Cardiovascular Surgery and Electrophysiology: Where are the

opportunities for a Combined Interdisciplinary approach in Atrial

Fibrillation?Felix Yang, MD, FACC, FHRS, CCDS

Associate Director, Cardiac ElectrophysiologyDepartment of Cardiology

Maimonides Medical Center

11/2018Philadelphia

Relevant Disclosures

• Consulting fees from Atricure, BiosenseWebster, Boston Scientific, Abbott

Paroxysmal AF Success Rates

PVI alone ~70% Success

PVI plus more extensive ablation ~70-80%

Catheter Ablation ofLong-Standing Persistent Atrial Fibrillation5-Year Outcomes of the Hamburg Sequential Ablation Strategy

Roland Richard Tilz, MD, Andreas Rillig, MD, Anna-Maria Thum, Anita Arya, MD, Peter Wohlmuth, Andreas Metzner, MD, Shibu Mathew, MD, Yasuhiro Yoshiga, MD, Erik Wissner, MD, Karl-Heinz Kuck, MD, Feifan Ouyang, MD

Hamburg, Germany

JACC Vol. 60, No. 19, 2012

Last ablation

First ablation

Catheter Ablation ofLong-Standing Persistent Atrial Fibrillation5-Year Outcomes of the Hamburg Sequential Ablation Strategy

Roland Richard Tilz, MD, Andreas Rillig, MD, Anna-Maria Thum, Anita Arya, MD, Peter Wohlmuth, Andreas Metzner, MD, Shibu Mathew, MD, Yasuhiro Yoshiga, MD, Erik Wissner, MD, Karl-Heinz Kuck, MD, Feifan Ouyang, MD

Hamburg, Germany

Journal of the American College of Cardiology Vol. 60, No. 19, 2012

AF <2 yrs

AF > 2 yrs

Multipleprocedure success

Limitations of Catheter Ablation Beyond PVINeed to Address Chronic Progressive Disease

High Late Recurrence Rate (VLR) in Successfully ablated patients (e.g. SR off AADs @ 1 year). • Persistent patients recur at a much higher rate than paroxysmal. • Patients with multiple risk factors also have a much higher recurrence rate.

Steinberg JS. Very long-term outcome after initially successful catheter ablation of atrial fibrillation. Heart Rhythm2014;11:771–776.

10 yrs

Parox

Persistent

HTN & persistent

PAF, no HTN

HTN or Persistent

Approaches to Catheter Ablation for Persistent Atrial Fibrillation

Atul Verma, M.D. et al for the STAR AF II Investigators

N Engl J Med 2015; 372:1812-1822

Singleprocedure success

What is the best method to deal with persistent atrial fibrillation?

Clinical factors associated with limited efficacy of AF ablationLong standing persistent AF

AF ablation can also be offered to those with persistent and long standing persistent AF but the expected efficacy is less.

Sleep apnea

Increased left atrial size (> 5.5 cm)

Increased age (> 70 yrs)

Severe obesity

“Frequently the factors that limit use of standard catheter ablation most often occur in patients who need the ablation the most”

HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation. Calkins H et al. Heart Rhythm 2007; 4(6): 816-61

Methodologies of AF ablation• A: The circumferential ablation lesions that are

created in a circumferential fashion around the right and the left PVs. The primary endpoint of this ablation strategy is the electrical isolation of the PV musculature.

• B: Some of the most common sites of linear ablation lesions. These include a “roof line” connecting the lesions encircling the left and/or right PVs, a “mitral isthmus” line connecting the mitral valve and the lesion encircling the left PVs at the level of the left inferior PV, and an anterior linear lesion connecting either the “roof line” or the left or right circumferential lesion to the mitral annulus anteriorly. A linear lesion created at the cavotricuspid isthmus is also shown.

• C: Also shows additional linear ablation lesions between the superior and inferior PVs resulting in a figure of 8 lesion set as well as a posterior inferior line allowing for electrical isolation of the posterior left atrial wall. An encircling lesion of the superior vena cava (SVC) directed at electrical isolation of the SVC is also shown.

• D: Some of the most common sites of ablation lesions when complex fractionated electrogramsare targeted (these sites are also close to the autonomic GP).

Importance of the Posterior Wall

Substrate

The problem is that much substrate exists on the posterior wall

Common regions of fibrosis

Adapted from Cochet et al. J Cardiovasc Electrophysiol 2015; 26: 489.

Schematic of Progressive Atrial Remodeling

Panel A: Schematic of progressive atrial remodeling. Pericardial reflections (green lines), their attachments to the posterior left atrium, and their relation to proposed high stress regions. Panel B: Ganglionated plexi (yellow) and epicardial fat (green). Left superior ganglionated plexi (LSGP), left inferior ganglionated plexi (LIGP), right anterior ganglionated plexi (RAGP), right inferior ganglionated plexi (RIGP), aortocaval ganglionated plexi (ACGP)

There are also additional factors that contribute to the AF substrate

The Risks of Posterior wall collateral injuryBut how can we safely treat

this substrate?

Convergent vs Thoracoscopic AF Ablation Lesion Set

Panel A: Schematic of the Convergent procedure lesion pattern relative to the high stress regions. Panel B: Thoracoscopic hybrid AF ablation lesion set. Hybrid AF ablation utilizing a thoracoscopic approach commonly involves pulmonary vein isolation, a roof line, posterior box line, exclusion of the left atrial appendage (blue lines). Endocardial ablation is performed to confirm bidirectional block across the lines and create a cavotricuspid isthmus line (red dotted line). Additional ablation may be performed to create an intercaval line, mitral line, and at ganglionated plexi.

How is convergent AF ablation performed?

EPi-Sense® SystemTips & Techniques

EPi-Sense® Coagulation Device Preshape device distal end so deflects along pericardium to reach roof pericardial reflections• Connect device vacuum connection to -400 to -450 suction• Always turn vacuum “off” when moving device• Place device above cannula guidewire to separate device from pericardium Always ensure arrows and dots extending from heel of electrode are facing epicardium Make sure saline is flowing from unpressurized bag of saline prior to initiation of RF energy delivery

Dots identify direction of heating

Arrows identify direction of heatingAblation coil electrode

Sensing electrodes

Vacuum openings

Advantages of the Convergent ApproachEndocardial Ablation of Reflections Eliminates Dissections

Ablating Posterior Left AtriumNo Dissecting of Reflections

Ablating RIPV @ Reflections Ablating Reflections to Complete Isolation of PVs

EPi-Sense® Directs Heating into Epicardial SurfaceProtects Collateral Anatomy by Cooling Device

20

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50

60

70

80

90

100

110

0 10 20 30 40 50 60 70 80 90

Tem

pera

ture

(C)

Time (sec)

Endocardial vs Epicardial Ablation Heating ProfileTemperature Reached Along Pericardium

[Myocardial Wall Thickness: 0.7 - 3.0mm]Catheter Ablation -

25Watts Max Tip Pressure 15g

Catheter Ablation -35Watts Max Tip Pressure 15g

Catheter Ablation -45Watts Max Tip Pressure 15g

Epicardial Ablation -nContact Device @ 30Watts

Collateral Heating, EPi-Sense Device

EPi-Sense Guides Epicardial AblationElectrogram Sensing & Pacing

Benefits

• Confirm target anatomy to ablate

Atrium vs Ventricle vs Pericardium

LAA vs Anterior Left Atrium

• Confirm lesion completeness

Visualize drop in electrogram signal

Pacing to confirm inability to capture

• Ensures posterior left atrium is ablated

No electrograms or inability to capture

Map posterior under endoscopic vision

Evaluation of Lesion CompletenessPre nContact Ablation

Post nContact Ablation

Electrophysiology portion of Convergent AF ablation

Efficacy of Convergent epicardial AF ablation. Confirmation of dense scar using endocardial electroanatomic mapping

Batul, S, Plawes, Z, Kupferstein, E, Israel Jacobowitz, IJ, Yang, F, Greenberg, Y. Maimonides Medical Center

Age 63.5 +8.9Lesions 40+6.6La size 4.77LA volume carto 162 +51BMI 33+6Dense Superior Scar 45.7%Dense Inferior Scar 52.5%Overall Dense Scar 47.68%

The Effect of Hybrid Ablation for AF on Left Atrial Function

Patel, JA, John, J, Greene, M, Chen, O, Greenberg, Y, Jacobowitz, IJ, Yang, F, Sadiq, A, Saxena, A.

Maimonides Medical Center

Pre and post-procedural echocardiograms of patients who underwent the Convergent AF ablation were evaluated for parameters of LA size and function using a rhythm independent Left Atrial Function Index .30 patients who underwent the Convergent AF ablation, 19 patients had pre and post-procedural echocardiograms where LAFI was calculated.

LA ESV Mean LAFI

Pre-procedure 104.5 ml pre-procedure 0.11

Post-procedure 92.2 ml post-procedure 0.13

p=0.048, 95% CI: 0.1 - 23.6

p=0.93, 95% CI: -0.065 - 0.060

Maimonides Persistent AF: A Difficult Substrate

• Mean age 62• Mean BMI 35.3• ~90% HTN• ~30% Diabetic• ~25% CAD• Mean CHADS 2.44• Mean LA Size 4.6cm• Mean LVEF 52%• Mean Time from First AF Dx 6.1 yrs• 18/100 with prior ablation

We had a much sicker populationThan STAR AF 2!

STAR AF2@1 year;Freedom From AF +/- AA

~50-60%

~25-30%~20-25%

~52%

Ganesan et al meta-analysis @1 year;Arrhythmia Free +/-AA; JAHA 2013

Hamburg@1 year;Arrhythmia Free +/- AA

~35%

Gaita et al@2 year;AF Free (34% on AA); Europace3/2018

~50%

Hamburg@2 year;Arrhythmia Free +/- AA

~40%

Gaita et al@3 year;AF Free (34% on AA); Europace3/2018

83%93%

OPE

N C

HEST

COX

IV

OPE

N C

HEST

COX

IV

OPE

N C

HEST

COX

IV

OPE

N C

HEST

COX

IV

73%85%

OPE

N C

HEST

COX

IV

OPE

N C

HEST

COX

IV

82%77%

Lawrence, Damiano et al; Annals of Cardiothoracic Surgery, Jan 2014

Hamburg@3 year;Arrhythmia Free +/- AA

The LAA

Watchman/Lariat

• Good data for Watchman for stroke prevention but doesn’t provide electrical isolation

• Lariat electrically isolates the LAA but more challenging to place

• Incidence of device related thrombus in patients with LAA imaging was 7.2%/year

27% of repeat ablation procedures had LAA firing

56%

28%

76%

56%

WITH LAA ISOLATION WITHOUT LAA ISOLATION

single procedure repeat procedure

Freedom From AF at 12 months

Atriclip : LAA Closure

Pro2

ProV

LAA Closure with Atriclip

Additional reasons to Close the Appendage

LAA Neurohormal interactions

• ANP is secreted by myocytes throughout the atria, with the LAA/RAA accounting for 30% of sources

• More ANP storage granules in RAA>LAA• LAA is innervated by parasympathetic and sympathetic fibers

(but not as densely as the LA posterior wall or pulmonary veins)

• Significant findings:– Persistent decline in epinephrine, norepinephrine,

renin, and aldosterone lasting at least 3 months with Lariat device

– Sustained and significant decrease in systolic and diastolic pressures of 15% and 12%

• Possible mechanisms:– Natriuretic peptide pathway (mostly short term effects)– Neurally mediated pathway

• Possibly by interruption or modification of neural reflexes by destruction of afferent fibers within the LAA or injury to peri-LAA ganglionated plexi during Lariat ligation

Combined Convergent with AtriclipEarly experience at Maimonides

• 29 patients• Age 61.5± 7.4yrs• Male 72%• BMI 34.2• CHADS2-VA2Sc 2.2 ± 1.1• Post procedure TEE performed in 12 patients

RESULTS• After 3 month blanking period only 1 patient on sotalol for VT. • 1 patient died 9 months post procedure due to MI• 5/29 discontinued a/c due to low CHADS-VASc score or increased

bleeding risk• Zero strokes / TIA• Mean f/u time 10.4 months

020406080

100

AF/AT free ±AA

AF/AT free offAA

97% 89%

Freedom from Arrhythmia

Freedom from Arrhythmia

Convergent + LAA AtriClip Closure

0

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50

60

70

80

90

100

Freedom from AF off AA Freedom from ATA off AA % on AA at last follow-up

86%

14%

49 average burns / patientMean follow up time: 499 days

Average Age = 6316 Female/35 Male

7/8 recurrences were AF1/8 Atrial Tachycardia

84%

51 Patients

Updated Results