AF Ablation- A Mandatory Job Dr. Moataz A. Zaki, MD Lecturer of Cardiology - Medical Research Institute – Alexandria University. Member -Editorial Board of Egyptian Cardiac Rhythm Association. Fellow EP lab, Spedali Civili di Breschia, Italy. M-EAPCI, M-EHFA
Electrophysiological mechanisms of AF Focal Activation Initiating focus lies within region of PVs The resulting wavelets represent fibrillatory conduction
Multiple –Wavelet Reentry Wavelets randomly reenter tissues previously activated
by them or another wavelet
Mechanism of AF
Inter-atrial fascicle Main circular fascicle
Myocardial sleeves Transverse fascicle
Vertical fascicle (Nathan and Eliakim, Hadassah University Hospital, Israel, 1966)
PV
LA
Myocardium
Myocardial sleeve
t al., 1999
PV LA
Relatively long ERP Slow conduction Decrimental conduction
PV
LA
AF Ablation Rate control AV nodal ablation.
Rhythm control Linear atrial ablation (trans-catheter Maze technique). Pulmonary vein ablation. Pulmonary vein + LA isthmus ablation.
His Bundle Ablation
Transvenous Catheter Ablation
Permanent Ventricular Pacing
Focal Origin of Atrial Fibrillation Hassaiguerre M, NEJM, 1998
RA
LA
94% of AF triggers from
Pulmonary Veins “90 – 95% of all AF is initiated by PV ectopy”
SVC
17
31
FO Pulmonary Veins
6
IVC CS
11
Lasso™ Guided PV Isolation Before Ablation
During Ablation
After Ablation
I PV-d CS-p CS-7/8 CS-5/6 CS-3/4 CS-d HRA PV-1/2 PV-2/3 PV-3/4 PV-4/5 PV-5/6 PV-6/7 PV-7/8 PV-8/9 PV-9/10 PV-10/1
100 ms
A PV
A PV
A
Left Atrium, Posterior Wall Pulmonary Vein Isolation
Nathan, Circ Res, 1969?
AF TREATMENT GOALS Treatment goals in symptomatic pts ↓ frequency of recurrences ↓ duration of recurrences ↓ severity of recurrences
Minimize risk of tachycardia induced
cardiomyopathy Safety is primary concern
Catheter ablation vs AAD
Risk analysis AA Drugs, AVJ Ablation AF Ablation
Interventional risk Embolism, 0.3% Tamponade, 1%; PV stenosis, ? Atrio oesophogeal fistula
Longer-term risks , 2-3%/yr; Hemorrhagic risks of Anticoag. 1.8% Adverse effects of AADs (Pacemaker dependence)
PV Ablation Options • Sequential point by point
ablation
• Simple • Individual optimisation of lesion
delivery possible • Obligatorily time consuming • Finite irreducible rate of gap occurrence
• Circular lesion making
devices
• Unfamiliar, more complex design • Difficult to optimize contact/to
generate consistent lesions • Still do not achieve rapid, one-shot isolation
3 Dimensional Electroanatomical Mapping CARTO
Cryoballoon Ablation Pre-Cryo
LSPV Image courtesy V. Reddy
Post-Cryo
Location of conduction recovery at redo
Linear Ablation Technologies
PV ablation times: segmental PVI: 35+15 min Hocini et al. and CPVA: 37+11 min Oral et al. PVAC: Boersma et al. 27+7 min, & Scharf et al. 32+12 min
Visually-Guided Ablation Using Laser
Aiming Beam
“Static” Blood in LSPV LIPV
LA
A
Remote Navigation Systems • Magnetic Navigation: Fixed Magnets (Stereotaxis) • ) • Robotic Navigation (Hansen Medical)
Fixed Magnetic Nav
Robotic Nav Electro-Magnetic Nav
Arya et al, Europace 2010 e-pub
robotic arm
3D mouse Sensei™ Robotic Catheter System
Rotational Angiography
Catheter Ablation as First-Line Treatment of AFib • Young very
symptomatic patients
• Endurance athletes with
paroxysmal AF
• who refuse long term
AADs and anticoagulation
• Young patients with
parox/persistent AF and sinus node dysfunction
Padanilam, et al, Circulation 2005, 112, 12239
• Brady-tachy syndrome
and parox AF
PV isolation cases 2005 - 2012 150 cases Cairo University 100 cases Ain Shams 100 cases NHI
Future technology for AF Ablation • New technology should
simplify ablation • Shorten the procedure by reducing ablation times • Provide rapid and reliable endpoint verification • Result in durable, nonproarrhythmic lines of isolation
Current standard of reference…
AF Ablation Dr. Moataz A. Zaki, MD Lecturer of Cardiology - Medical Research Institute – Alexandria University. Member -Editorial Board of Egyptian Cardiac Rhythm Association. Fellow EP lab, Spedali Civili di Breschia, Italy. M-EAPCI, M-EHFA