Approaches to Ablate Persistent in 2019: The Problems with Mapping AF

Slides:

Advertisements

Similar presentations

Substrate Ablation (CAFE) A Promising or Vanishing Technique

Advertisements

Ali Alsayegh, MD, FRCPC,FACC Consultant Cardiologist, Consultant Cardiac Electrophysiologist.

The Future of Minimally Invasive Cardiac Surgery Marco A. Zenati, M.D. Professor of Surgery and Bioengineering University of Pittsburgh School of Medicine.

Noninvasive Electrocardiographic Imaging for Cardiac Electrophysiology and Arrhythmia Charulatha Ramanathan, Raja N Ghanem, Ping Jia, Kyungmoo Ryu & Yoram.

Optimal Method and Outcomes of Catheter Ablation of Persistent AF: The STAR AF 2 Trial Atul Verma, Jiang Chen-yang, Tim Betts, John Radcliffe, Jian Chen,

Atrial Fibrillation Ablation Cardiology Symposium December 6, 2004 Paul R. Steiner, M.D. Cardiac Electrophysiology.

Basic Mechanisms of Atrial Fibrillation Relative to Ablation Osama Diab MD, Cardiology Lecturer of Cardiology, Ain Shams Universitry-Cairo Consultant Electrophysiologist,

New targets of AF ablation – CFAE and GPs Helmut Pürerfellner Public Hospital Elisabethinen, Academic Teaching Center Linz, Austria.

Constellation™ Taiki Esheim Product Manager, EP.

Catheter Ablation of Atrial Fibrillation: Who? How? How Good? John D. Day, M.D. Director, Utah Cardiovascular Research Institute Utah Heart Clinic Arrhythmia.

EGM-Guided Ablation: CFE, Ganglia, Rotors… ISHNE 2009 Atul Verma, MD FRCPC Staff Cardiologist, Electrophysiologist Southlake Regional Health Centre Newmarket,

Redo afib ablation John R Onufer MD FHRS

Catheter Ablation of AF Electrogram-based Approach

Asklepios Klink St. Georg, Hamburg

COMMON CARDIAC ARRHYTHMIAS 2 the complex arrhythmias Mark Earley, St Bartholomew’s Hospital.

Catheter Ablation of Atrial Fibrillation in the Last 10 Years: Breakthroughs and Advances Dr. Feifan Ouyang Asklepios Klinik St. Georg Hamburg Sept. 19th,

Catheter Ablation of AF Electrogram-based Approach Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei,

Date of download: 6/25/2016 Copyright © The American College of Cardiology. All rights reserved. From: Mechanism, localization and cure of atrial arrhythmias.

New interpretation of fractionated electrogram (EG) activity and late potentials. Desynchrony in the appearance of the epicardial action potential second.

Is There a Need to Address AF in patients Undergoing Valve Surgery?

RESULTS AND DISCUSSION

Thomas A. Csepe, BSc, Brian J. Hansen, BSc, Vadim V. Fedorov, PhD

Left atrial ablation for atrial fibrillation. A

Surgical treatment of atrial fibrillation: State of the art, 2012

Reentrant and Focal Activations During Atrial Fibrillation in Patients With Atrial Septal Defect Takashi Nitta, MD, PhD, Shun-ichiro Sakamoto, MD, PhD,

The Journal of Heart and Lung Transplantation

Circ Arrhythm Electrophysiol

Circ Arrhythm Electrophysiol

Circ Arrhythm Electrophysiol

Targets and End Points in Cardiac Autonomic Denervation Procedures

Circ Arrhythm Electrophysiol

Circ Arrhythm Electrophysiol

by Takanori Ikeda, Lawrence Czer, Alfredo Trento, Chun Hwang, James J

Circ Arrhythm Electrophysiol

Volume 15, Issue 1, Pages (January 2018)

Clinical Intracardiac Electrophysiologic Testing: Technique, Diagnostic Indications, and Therapeutic Uses STEPHEN C. HAMMILL, M.D. Mayo Clinic Proceedings

David Filgueiras-Rama, and José Jalife JACEP 2016;2:1-13

Volume 9, Issue 1, Pages (January 2012)

Initial Experience of Sequential Surgical Epicardial-Catheter Endocardial Ablation for Persistent and Long-Standing Persistent Atrial Fibrillation With.

Junaid A.B. Zaman et al. JACEP 2017;3:

Gregory F. Michaud, and Saurabh Kumar JACEP 2016;2:

Radial approach: a new concept in surgical treatment for atrial fibrillation. II. Electrophysiologic effects and atrial contribution to ventricular filling

Sébastien P.J. Krul et al. JACEP 2015;1:

AFACT Trial design: Patients with long-standing atrial fibrillation were randomized to ganglion plexus ablation (n = 117) vs. control (n = 123) on top.

Nat. Rev. Cardiol. doi: /nrcardio

Junaid A.B. Zaman et al. JACEP 2017;3:

Long-standing persistent atrial fibrillation ablation without use of fluoroscopy in a patient with cor triatriatum Saumil R. Shah, MD, Guru P. Mohanty,

Junaid A.B. Zaman et al. JACEP 2017;3:

Junaid A.B. Zaman et al. JACEP 2017;j.jacep

Masatoshi Yamazaki et al. JACEP 2015;1:

Figure 5 Rotors, wavebreak, and multiple circuit re-entry

ATRIAL FIBROSIS IMAGING IS CHANIGNG THE WAY WE MANAGE AF

Risk Factor Modification

Stavros Stavrakis et al. JACEP 2015;1:1-13

Incessant bundle branch reentrant ventricular tachycardia in a patient with corrected transposition of the great arteries Ken Kato, MD, Daigo Yagishita,

Successful atrial fibrillation ablation without pulmonary vein isolation utilizing focal impulse and rotor mapping in an atriopulmonary Fontan Madhukar.

Andreu Porta-Sánchez, MD, Andrew C. T

Substrate mapping for unstable ventricular tachycardia

Paul Knops, BSc, Charles Kik, MD, Ad J. J. C

Dual-loop biatrial concomitant macroreentrant tachycardia in a patient without previous history of surgery or ablation Song-Yun Chu, MD, Li-Bin Shi,

Cardiac fibrillation: From ion channels to rotors in the human heart

Focal atrial tachycardia and atrial fibrillation from a pulmonary vein aneurysm Konstantinos Sotiropoulos, MD, Benjamin Berte, MD, PhD, Vanessa Weberndoerfer,

Noninvasive mapping before surgical ablation for persistent, long-standing atrial fibrillation Marek P. Ehrlich, MD, Guenther Laufer, MD, Iuliana Coti,

Circular mapping recordings in a persistent left superior vena cava during atrial tachycardia: Was isolation achieved? Sandrine Venier, MD, Jason G.

Arrhythmogenic triggers associated with an autonomic response from a posteroseptal region after extensive ablation in a patient with long-standing atrial.

Lengthening the atrioventricular delay reduces large left atrial v waves and dyspnea after atrial fibrillation and tachycardia ablation Raman Mitra,

HeartRhythm Case Reports

Catheter ablation for the treatment of persistent atrial fibrillation: Maintenance of sinus rhythm with left atrial appendage and coronary sinus isolation.

Figure 1. Radiofrequency ablation findings

Electrophysiological evidence of localized reentry as a trigger and driver of atrial fibrillation at the junction of the superior vena cava and right.

Presentation transcript:

Approaches to Ablate Persistent in 2019: The Problems with Mapping AF Gregory F. Michaud, MD Professor of Medicine Vanderbilt University School of Medicine Chief, Arrhythmia Service VHVI Western AF 2019 Park City , UT

Disclosures 2019 Boston Scientific – Honoraria Medtronic – Honoraria St Jude Medical – Honoraria Biosense-Webster – Honoraria Biotronik – Honoraria Pfizer – Consulting S4 Medical - Consulting VanderbiltHeart.com

Targets to Enhance Success of Persistent AF Identification and ablation of triggers Atrial fibrosis/scar Ganglionated plexus ablation Anatomic: PVI, posterior LA, LAA isolation? Identifying and ablating critical mechanisms for persistence Foci Rotors ????

Nattel Circ Research 2018 VanderbiltHeart.com

Rotors Wavefronts bend and possibly break when they encounter complex anatomy or tissue heterogeneity Wavefronts under certain conditions can rotate around a phase singularity which represents the point of maximal curvature, slowest conduction velocity and shortest refractory period Unlike reentry in the leading circle theory, the core of rotors can migrate VanderbiltHeart.com

Phase Singularities Tend to Move Waks, Josephson Arrhythmia Electrophysiol Rev 2014 VanderbiltHeart.com

Experimental sheep models of atrial fibrillation with optical mapping show rotors (after some math) Gray RA, Pertsov AM, Jalife J. Spatial and temporal organization during cardiac fibrillation. Nature. 1998; 392:75–78. VanderbiltHeart.com

Rotors demonstrated by FIRM phase mapping are often stable Compared with optical mapping, basket catheters have low resolution Not a unifying theory based on other data Naryan

Some mapping systems do not rely on contact electrodes: meandering rotation Cardioinsight Haissaguerre Circ 2014 Acutus high density noncontact intracardiac map

Alternative hypotheses raised by activation mapping in humans… Alessie, Waldo and Kalman VanderbiltHeart.com

Two-Layer Hypothesis in Long-Standing Persistent AF Numerous, transient and widespread epi to endo (or the other way around) breakthrough de Groot NMS, Houben RP, Smeets JL, et al. Circulation. 2010;122:1674-1682.

Hansen, JACCEP 2017 Jun;3(6):531-546. doi: 10.1016 Federov lab OSU VanderbiltHeart.com

Surgical Epicardial Mapping of Persistent AF Patients Activation sequence maps of bipolar and unipolar activation (500 electrodes for 32 s) No reentry was observed Foci – drivers (QS) and breakthroughs Lee S, Circ Arrhythm Electrophysiol. 2015 Oct 23 VanderbiltHeart.com

Wannabe reentry VanderbiltHeart.com Lee S, Sahadevan J, Khrestian CME, Cakulev I, Markowitz A, Waldo AL, Simultaneous bi-atrial high density (512) electrodes) epicardial mapping of persistent atrial fibrillation in patients: new insights into mechanism of its maintenance. Circ Arrhythm Electrophysiol. 2015 Oct 23;doi: 10.1161/CIRCULATIONAHA.115.017007. VanderbiltHeart.com

Continued obstacles to AF mapping… From preclinical data, AF mapping requires high resolution, simultaneously and continuously recorded electrograms. Complex transformation is required to get from EGMs to phase maps, which may create artifact, particularly in low resolution systems. Epicardial and endocardium are dissociated. Focal sources may actually represent breakthrough points and not clear targets. How do we interpret what we’re seeing without a solid understanding of predominant mechanisms? VanderbiltHeart.com

Thank you VanderbiltHeart.com