1. AF ablation with 3D mapping: our technique and results
Dr Dhiraj Gupta MRCP MD DM
Liverpool Heart and Chest Hospital
Northern UK AF experts Best Practice meeting
Langdale Hotel, Cumbria 5 Feb 2010

2. Schema Our approach to AF ablation at LHCH Our reasons for each step
Our in-lab and follow-up results

3. Our approach in a nutshell
PVAI with Wide area circumferential ablation
CT image integration using CARTO
Individualised lesion set prescription
Aim to ablate out of AF, ideally to SR
Procedure duration limit of 5 hours

4. CT image registration Critical part of the process 2 steps
Single point Landmark registration
Surface Registration with Fast Anatomical Mapping
Takes 5-10 minutes

5. CT image segmentation

6. Fast Anatomical Map creation

7. Image Surface registration

8. Why the individualised approach?
Heterogeneity amongst AF population
Trigger removal vs Substrate Modification
Aim to achieve high single procedure success rates
Incremental risk with multiple procedures
That’s what the patient wants
That’s what the health economists want!

9. Patient selection criteria
Patients not offered Catheter ablation if
Very long standing Persistent AF (>3 years)
Very large LA (>5.5 cm)
Morbid Obesity (BMI >40), Sleep Apnea
Significant RA dilatation (>LA)
Patients not offered first redo at least for 6 months
Not offered Second redo if still in PsAF

10. Not all AF patients are the same
True PAF
Short lived episodes, short history, normal sized LA
Sustained PAF: 2 or more of the following
AF episodes>24 hours, History of AF > 5 years, LA size >4.5 cm, Age >65 years, Documented flutter, High AF burden (most days)
Persistent AF
Long standing Persistent AF (>12 months)

11. Minimum RF Lesion set True PAF PVAI using WACA Sustained PAF
+ LA roof line + RA flutter line
Persistent AF
+ LA floor line + Mitral isthmus line
Long standing Persistent AF
+ Epicardial CS ablation+ CAFÉ ablation

12. Paroxysmal PAF

13. Sustained PAF

14. Persistent AF

15. Long standing Persistent AF

16. Surgical Maze for ‘Permanent AF’
Still the Gold standard in terms of results
96% free of AF at 5 years*
* SM Prasad et al, J Thorac Cardiovasc Surg 2003; 126:

17. Results with ‘Catheter Maze’N
Redo
AAD therapy
Results
Complications
Haissaguerre
JCE 2005 60
1/2
Stopped at ablation
95% at 11 months
2 Tamponades
Oral
NEJM 2006 77
1/3
Amio 6/52 pre & 3/12 post
77% at 1 year
Postch
Circ 2008 88
81% at 20 months
1 TIA Lo
JCE 2009 87
1/4
AAD for 2/12 post
79% at 21 months
1 Tamponade

19. Why CT image integration?
Forewarned is forearmed: PV anatomical variations
Common Left Pulmonary Vein
Additional pulmonary vein(s)
Important anatomical information
thickness of the LAA ridge, intervenous carina
extent of the PV antra
length of the mitral isthmus

20. Why CT image integration?
Dramatically reduces procedural fluoro times:
<10 minutes for PAF cases
10-20 minutes for PsAF cases
Decreases fatigue
Removes ‘the fear of the unknown’…..
Demystifies AF ablation for the nurses/ radiographers!

23. Why CARTO rather than ESI?
Unmatched catheter stability
no catheter ‘dive’ with onset of RF delivery
Allows linear lesions
No need for stable intracardiac reference
Ability to perform activation mapping if needed
Great CT image integration software

24. Advances with CARTO-3
Hybrid of impedance and magnetic catheter location
Ability to see all catheters
Ability to create fast anatomical maps
Makes CT image integration easier
More streamlined patient set-up

25. Why WACA? PV ostial/ antral triggers
Substrate modification by Atrial debulking
Less risk of PV stenosis
Quicker than segmental PVI
Easy to anchor linear lesions on either side
‘Et tu, Bordeaux?!’

26. Why our RF settings? Continuous RF: 35 W, 50°C, 10 ml/ min flow
Quicker signal obliteration than 30/25 W
Short procedure time (20-30’ per WACA)
Prevents peri-lesion edema (?  reconnection risk)
RF controlled by Foot pedal
Frees up a cardiac physiologist
Imposes discipline on use of X-ray pedal!

27. 131 consecutive pts. between Jan 08-July 09
Our results
131 consecutive pts. between Jan 08-July 09

28. Individualised ablation strategy
True PAF (n=45)
PVAI using WACA
Sustained PAF (n=31)
+ LA roof line+ RA flutter line
Ps AF (n=22)
+ LA floor line+ Mitral isthmus line
Long standing Ps AF (n=33)
+ Epicardial CS ablation+ CAFÉ ablation

29. In-lab results All patients received prescribed minimum lesion set
Mean Procedure time 173 min (98-300)
Fluoroscopy times
Mean 26.5 min (13-58) (as pre-CARTO 3 era)
Now with CARTO-3 (n=36): Mean 14 min (6-21)
Complications
1 tamponade (PVI group), 1 AV fistula

30. Our follow-up strategy
Antiarrhythmic drug therapy for 2-3 months
Early post-op arrhythmias
DC CV if sustained and poorly tolerated (n=1)
No redo ablation procedure for at least 6 months
Mean follow up 11.3 months (6-24)

31. Our Clinical Results Definition of Procedural Success:
No symptoms beyond 3 months, AND
Absence of AF/AT on 24 hour Holter at 6 mo
Single procedure success rates at 6 months
PAF 84%
PsAF 86%
Sustained PAF 77% (p=0.05)
Long standing PsAF 64% (p<0.001)

32. Conclusions Single procedure success should be the goal
Most patients need substrate modification in addition to trigger removal
This needs application of linear lesions
3D mapping guided ablation the gold standard

33. Acknowledgements to Dr Richard Schilling, my mentor and guide
Thank You