marrouche, NF, Martin, DO, Wazni, O, et al.Circulation (2003) 107: 2710
PV Antrum Ablation: ResultsFre
ed
om
fro
m r
ecu
rren
t A
F (
%)
30
Follow-up (days)
150 270 390 510 750630 8700
100
90
70
50
80
60
40
Group 1 (n=56)Group 2 (n=107)Group 3 (n=152)
Group 1 vs Group 3; p=0.009Group 1 vs Group 2; p=0.08Group 2 vs Group 3; p=0.08
Marrouche NF, et al. Circulation (2003) 107: 2710
PV Antrum Ablation: ResultsIntracardiac echocardiography improves the outcomeof cooled-tip PV isolation
Fre
ed
om
fro
m r
ecu
rren
t A
F (
%)
30
Follow-up (days)
150 270 390 510 750630 8700
100
90
70
50
80
60
40
ICE (n=259)No ICE (n=56)
p=0.01
Marrouche NF, et al. Circulation (2003) 107: 2710
2004: Double LASSO® Catheter Ablation
• Isolates pairs of pulmonary veins using two LASSO® catheters
• Continuous circular lesions (CCLs) around PVs guided by 3D mapping
Complete Isolation of Left Atrium Surrounding the Pulmonary VeinsNew Insights from the Double-Lasso Technique in Paroxysmal Atrial Fibrillation
Ouyang, F, Bänsch, D, Ernst, S, et al.Circulation (2004) 110: 2090
2004: Double LASSO® Catheter Ablation
reproduced with permission, Ouyang F, et al. Circulation (2004) 110: 2090
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
Double LASSO® Catheter Ablation: Results and Conclusions
• During a mean follow-up of 6 months, recurrence occurred in 10 patients. Nine patients underwent a repeat procedure
• Conduction gaps in the left CCL in 9 patients and in the right CCL in 2 patients were closed during the second procedure
• No AFib recurred in 39 patients after PV isolation during follow-up
• These results strongly support the hypothesis that it is necessary to isolate all PVs to prevent recurrence and stress the importance of the PV-LA junction in the initiation and perpetuation of PAF
Ouyang F, et al. Circulation (2004) 110: 2090
2004: Complex Fractionated Electrograms (CFAEs) Site Ablation
• Complex fractionated electrograms (CFAEs) recorded during AFib used as target sites for ablation
• Based on CARTO™ System mapping, the biatrial replica could be divided into distinct areas where RF energy was delivered according to CFAE detection
A New Approach for Catheter Ablation of Atrial Fibrillation: Mapping of the Electrophysiologic Substrate
Nademanee, K, McKenzie, J, Kosar, E, et al. J Am Coll Cardiol (2004) 43: 2044
2004: Complex Fractionated Electrograms (CFAEs) Site Ablation
reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
•Fractionated electrograms with continuous prolonged activation complex over posterior septal areas
CFAEs Site Ablation
reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
CFAEs Site Ablation
reproduced with permission, Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
CFAEs Site Ablation: Results and Conclusions
Nademanee K, et al. J Am Coll Cardiol (2004) 43: 2044
• Ablations of areas associated with CFAEs terminated AFib in 115 of 121 patients (95%)
• After one-year, 110 (91%) patients were free of AFib
• Areas with CFAEs are ideal target sites for ablation of AFib
2004: Spectral Analysis to Guide Catheter RF Ablation
• A new method for treating paroxysmal AFib by targeting AFib “nests” of “fibrillar” myocardium – areas of atrial substrate that can be identified by spectral analysis through fast Fourier transforms (FFTs)
A New Treatment for Atrial Fibrillation Based on Spectral Analysis to Guide the Catheter RF-Ablation
Pachon, JC, Pachon, EI, Pachon, JC, et al.Europace (2004) 6: 590
Spectral Analysis to Guide Catheter RF Ablation
reproduced with permission, Pachon JC, et al. Europace (2004) 6: 590
Spectral Analysis to Guide Catheter RF Ablation
Pachon JC, et al. Europace (2004) 6: 590
•Six control and 34 drug-refractory paroxysmal or persistent AFib patients were studied and treated
•RF was applied to all sites outside the pulmonary veins presenting right-FFT-shift (AFib nests)
•RF-ablation of AF nests, decreasing the fibrillar/compact myocardium ratio, eliminated 94% of the paroxysmal AFib in patients at 9.9+5 months of follow-up
•Paroxysmal AFib may be cured or controlled by applying RF in several places outside the PV, thus avoiding PV stenosis
Identification of an Atrial Frequency Gradient using Dominant Frequencies
• Investigated whether patients with AFib manifest a left-to-right atrial frequency gradient
Presence of Left-to-Right Atrial Frequency Gradient in Paroxysmal but Not Persistent Atrial Fibrillation in Humans
Lazar, S, Dixit, S, Marchlinski, FE, et al.Circulation (2004) 110: 3181
DF Atrial Gradients: Results and Conclusions
• In patients with paroxysmal AFib there is a significant left-to-right atrial DF gradient, with DF highest at the PV/LA junction, intermediate at the coronary sinus and lowest in the RA
• In patients with persistent AFib there are no significant differences between DF recorded from the LA/PV junction, CS, and RA
•These findings suggest that in induced paroxysmal AFib, the posterior LA may serve an important role in maintaining AFib
Lazar S, et al. Circulation (2004) 110: 3181
Ablation of Sites of Dominant Frequency Activation using Spectral Analysis
• Electroanatomic mapping performed in 32 patients with 5-second electrograms obtained at each point to determine the highest-amplitude frequency on spectral analysis and to construct 3D dominant frequency (DF) maps
• Ablation was performed with the operator blinded to the DF maps to determine the effect of ablation at sites with or without high-frequency DF sites
Spectral Analysis Identifies Sites of High-Frequency Activity Maintaining Atrial Fibrillation in Humans
Sanders, P, Berenfeld, O, Hocini, M, et al.Circulation (2005) 112: 789
Ablation of Sites of Dominant Frequency Activation using Spectral Analysis
reproduced with permission, Sanders P, et al. Circulation (2005) 112: 789
A: DF map in patient with paroxysmal AFib (6 hours). Note DF sites in each PV.
B: DF map in patient with permanent AFib (24 months). Maximal DF and atrial frequency are higher than in patient in A. In addition, many DF sites are located outside PVs.
Ablation of Sites of Dominant Frequency Activation using Spectral Analysis
Paroxysmal AF Permanent AF
Anterior Anterior
Posterior Posterior
IVC IVC
CS CS
LAA LAA
MV MVTV TV
RAA RAA
SVC SVC
adapted with permission, Sanders P, et al. Circulation (2005) 112: 789
Greater clustering of DF sites seen in paroxysmal AFib
Ablation of DF Sites using Spectral Analysis: Results and Conclusions
•The spatial distribution of the DF sites was different in patients with paroxysmal and permanent AFib
– In patients with paroxysmal AFib, the DF sources of activity are often localized to the PVs. In contrast, patients with permanent AFib demonstrate DF sites that are more often localized to the atria, including RA sites
•Ablation at these DF sites resulted in a significant slowing of the fibrillatory process and termination of sustained AFib in 87% of patients with paroxysmal AFib, confirming the role of localized sites of high frequency in the maintenance of AF
•All patients with persisting AFib had additional DF sites outside the ablated zones
Sanders P, et al. Circulation (2005) 112: 789
2004: Ostial or Circumferential or Antral PV Ablation plus Extra Lines
Jaïs P, et al. Circulation (2004) 110: 2996
• In addition to PV isolation, other investigators have shown that extra ablation lines may further improve results
- Mitral isthmus (Jaïs 2004)
- LA roof (Hocini 2005)
- Posterior wall
2004: Ostial or Circumferential or Antral PV Ablation plus Extra Lines
• Prospective, randomised study of mitral isthmus ablation vs PV isolation alone
Technique and Results of Linear Ablation at the Mitral Isthmus
Jaïs, P, Hocini, M, Hsu, L-F, et al.Circulation (2004) 110: 2996
reproduced with permission, Jaïs P, et al. Circulation (2004) 110: 2996
Incomplete block
Complete block during CS
pacing
Completely blocked mitral
isthmus
Linear Ablation at the Mitral Isthmus
Jaïs P, et al. Circulation (2004) 110: 2996
Linear Ablation at the Mitral Isthmus
• Bidirectional isthmus block was confirmed by demonstrating (1) a parallel corridor of double potentials during CS pacing (2) an activation detour by pacing either side of the line, and (3) differential pacing techniques
• At 1 year after the last procedure, 87/100 patients with mitral isthmus ablation and 69/100 without were arrhythmia free without AADs
• Cardiac tamponade was noted in 4% of patients
• Prospective, randomised study of roofline ablation vs PV isolation alone in 90 patients with paroxysmal AFib
• Roofline ablation joining the 2 superior PVs
Linear Block at the Left Atrial Roof
Techniques, Evaluation, and Consequences of Linear Block at the Left Atrial Roof in Paroxysmal Atrial Fibrillation: A Prospective Randomized Study
Hocini, M, Jaïs, P, Sanders, P, et al.Circulation (2005) 112: 3688
Linear Block at the LeftAtrial Roof
I
II
III
V1
1
2
3
4
MapLSPV
LIPV
RSPV
RIPV
1 2 3 4
adapted with permission, Hocini M, et al. Circulation (2005) 112: 3688
Hocini M, et al. Circulation (2005) 112: 3688
• Roofline ablation resulted in a significant increase in the fibrillatory cycle length and non-inducibility of AFib
• At 15+4 months, 87% of the roofline group and 69% with PV isolation alone were AFib-free without AADs
• Linear block of the LA roof may prolong the fibrillatory cycle and terminate AFib, and may be associated with better clinical outcome compared to PV isolation alone
Linear Block at the Left Atrial Roof
2004: Adjunctive PV Denervation during Circumferential PV Ablation
• Ablation of all evoked vagal reflexes around all PV ostia (complete vagal denervation)
Pulmonary Vein Denervation Enhances Long-Term Benefit After Circumferential Ablation for Paroxysmal Atrial Fibrillation
Pappone, C, Santinelli, V, Manguso, F, et al.Circulation (2004) 109: 327
2004: Adjunctive PV Denervation during Circumferential PV Ablation
reproduced with permission, Pappone C, et al. Circulation (2004) 109: 327
Vagal reflexes evoked (blue dots)
Adjunctive PV denervation During Circumferential PV Ablation
reproduced with permission, Pappone C, et al. Circulation (2004) 109: 327
• Pre- and post-ablation voltage mapsvagal reflexes abolished after ablation
Pappone C, et al. Circulation (2004) 109: 327
0.8
0.6
0.4
0.2
0
Cu
mu
lati
ve p
rop
ort
ion
of
pati
en
ts
AFib Recurrence (months)
0 2 4 6 8 10 12
1.0
Vagal reflexesNo vagalreflexes
101101 101102 101 101
166166 166195 166 166
# at risk
101
166
Vagal reflexesNo vagal reflexes
Log-rank p=0.0002
Adjunctive PV Denervation During Circumferential PV Ablation
Pappone C, et al. Circulation (2004) 109: 327
• In 297 patients undergoing circumferential PV ablation for paroxysmal AFib complete vagal denervation was achieved in 34.3% of cases
• Patients undergoing complete vagal denervation were less likely to have recurrence of AFib
• Only the percentage area of left atrial isolation and complete vagal denervation were predictors of AFib recurrence
Adjunctive PV Denervation: Results and Conclusions
Trigger -Ectopic Foci
PV & non-PV Foci Ablation,
PV Isolation
Autonomic Nervous System
AFib
CFAEs AblationLinear Lesions
(e.g. mitral isthmus, roof)
Substrate -Atrial tissue
A Combination of Techniques may be used Depending on the Type of AFib
Vagal Denervation
(parasympathetic ganglia ablation)
Tailored Approach to Catheter Ablation
•This study determined the feasibility of a tailored catheter ablation strategy guided by the electrophysiological characteristics of AFib, without the use of a standardized lesion set (PV isolation and/or encirclement with or without additional ablation lines)
•Primary end point was absence of frequent atrial ectopy and spontaneous AFib during isoproterenol infusion and non-inducibility of AFib
A Tailored Approach to Catheter Ablation of Paroxysmal Atrial Fibrillation
Oral, H, Chugh, A, Good, E, et al.Circulation (2006) 113: 1824
Tailored Approach to Catheter Ablation
• Tailored ablation - after encircling of the right-sided pulmonary veins, left atrial ablation was performed to target high-frequency and/or complex electrograms.
reproduced with permission, Oral H, et al. Circulation (2006) 113: 1824
Tailored Approach to Catheter Ablation: Results and Conclusions
Oral H, et al. Circulation (2006) 113: 1824
•During follow-up, left atrial flutter developed in 19% of patients and was still present in 10% at 12 weeks of follow-up
•A repeat ablation procedure was performed in 18% of patients
•During a mean follow-up of 11+4 months, 77% of patients were free from AFib and/or atrial flutter without AADs
•Acute non-inducibility of AFib after ablation was associated with a better clinical outcome than in patients left with inducible AFib
Tailored Approach to Catheter Ablation
•Evaluated a step-wise approach to achieve non-inducibility of AFib
•74 patients with paroxysmal AFib underwent PV isolation, if still inducible one or two additional linear lesions were placed at the mitral isthmus or LA roof
Long-term Evaluation of Atrial Fibrillation Guided by Noninducibility
Jaïs, P, Hocini, M, Sanders, P, et al.Heart Rhythm (2006) 3: 140
Tailored Approachto Catheter Ablation
No: stop
Inducible or persisting arrhythmia after step 1 ?
Yes
Step 1
No: stop
Inducible or persisting arrhythmia after step 2 ?
Yes
Step 2
Step 3
or
adapted from Jaïs P, et al. Heart Rhythm (2006) 3: 140
Jaïs P, et al. Heart Rhythm (2006) 3: 140
Tailored Approach to Catheter Ablation: Results and Conclusions
• In 42 patients (57%), PV isolation restored SR and AFib was non-inducible
• In the remaining 32 patients, a single linear lesion achieved non-inducibility in 20 patients
•An additional linear lesion was required in 12 patients, with 10 remaining non-inducible
•At 18+4 months follow-up, 91% of patients were free from AFib without AADs
3. Technological Aspects
Technological Aspects of Catheter Ablation
•Ablation catheters
•Energy sources
•Mapping catheters
•Electrophysiological mapping systems
•Cardiac imaging technologies
3. Technological Aspects
Ablation catheters and energy sources
Ablation Catheters
•Non-irrigated tip catheters
– 4mm and 8mm
• Irrigated tip catheters
– open shower, chilled
•Balloon catheters
– ultrasound, laser
Ablation Catheters
• Irrigated RF catheters
– Permit use of higher radiofrequency energy
– Ablation temperatures reduced
– Char formation minimized
Light Ring Inflatable Balloon Catheter
Energy Sources
•Radiofrequency
– Most common source
•Cryoablation
•Ultrasound
•Laser
•Microwave
3. Technological Aspects
Mapping catheters
Special Mapping Catheters
•Circular multi-electrode mapping catheter (LASSO® Catheter)
•Other multi-electrode mapping catheters
– BASKET, MESH, PENTARAY™ Catheter
Circular Mapping Catheter (LASSO®
Catheter)
1
2
3
45
6
7
8
910
RSPV mapping
Fully Expanded
25 mm
Precise mapping of potentials and exit sites at PVs
Fully Contracted
15 mm
LSPV mapping
12 3
4
5
67
89
10
• 5 radiating spines (markers on spine A and B)
• 20 localized electrodes
• Central irrigation lumen
High Density Multi-Electrode Mapping Catheter (PENTARAY™ Catheter)
AA
BB
CC
DD
EE
BB
AA
3. Technological Aspects
Electrophysiological mapping systems
Electrophysiological Mapping Systems
•3D-electroanatomic mapping
– CARTO™ System / CARTOMERGE™ Image Integration Software Module
•Robotic magnetic navigation
– Stereotaxis
CARTO™ System– Localization of catheter to within 1 mm
– Increase safety margin during ablation
Anatomic Maps Using CARTO™ System
• 3D-electroanatomic maps (CARTO™ System) showing ablation points encircling PVs
Circumferential Electroanatomical Ablation around PV Ostia
reproduced with permission, Pappone C, et al. Circulation (2001) 104: 2539
Pre-ablation Post-ablation
Delayedactivation
Point by pointRF lesions
• 3D-electroanatomic maps (CARTO™ System) showing pre- and post-ablation electrical activity
• Endpoint is complete electrical isolation of left atrium