DIU de rythmologie et stimulation cardiaque. Orateur : Serge BOVEDA Le 25 janvier 2012

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1 DIU de rythmologie et stimulation cardiaque Titre : Fibrillation atriale paroxystique : ablation, résultats, complications Orateur : Serge BOVEDA Le 25 janvier 2012

2 Fibrillation Atriale Paroxystique : ablation, résultats, complications DIU Rythmologie Paris, le 25/01/12 s.boveda@clinique-pasteur.com

3 1 A disease with bad consequences RR de patients en FA comparé avec des patients sans FA ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation Population de FA X 2 entre 1995 et 2030 Go et al, JAMA 2001

4 1 Afib ablation : is it THE Solution? Mortality, Morbidity, and Quality of Life after Circumferential Pulmonary Vein Ablation for Atrial Fibrillation Outcomes from a Controlled Nonrandomized Long-term Study Pappone C et al. J Am Coll Cardiol 2003 Pulmonary vein ablation improves mortality, morbidity, and QoL as compared with medical therapy Our findings pave the way for randomized trials to prospect a wider application of ablation for AF All patients should be ablated...

5 2 Afib ablation : theoretical aspects Haissaguerre M et al. NEJM 1998

6 2 Afib ablation : theoretical aspects Foyer FA

7 2 Afib ablation : theoretical aspects

8 2 Afib ablation : theoretical aspects * * * * *

9 Strategy of Afib ablation Initiation = Paroxysmal = Persistent Sustained = LA substrate Primary focuses (95% PV) Focal ablation Altered Tissue Linear lesions

10 2 Afib ablation : theoretical aspects

11 2 Afib ablation : theoretical aspects 3-D + Irrigated Single shot tools Kuck, Pappone Pappone Pappone Lasso + Irrigated Bordeaux 2000 Bordeaux 1999 Bordeaux 2001

12 3 Afib ablation : technical aspects Decapolar Lasso Catheter for PV mapping

13 3 Afib ablation : technical aspects VPSD VPSG VPID VPIG

14 3 Afib ablation : technical aspects Kato R. et al. Circulation 2003;107:

15 Bilan anatomique des veines pulmonaires Angiographie per-procédure, IRM, TDM multibarrettes +++ :

16 3 Afib ablation : technical aspects All 4 veins deconnection assessed by the absence of PV potential at the ostium of each vein Control of the 4 veins just before removing the catheters (frequent recurrences +++)

17 Right superior PV before/after RF

18 Left superior PV before/after RF

19 LIPV disconnection

24 Follow-up - Holter just after the procedure, after 3, 6 and 12 months - Warfarin at least during 6 months in case of afib recurrences

25 Why still so much recurrences?

26 3 Afib ablation : technical aspects Navigation systems Nowadays: Carto 3

27 Circumferential PVI Arentz T. Circulation 2007

28 PV Isolation: the larger the better? 110 Patients Ostial segmental PVI = small isolation Circumferential Isolation = large isolation Arentz et al. Circulation 2007

29 PV Isolation: the larger the better!!! Arentz et al. Small or large isolation areas around the PVs. Circulation 2007

30 3 Afib ablation : technical aspects Single shot tools for paroxysmal AFib

31 PVAC : pulmonary vein ablation catheter I III V1 PVAC 1 PVAC 2 PVAC 3 PVAC 4 PVAC 5 CS prox CS dist 1 Minute Ablation time

32 PAF Typical baseline ECG

33 Afib coming from RSPV

34 LSPV before RF ablation

35 LSPV after first RF application : 1 st degree PV block

36 LSPV after RF ablation

37 Pacing inside LSPV showing LA dissociation

38 Pacing inside LIPV : still connected

39 LIPV pre RF ablation

40 LIPV post RF ablation

41 RSPV pre RF ablation

42 RSPV dissociation after RF ablation

43 RIPV pre RF ablation

44 RIPV post RF ablation

45 3 Afib ablation : technical aspects Cryoablation - Methods 240 sec per application 23 mm 28 mm At least 2 applications per vein with good occlusion achieved during venography, through <-40 Size of the balloon : - 28 mm or 23 mm according to : the PV diameter (CT scan > or < 15/16 mm), Gender: Women, low BMI : 23 mm ++ Size of the RSPV

47 Cryoablation is it superior to radiofrequency ablation? Cryolesion1 week (dog, LV) Freezor 4 mm, -75 C, 240 s Less endocardial disruption Preservation of underlying tissue architecture reduce platelet and clotting activation and thrombus formation > thromboembolism Khairy P, et al. Circulation. 2003;107:

48 If the diameter of the PVs is >15 mm 28 mm balloon

49 LSPV /Achieve

50 Achieve in the LSPV, isolation at 35 s freeze during CS pacing

51 (1) Paroxysmal AF, Achieve in the LSPV, without pacing - Where is the A potential? - Where is the venous potential? where is the ventricular potential?

52 (2) During cryo ablation at 15 sec

53 4 Afib ablation : results Parox AF ablation: success rate Meta-analysis of catheter ablation studies Ablation method Patients Paroxysmal AF SHD 6 mo cure 6 mo OK Linear % 26 % 33 % 55 % Focal % 35 % 54 % 71 % Isolation 2, % 36 % 62 % 75 % Circumferential (all) 15, % 37 % 64 % 74 % Circumferential (LACA, WACA) 2, % 37 % 59 % 72 % Circumferential (PVAI) 11, % 42 % 67 % 76 % Substrate ablation (CFAE) % 49 % 75 % 87 % Total 23, % 55 % 63 % 75 % The VeniceChart international consensus document

54 PAF Ablation : Randomized Studies AF - ESC Guidelines, EHJ 2010

55 Study Design of the STOP-AF Trial Inclusions: Patients >2 AF episodes in 2 months w ECG doc. of 1 Rx Failure of > 1 AA Rx Follow- up 1,3,6,9, &12 mo Holters Weekly TTMs

56 Primary Effectiveness Analysis Treatment Success days Treatment success (%) Blanked CRYO 69.9% 114/163 P<0.001) DRUG Rx 7.3% 6/ KM estimate 68.6% (SE 3.9%) Days vs 7.3% (SE 2.9%)

57 4 Afib ablation : CP results

58 4 Afib ablation : CP results Success without AAD Success with AAD Paroxysmal Afib Persistent/ Afib (1 year) 72 % 80 % 52 % 63 %

59 4 Afib ablation : elderly patients Zado et al, J Cardiovasc Electrophysiol 2008

60 4 Afib ablation : athletes patients In patients with documented focal induction of nonpermanent AF and absence of structural heart disease, PVI is as effective in athletes as in other patients Koopman P, Europace 2011

61 5 Afib ablation : complications Accès Percutané Complications «locales» : Fistule artério/veineuse, Hématome fémoral Manipulation cathéters / Ponction Transeptale Perforation cardiaque / Tamponnade ; Perforation du sinus coronaire ; lésion aortique Energie Délivrée Perforation cardiaque / Tamponnade ; Lésion valvulaire ; AVC ; Fistule oesophagienne

62 5 Afib ablation : complications Verma A et al. ( Circulation 2005;112: ) Global risk between 2 and 3% (higher for persistent Afib?...)

63 5 Afib ablation : complications AVC : incidence = 0 à 4%... ACT (per-op + post-op) Surveillance clinique per-op + post-op Stroke center / Fibrinolyse Troughton R, Heart 2003 Dixit S, Heart Rhythm 2007

64 5 Afib ablation : complications Tamponnade : incidence = 1.2 à 6%... Drainage sous-xyphoïdien Chirurgie +++ Wu R, J Cardiovasc Electrophysiol 2002

65 5 Afib ablation : complications Fistule atrio œsophagienne : incidence < 0.25% / Mortalité = 50%... Sra J, J Interv Card Electrophysiol 2008 Dixit S, Heart Rhythm 2007

66 5 Afib ablation : complications PV stenosis : up to 15% / Severe >70% : 1-3% Sra J, J Interv Card Electrophysiol 2008

67 5 Afib ablation : complications Asymptomatic PV stenosis 3 months after ablation

68 6 Looking at the Guidelines?

69 6 Looking at the Guidelines

70 7 Should we ablate before? This suggests that the selection of patients for the invasive strategy should be considered at an earlier stage of the disease, even before AAD Europace 2011

71 Take Home Message 1. Symptomatic parox Afib ablation after AAD failure is a IIa / I indication with a 75% success and 2-3% complication rates 2. Afib ablation is cost-effective in these patients 3. Persistent Afib ablation remains challenging, with long fluoro exposure time, higher morbidity and lower success rates 4. Afib type, absence of SHD, LA enlargement, LA fibrosis/srm seem to be important factors for a better outcome after ablation 5. try to ablate before Afib becomes persistent 6. at earlier stages of the disease 7. but not before AAD treatment : IIb indication

Ablation For Atrial Fibrillation. Bill Petrellis Electrophysiologist

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