2008 roma, convegno updating in cardiologia. l'ablazione della fibrillazione atriale

Stefano Nardi, MD, PhD

AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNIDIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE

UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA

La terapia ablativa della La terapia ablativa della Fibrillazione AtrialeFibrillazione Atriale

L’ entusiasmo dell’ L’ entusiasmo dell’ elettrofisiologoelettrofisiologo

C O N V E G N OUPDATINGDI CARDIOLOGIA15 novembre 2008Auditorium ex I Clinica MedicaPoliclinico Umberto I - ROMA

Atrial FibrillationAtrial Fibrillationanalysisanalysis

9,6

13,4

15,3

18

25,7

28,9

49,8

0 10 20 30 40 50 60

SOLVD (I I -I I I )

V-HeFT (I I -I I I )

CHF-STAT (I I -I I I )

ATLAS (I I I )

DIAMOND-CHF (I I -I I I )

GESICA (I I -IV)

CONSENSUS (IV)

Prevalenza FA (%)

• All AFib affected pts have an increased Morbidity

• The overall increased Mortality is 1,6-2,6% (Manitoba and Framingham Studies)

• 5% year ischemic stroke

• 1/6 Cerebro-Vascular Accident (CVA)

• Framingham StudyRHD 17 X rate of CVA Risk of Stroke increased with age (1,5% 50-59 yrs vs 23,5% at 80-89 yrs)

MagnitudeMagnitude

FA

CURA controllo clinico

controllo FARipristino RS

controllo clinico

parossistica permanentepersistente

Atrial FibrillationAtrial Fibrillationdifferent strategiesdifferent strategies

L’importanza di seguirela giusta via

AFFIRM

STAFSTAF

PIAPIAFF

HOT CAFÉHOT CAFÉ

PAF-PAF-22

RACRACEE

• Paroxysmal Atrial Fibirllation 2 (PAF2) Eur Heart J ’02

• Pharmacological Intervention in AF (PIAF) Lancet ’00.

• Comparison of rate control and rhythm control in pts with AF (AFFIRM) NEJM ‘02.

• Randomized trial of rate-control versus rhythm CTR in PeAF: the Strategies of Treatment of AF (STAF) study. JACC ‘03.

• Effect of rate or rhythm control on QoL in PeAF: results from the Rate CTR vs ECV (RACE) Study. JACC ‘ 04.

• How to treat C-AF (HOT-CAFÉ`) New New DehliDehli

Atrial FibrillationAtrial FibrillationRandomized TrialsRandomized Trials

- Strategies based to maintaining SR at 1 yrs FU without AADs is <30% (recurrence between 50-70%) ....

Pooled (meta-analysis) data from PAF2,

PIAF, STAF, AFFIRM e RACE

- … however in most cases AADs based strategies are not able to prevent RECURRENCE of A Fib.

• Global acute efficacy 40-50% (reduce in long term FU)

25% interruption of treatment !

• SIDE EFFECTS– Until 20% of cases (3-5% TdP)

• Arrhythmia-free survival after ECV in pts with PeAF

Lower Curve Outcome after a single shock when no prophylactic AADs was given

Upper curve Outcome with repeated ECV in conjunction with AADs prophylaxis

Pooled (meta-analysis) data from PAF2,

PIAF, STAF, AFFIRM e RACE

The original AFFIRM STUDY

One year later…

AFFIRM revisited…AFFIRM revisited…



“l’importanza di usare gli STRUMENTI giusti

therapeutic Approachtherapeutic ApproachAtrial FibrillationAtrial Fibrillation

Atrial FibrillationAtrial FibrillationTherapeutic ApproachTherapeutic Approach

Electrophysiologic Electrophysiologic BackgroundBackground

Pulmonary vein anatomy

TRIGGERTRIGGER

RF


TRIGGERTRIGGER

Haissaguerre, NEJM ’98

Action Potential, Ca++ and Contractility in AFib pts

1.1. Reduction in amplitude and increase in duration of Reduction in amplitude and increase in duration of APAP

Control Control A FibA FibAP (EAP (Emm))

[Ca[Ca2+2+]]ii

ContractioContractionn

2.2. Reduction in the upslope and downslop of the CaReduction in the upslope and downslop of the Ca++++ transienttransient

3. Parallel reduction in the upslope and downslop of the peak developed tension

ContractionContraction

[Ca2+]i[Ca2+]iAP (EmAP (Em))

Atrial Fibrillation histopathology

• Karpawich (‘90) – Canine mod.– LA myofibril disarray was found after 4

months of AFib

– Appearance of prominent cells in subendocardium, variable-sized mitochondria, and dystrophic calcification

• Adomain (‘86)– Myofibril disarray was found in 75%

of canine hearts after 3 months of pacing from AFib

• Karpawich (‘99) – Pediatric Pts– Myofibril hypertrophy, intracellular

vacuolation, degenerative fibrosis, and fatty deposits in the LA after more than 3 years of AFib

Left common trunk 3 right lower veins

Normal


TRIGGERTRIGGER

The Antral Zone

Hocini M, Card. Res ’02, Circulation ‘02

SUBSTRATESUBSTRATE

Atrial Fibrillation ApproachAtrial Fibrillation ApproachAnatomical considerationsAnatomical considerations

Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture





Atrial Fibrillation ablationAtrial Fibrillation ablation

Inferomediale

Infero-laterale

VPIL

VPSL

Atrial Fibrillation ablationAtrial Fibrillation ablationPVs anatomyPVs anatomy

Ma qual’è l’impatto delle nuove tecnologie ?

Atrial Fibrillation ablationAtrial Fibrillation ablationPVs activity mappingPVs activity mapping

Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction




Mandapati, Circulation `00Haissaguerre, NEJM ’98

SubstrateSubstrateTriggerTrigger

Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms

Atrial Fibrillation ablationAtrial Fibrillation ablationPVs trigger ablationPVs trigger ablation

SUBSTRATE modificationSUBSTRATE modification


Atrial Fibrillation ablationAtrial Fibrillation ablation3D Mapping System3D Mapping System


Atrial Fibrillation ablationAtrial Fibrillation ablationAnatomical considerationsAnatomical considerations



Atrial Fibrillation ablationAtrial Fibrillation ablationduring AF ablationduring AF ablation

Circumferential lesion pathway

PVPs

Atrial potentials

Lesion Validation (Preablation)Lesion Validation (Preablation)

Incomplete lesion

Lesion Validation Lesion Validation ((AblationAblation))

Complete lesion

Lesion Validation Lesion Validation ((AblationAblation))

Atrial potentials breakdown

PVPs disappearance

Lesion Validation Lesion Validation ((PVPs PVPs AbolitionAbolition))

0.1mV

0.05mV

Validazione delle lesioniValidazione delle lesioni ((abbattimento dei abbattimento dei potenzialipotenziali))

Atrial Fibrillation ablationAtrial Fibrillation ablationVagal GangliaVagal Ganglia

Atrial Fibrillation ablationAtrial Fibrillation ablationVagal GangliaVagal Ganglia

Atrial Fibrillation ablationAtrial Fibrillation ablationPVs analysisPVs analysis





137 pz (età media: 62 a)

FA parossistica o persistente

Randomizzazione a tx antiaritmica da sola o in associazione ad ablazione transcatetere (ablazione circonferenziale, lesioni lineari in AD e AS)

End-point: assenza di recidive aritmiche (>30 s) ad un f.u. di 1 anno

Recidive aritmiche: 91.3% farmaci vs 44.1% farmaci + ablazione

Complicanze maggiori: 4.4% (solo in relazione all’ablazione)

• Anatomia avversa e variabile per la realizzazione di un isolamento elettrico completo

• Rischio di recidiva di conduzione attraverso una linea di blocco INCOMPLETA

OSTACOLO CONSEGUENZA

• Difficoltà alla realizzazione di lesioni transmurali all’orifizio delle VP

• Rimodellamento elettrico

• Volume consistente di tessuto aritmogeno tra l’orifizio della VP e la linea di blocco

• Vulnerabilità all’innesco di FA in risposta a triggers non clinici (BESV da siti innocenti)

Atrial Fibrillation ablationAtrial Fibrillation ablationPITFALLPITFALL

tipo di FAtipo di FA cardiopatia sottostantecardiopatia sottostante

isolamento delle VP isolamento delle VP (ostiale, antrale, (ostiale, antrale, ecc)ecc)

ablazione ablazione circonferenzialecirconferenziale

lesioni lineari aggiuntivelesioni lineari aggiuntive ablazione in aree a ablazione in aree a

conduzione rallentataconduzione rallentata

effettivo isolamento VP

Riduzione/modifica del substrato

Δ tono autonomico

creazione di barriere elettriche complete e non

non inducibilità della FA

recidive aritmiche recidive aritmiche sintomatiche/asintomatichesintomatiche/asintomatiche

utilizzo terapia antiaritmicautilizzo terapia antiaritmica

Disomogeneità Disomogeneità delle popolazioni delle popolazioni

arruolatearruolate

Differenze della Differenze della tecnica ablativatecnica ablativa

End-point End-point procedurali non procedurali non

uniformiuniformi

Metodologia del Metodologia del follow-upfollow-up

“l’importanza di TROVARE il bandolo della matassa

181/777 181/777 Laboratori in tutto il mondo Laboratori in tutto il mondo8.7458.745 pz da 90 Laboratori pz da 90 Laboratori10.19910.199 ATC x FA (90% in ASn) ATC x FA (90% in ASn)PERIODOPERIODO:: 1995 – 2002 1995 – 2002SUCCESSO CLINICOSUCCESSO CLINICO::

52% (52% (3,866 pts) senza f. antiaritmici senza f. antiaritmici75.9% (7408 pts) con f. antiaritmici75.9% (7408 pts) con f. antiaritmici

Worldwide AFib SurveyWorldwide AFib Survey

Cappato R, Circulation ‘04


Who benefits from AF ablation ?Pts selectionPts selection

Ablazione Ablazione dell’FAdell’FA

Disertori M, et al. GIAC 2006Disertori M, et al. GIAC 2006

Linee Guida AIACLinee Guida AIAC

Ablazione Ablazione dell’FAdell’FA

Disertori M, et al. GIAC 2006Disertori M, et al. GIAC 2006

Linee Guida AIACLinee Guida AIAC

What is success?

• Complete freedom of AF, off drug RX?• No symptoms, but drug Rx required?• Dramatic decrease in symptoms, but

AADs still required?• QoL• How do we detect asymptomatic

episodes?• Anticoagulation ………………...?

QUESTIONSQUESTIONS

Mickelson S, JICE ‘05

Cappato R, Circulation ‘05

In US EP believe 29% of pts with AF are candidates for RFCA

• Lower volume centres have lower success rates and higher complication rate


Scientific Paper

• Results coud be Results coud be matched with matched with hystorical hystorical clinical data clinical data

Registry

“Real life” results

Clinical PracticeAcceptance degree of

randomized studies in clinical practice

Prospectic data retrived of clinical aspects in pts already implanted with a PM

Evaluation of clinical benefits due to specific PM functions (ex. Impact of special modality on several specific “end-point”)

Hp, Control groups,

economic evaluation

CLINICAL Practice VS Registries

Courtesy of Dr. Botto

TherapyTherapy

MortalityMorbidity

QoL

“l’importanza di trovare le giuste “PROPORZIONI”

Impact of AFib ablation




Esophageal contiguity with LA3D mapping system in AFib3D mapping system in AFib

Atrial Fibrillation ablationAtrial Fibrillation ablationCCH ptsCCH pts

LA Medial-RPV Junction

RPV Carena

LAA-LSPV Junction

LAA-LIPV Junction

LPV Carena

LAA-LSPV Junction

MV IsthmusLSPV-LAA Junction

PRE-ABLATION POST-ABLATION


Seeking answers, but Seeking answers, but what about some what about some

questions?questions?Who benefits from

AF ablation ?

What we can do ?

Selezione dei pts che possono beneficiare

dell’ablazione dell’FA: l’importanza di fare la

SCELTA giusta

Atrial Fibrillation ablationAtrial Fibrillation ablationPVs potential ablationPVs potential ablation



Atrial Fibrillation ablationAtrial Fibrillation ablationSurface EKGSurface EKG

Atrial Fibrillation ablationAtrial Fibrillation ablationEGM 25 mmEGM 25 mm




Who benefits from AFib ablation?




Health & Medicine

2008 roma, convegno updating in cardiologia. l'ablazione della fibrillazione atriale