Atrial Fibrillation Ablation: My personal experience 2000-2008 Helmut Pürerfellner MD, Assoc. Prof. Division of Cardiology St.Elisabeth´s Sisters Hospital Academic Teaching Center Linz/Austria

Rationale for Catheter ablation of AFib: Poor drug efficacy

Pulmonary vein potentials (PVP)

Right atrium Left atrium 17 31 11 6 Superior caval Vein Inferior caval vein Fossa ovalis Coronary Sinus Pulmonary Veins Septum

… critical zone Microreeentrant circuits LOM PV foci Sueda Ann Thorac Surg 1997 Microreeentrant circuits Modificata dovrebbe andar questa LOM Hwang Circulation 2000 Haissaguerre NEJM 1998 PV foci

Ablation of AFib - Techniques Trigger approach: Focal (within PV) Segmental ostial Substrate approach: Circumferential atrial Additional lines (roof, mitral isthmus) Substrate mapping (CAFE, DF) Ganglionated plexus (GP) Tailored approach

PV-Angiographie (LIPV)

Lasso Catheter Deflectable Tip (B curve) Atraumatic tip Different loop diameters available Micro-catheter loop featuring 10 electrodes (3F)

Ablation LIPV

PV-Diskonnektion

… critical zone Microreeentrant circuits LOM PV foci Sueda Ann Thorac Surg 1997 Microreeentrant circuits Modificata dovrebbe andar questa LOM Hwang Circulation 2000 Haissaguerre NEJM 1998 PV foci

Ablation of AFib - Techniques Trigger approach: Focal (within PV) Segmental ostial Substrate approach: Circumferential atrial Additional lines (roof, mitral isthmus) Substrate mapping (CAFE, DF) Ganglionated plexus (GP) Tailored approach

PV-Antrum (CT/ICE)

Wide areas circumferential ablation (WACA) (+ left atrial lines± ostial ablation)

SOI vs WACA Oral et al, Circulation 2003; 108:2355-60 Decrease in local atrial electrogram amplitude >50% or amplitude <0,1mV (voltage abatement) Additional ablation within circumferential lines in 32%

SOI vs WACA Oral et al, Circulation 2003; 108:2355-60

Success rates (extraostial)

Complication rates (extraostial)

AFib-Ablation Elisabethinen Hospital Linz 2001-2005 Period 01/2001 – 05/2005 N=200 Pat. Age 53±10 a 82%m, 18%f

Arrhythmia Paroxysmal: n=162 (81%) Persistent: n=32 (16%) Permanent: n=5 (2,5%)

Procedures N=276 Procedures: Lasso (segmental ostial) Pappone (circumferential) Combi (circumferentiell + ostial) Mixed

Follow up Fu after 1 month (clinical examination, 24h-Holter-EKG, QOL) In hospital Fu at 3, 6 und 24 months (clinical examination, Holter/Monitor, Echo, stress test, Spiral-CT, TEE, QOL; Lung scan and MRI as needed)

Classification of success Complete : 0 recurrences, 0 drug Partial: 0 recurrences, + drug failure: + recurrences, + drug Clinical response: complete + partial success

Success/patient

AFib paroxysmal

JICE 2007

Study design 40 consecutive patients (56.4 ± 9.6 y; 36 male)

Multislice computed tomography imaging 16-slice MSCT Non ionic contrast agent Caudocranial scanning Exspiratory breath-hold Barium contrast (esophagus)

Electroanatomic mapping 4-mm irregated tip quadripolar catheter Contact mapping of LA and PVs EAM and MSCT displayed next to each other

Allignment of MSCT and EAM Landmark registration Visual allignment Surface registration

AF ablation procedure Circumferential approach PV-Isolation (Pappone C et al., Circulation 2000;102(21):2562-4) PV-Isolation (Haissaguerre M et al., N Engl J Med 1998;339:659–65) Additional lines

Accuracy (position error) Mean = 1.6mm Mean = 2.3mm > No difference between SR and AF. > Independent of number of points.

Studies Our results: 1,6 ± 1,2 mm (pre) 2,3 ± 1,8 mm (post) Position error: 2.3 ± 0.4 mm (J Cardiovasc Electrophysiol, Vol. 17, pp. 341-348, April 2006) Our results: 1,6 ± 1,2 mm (pre) 2,3 ± 1,8 mm (post) Position error: 2.1 ± 0.2 mm (Heart Rhythm 2005;2:1076 –1081)

Conclusion Integration of MSCT scanning into 3D EAM is feasible and accurate. Cardiac rhythm during procedure has no influence on the precision of fusion. Matching accuracy decreases after multiple ablations. Combining EAM and imaging methods might provide easier, faster and more reliable ablation procedures in AF.

INTRODUCTION Does MSCT integration into 3D EAM … …lower complication rate of RF ablation? …improve of clinical outcome? …enhance procedural efficacy? Procedural duration Radiation times The study, which I am able to present here today, investigated whether the use of CT integration into the EAM provided by the CARTO Merge system translates into a lower complication rate with the endpoints PV-stenosis, phrenic nerve injury, Stroke/TIA or pericardial effusion. Secondly we investigated the potential improvement of clinical outcome or procedural efficacy evaluated by procedure and radiation times in comparison with conventional 3D EAM.

METHODS 161 consecutive patients (134 male) Mean age 55.5 ± 9.5 y Multi-drug-resistant AF (2.4±1.1 failed AAD) Serial MSCT before and 3 months after ablation 24-hour Holter and patients questionnaire at 3 months after procedure 161 consecutive patients (134 male, mean age 55.5±9.5y) with multi-drug-resistant AF (2.4±1.1 failed AAD) entered the study. Patients underwent serial MSCT before and 3 months after ablation to screen for significant PV stenosis which was defined as luminal narrowing over 50%. Outcome was evaluated by 24-hour Holter and patients questionnaire at 3 months after procedure.

CartoXPTM vs. CartoMergeTM 79 pts. CARTO Merge: 82 pts. 79 pts. were included in the conventional group, 82 in the CT integration group.

BASELINE CHARACTERISTICS These were the baseline characters, which did not differ between the gruops.

RESULTS - SAFETY Zero PV stenosis in the CartoMERGE group versus Five in the conventional group (p=0.021). Severe adverse events in total considerably reduced (8 vs. 2; p=0.043). RESULTS: Comparison of outcome data between conventional EAM (CartoXP, 79 patients) and image integration (CartoMERGE, 82 patients) resulted in a significant improvement in procedural safety with no single PV stenosis more than 50% in the CartoMERGE group versus 5 in the conventional group (p=0.021) of which one had to be treated with ballon angioplasty due to hemoptyses. Severe adverse events (PV stenosis, TIA, cerebral infarction, pericardial effusion, phrenic nerve injury) in total were also considerably reduced (8 vs. 2; p=0.043).

RESULTS - OUTCOME Martinek et al, PACE 2007 Overall success after 3 months: - CARTO XP 71% - CARTOMerge 87.5% p = 0.019. Overall success was furthermore drastically improved in the image integration group (71% vs. 87.5%; p=0.019). Martinek et al, PACE 2007 Outcome at 3 months

RESULTS - EFFICACY Both procedure and fluoroscopy times remained unchanged in our cohort. But keep in mind, we did compare conventional EAM vs. EAM plus CT integration, not EAM and conventional fluoroscopic approach.

CONCLUSION MSCT image integration into 3D EAM … … significantly improves safety … … significantly enhances success … of WACA with confirmed PV isolation and additional lines. MSCT image integration into EAM avoids severe complications and significantly improves safety and success of WACA with confirmed PV isolation and additional lines.

Image Integration

AFib Ablation Lesion Sets

Are you sure you know what you are doing ?

Journal of Cardiovasc Electrophysiol 2007

Catheter Ablation of AF 2008 – Open issues AF as first-line treatment (RAAFT, CACAF, APAF) Persistent/long standing persistent AF („chronic AF“) Energy Source/Catheter design Remote navigation Vs AAA (CABANA), vs A+P (PABA-CHF) AF and CHF Mortality (CASTLE-AF) Cost-effectiveness