1. 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

2. Rationale for Catheter ablation of AFib: Poor drug efficacy

3. Pulmonary vein potentials (PVP)

4. Right atrium Left atrium17 31 11 6
Superior
caval Vein
Inferior caval vein
Fossa
ovalis
Coronary
Sinus
Pulmonary Veins
Septum

5. … 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

6. 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

8. PV-Angiographie (LIPV)

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

10. Ablation LIPV

11. PV-Diskonnektion

16. … 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

17. 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

18. PV-Antrum (CT/ICE)

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

20. 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%

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

22. Success rates (extraostial)

23. Complication rates (extraostial)

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

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

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

27. 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)

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

29. Success/patient

30. AFib paroxysmal

31. JICE 2007

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

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

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

35. Allignment of MSCT and EAM
Landmark registration
Visual allignment
Surface registration

36. 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

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

38. 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 , 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)

39. 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.

40. 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.

41. 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.

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

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

44. 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).

45. RESULTS - OUTCOME Martinek et al, PACE 2007 Overall success after
3 months:
- CARTO XP 71%
- CARTOMerge 87.5%
p =
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

46. 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.

47. 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.

48. Image Integration

49. AFib Ablation Lesion Sets

50. Are you sure you know what you are doing ?

51. Journal of Cardiovasc Electrophysiol 2007

56. 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