RADIOFREQUENCY ABLATION OF FIBRILLATION: What clinicians should know.

DR CARLOS LABADETElectrophysiology Sector

Dr. Cosme Argerich Hospital

WHAT ARRHYTHMIAS ARE CURED?

• Wolff-Parkinson-White syndrome

• Supraventricular paroxysmal tachycardia

• Atrial flutter

• Atrioventricular node

• Atrial tachycardias

SUCCESS 90 - 100 %

ADVANCEMENTS IN ABLATION

• ATRIAL FIBRILLATION

• VENTRICULAR TACHYCARDIAS

• VENTRICULAR EXTRASYSTOLE

• ATYPICAL ATRIAL FLUTTERS

Sucess…~ 70%

ATRIAL FIBRILLATIONProblems

• 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.)

Increase of LA

LV systolic dysfunction

LV diastolic dysfunction

HTN

Toxic

Genetic

Tachycardia begets more tachycardia

Age

Obesity

Metabolic syndrome

Diabetes

Sleep apneaRespiratory

disorders

Inflammation

Degenerative

diseases

Atrial fibrosis

ATRIAL FIBRILLATION

HOW TO AVOID THIS WITH AN “ANTIARRHYTHMIC” DRUG??

Endocrinological disorders

Pericardial fat

Spanish Registry of Ablation 2007

Rev Esp Cardiol 2008;61:1287

Male, 26 years old, he consults due to palpitations

ORAL PROPAFENONE 450 mg

Male, 40 years old, no heart disease, palpitations

5 h

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.

LA

LSVP

Anatomia e Histologia de venas pulmonares Anatomy and histology of pulmonary veins

Myocardial bands

MECHANISM OF AF AND OBJECTIVES OF ABLATION

Haissaguerre et al. Circulation 1997;95:1120

FOCUSED TRIGGERS IN PULMONARY VEINS

TECHNIQUE OF ELECTRIC DISCONNECTION OF PULMONARY VEINS

LSPVLIPV

RSPV

RIPV

LSPV

LIPV

CIRCUNFERENTIAL ISOLATION

ANTRUM

PRE-RF LSPV POST-RF LSPV

VP

S

PRE

ABLATION

POST ABLATION

A A AAV V V V

DESCONEXION ELECTRICA VP-AI

120 mseg

FA

REGISTRO DE VENAS PULMONARES

A A A A

Ablación unión VP-AI

PULMONARY VEIN ABLATION – Potential mechanisms

• PV and foci isolation

• Removal of focused triggers

• Modification of substrate

• Autonomic denervation (vagal plexi)

AF ABLATION IN REFERENCE CENTERSRESULTS

ABLATION OF AF RECURRENCE

Pappone et al J Am Coll Cardiol 2003;42:185–97)

70% success50% 2nd RFA2-3% complic.

NEJM 2004;351:2373

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%

European Guidelines of Cardiology 2010

Circulation 2005;111:1100

AF ABLATION IN THE REAL WORLD

COMPLICATIONS

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 SPANISH REGISTRY OF ABLATION 20072007

1,624 accessory pathways: mortality = 1,624 accessory pathways: mortality = 1/10001/1000

2,065 nodal reentry: mortality = 2,065 nodal reentry: mortality = 0.5/10000.5/1000

Spanish Registry of Ablation 2007Complications

Rev Esp Cardiol 2008;61:1287

CURRENT INDICATIONS OF AF ABLATION

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

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.

• 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 ablationLong term

3-D navigation system of AF ablation

LA

VPSD

VPSI

VPIILAA

Catéter circular

Catéter de ablación

USEFULNESS OF 3-D NAVIGATORS

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

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.

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.

Thank you for your attention!!