1. RADIOFREQUENCY ABLATION OF FIBRILLATION: What clinicians should know. DR CARLOS LABADET Electrophysiology Sector Dr. Cosme Argerich Hospital

2. WHAT ARRHYTHMIAS ARE CURED? Wolff-Parkinson-White syndrome Supraventricular paroxysmal tachycardia Atrial flutter Atrioventricular node Atrial tachycardias SUCCESS 90 - 100 %

3. ADVANCEMENTS IN ABLATION ATRIAL FIBRILLATION VENTRICULAR TACHYCARDIAS VENTRICULAR EXTRASYSTOLE ATYPICAL ATRIAL FLUTTERS Sucess…~ 70%

4. ATRIAL FIBRILLATION Problems Increase in mortality! Embolism and stroke Hospitalization CHF: lack of atrial systole Cardiomyopathy by tachycardia Left atrial (LA) dilatation by AF Chronic anticoagulation Chronic symptoms of AF (palpitations, fatigue, etc.)

5. Increase of LA LV systolic dysfunction LV diastolic dysfunction HTN Toxic Genetic Tachycardia begets more tachycardia Age Obesity Metabolic syndrome Diabetes Sleep apnea Respiratory disorders Inflammation Degenerative diseases Atrial fibrosis ATRIAL FIBRILLATION HOW TO AVOID THIS WITH AN “ANTIARRHYTHMIC” DRUG?? Endocrinological disorders Pericardial fat

7. Spanish Registry of Ablation 2007 Rev Esp Cardiol 2008;61:1287

8. Male, 26 years old, he consults due to palpitations

9. ORAL PROPAFENONE 450 mg Male, 40 years old, no heart disease, palpitations 5 h

10. AF: WHAT IS THE MECHANISM AF is started by focused triggers, 95% in the pulmonary veins (PV) AF is perpetuated by multiple microreentries or “rotors” Dominant rotors locate in the PV-LA junction Vagal impulse can trigger and maintain AF. There are vagal ganglionic areas in the PV-LA junction.

11. LA LSVP Anatomia e Histologia de venas pulmonares Anatomy and histology of pulmonary veins Myocardial bands MECHANISM OF AF AND OBJECTIVES OF ABLATION

12. Haissaguerre et al. Circulation 1997;95:1120 FOCUSED TRIGGERS IN PULMONARY VEINS

13. TECHNIQUE OF ELECTRIC DISCONNECTION OF PULMONARY VEINS LSPV LIPV

14. RSPV RIPV LSPV LIPV CIRCUNFERENTIAL ISOLATION ANTRUM

15. PRE-RF LSPV POST-RF LSPV VP S

16. PRE ABLATION POST ABLATION

17. AAAA VVVV DESCONEXION ELECTRICA VP-AI 120 mseg

18. FA REGISTRO DE VENAS PULMONARES AAAA Ablación unión VP-AI

19. PULMONARY VEIN ABLATION – Potential mechanisms PV and foci isolation Removal of focused triggers Modification of substrate Autonomic denervation (vagal plexi)

20. AF ABLATION IN REFERENCE CENTERS RESULTS

21. ABLATION OF AF RECURRENCE Pappone et al J Am Coll Cardiol 2003;42:185–97)

22. 70% success 50% 2nd RFA 2-3% complic. NEJM 2004;351:2373

23. STROKE /YEAR: SINUS RHYTHM 0.4% AF 2% Nademanee JACC 08,50:843 EF>40 SR EF<40 AF EF>40 AF EF<40 SR (AFFIRM type) >65 y.o.+ HTN-Diab-CHF-ACV-LVEF<40%

24. European Guidelines of Cardiology 2010

25. Circulation 2005;111:1100 AF ABLATION IN THE REAL WORLD COMPLICATIONS

26. JACC 2009;53:1798 162 centers with 45,115 procedures in 32,569 pts.(1995-2006) Mortality at 30 days = 0.98/1,000 pts. SPANISH REGISTRY OF ABLATION 2007 1,624 accessory pathways: mortality = 1/1000 2,065 nodal reentry: mortality = 0.5/1000

27. Spanish Registry of Ablation 2007 Complications Rev Esp Cardiol 2008;61:1287

28. CURRENT INDICATIONS OF AF ABLATION

29. Post-AF ablation – immediate control Remain with anticoagulation for 1-3 months During first 72 hs pericarditis may appear (fever, precordial pain, effusion, evaluate by echo) PAF commonly appears as an effect of rF Discharge at 24-48 h Maintain antiarrhythmic agents during the first 1 to 3 months

30. Post-AF ablation Long term Patients may present left AF or AFl during the first 3 months, not associated to subsequent recurrene. The most severe complication: atrioesophageal fistula (0.01%). It appears between the first and second week: fever, bacteriemia, leukocytosis, epigastric pain, neurological focus=hospitalization=NMR or CT=NON- endoscopic surgery or contrast study.

31. PV stenosis: around 1%: between the 2nd and 5th months: dyspnea, cough, hemoptysis, chest pain Severe stenosis of a vein or multiple veins Angioplasty with stent Post-AF ablation Long term

32. 3-D navigation system of AF ablation LA

33. VPSD VPSI VPII LAA Catéter circular Catéter de ablación USEFULNESS OF 3-D NAVIGATORS

34. AF ablation: Who are the main candidates? PAROXYSMAL or PERSISTENT AF <1 year, symptomatic, recurrent with drugs. Age <65 years old Minimal or no heart disease Left atrium <50 mm

35. CONCLUSIONS The patients with paroxysmal forms of AF and with minimal heart disease obtain the greatest results with radiofrequency ablation. Those wiht persistent forms greater than 1 year or permanent, require more prolonged procedures and frequently require a second ablation.

36. CONCLUSIONS Although the information comes from observational studies, those with AF + left ventricular dysfunction present an improvement in ejection fraction Currently, studies on heart failure and ventricular impairment are being developed to assess this phenomenon.

37. Thank you for your attention!!