Transcript Diapositiva 1 - Cardioaritmie

Risultati e complicanze dell’ablazione
transcatetere della fibrillazione atriale
Dott. Giovanni Carreras
U.O.S.Aritmologia
Ospedale S. Maria
Terni
Atrial Fibrillation
• The most common significant heart rhythm
disturbance
• Incidence increases with age and the development of
structural heart disease
• Common cause of stroke (10-15% of all strokes)
• Associated with significant cardiovascular morbidity
and mortality
• Tends to recur in at least half the patients treated
with antiarrhythmic drug therapy
AF is associated with a high risk of mortality
2.3 million US adults currently have AF. This will
increase to more than 5.6 million by the year 2050.
Purpose of the study: to provide a systematic multicenter
survey on the incidence and causes of DEATH occurring
in the setting of or a consequence of Catheter Ablation of
Atrial Fibrillation (1995-2006)
546 centers worldwide identified / 162 partecipating
45.115 procedures / 32.569 patients
Survey - Main Carachteristics
• Male
patients: 61,9 %
•Proportion of centers based on Nr. Of Procedures/Year:
<20
21-50
51-100
>100
35%
28%
24%
13%
Proportion of centers w. Experience in one ablation technique:
Lasso Technique
27%
Carto-guided TechniqueTechnique 48%
Other Techniques
4%
Combination
22%
Effects of sex on the incidence of cardiac tamponade after
catheter ablation of atrial fibrillation: results from a
worldwide survey in 34 943 atrial fibrillation ablation
procedures.
• CONCLUSIONS: Tamponade during AF ablation
procedures is relatively rare. Women have an
≈2-fold higher risk for developing this
complication. The risk of tamponade among
women decreases substantially in high-volume
centers. Surgical backup and acute
management skills for treating tamponade are
important in centers performing AF ablation.
Clinical and procedural predictors of early
complications of ablation for atrial fibrillation: Analysis
of the national registry data.
•
CONCLUSION
• The risk of early complications is increased by female
sex, hypertrophic cardiomyopathy, valvular heart
disease, deep sedation, and complex fractionated atrial
electrocardiogram ablation. It is decreased by
preprocedural transesophageal echocardiography,
periprocedural novel oral anticoagulant,
come ridurre il rischio?
• Effettuare la procedura in regime di
anticoagulazione
• Utilizzo NOA durante e dopo la procedura
• Utilizzare TAC o RMN
• Utilizzo ICE o TEE
• Monitoraggio attento parametri vitali
• Controllo temperatura esofagea
• Valutare età e comorbidità del paziente
A novel radiofrequency ablation catheter using contact
force sensing: Toccata study.
Kuck KH1, Reddy VY, Schmidt B, Natale A, Neuzil P,
Saoudi N, Kautzner J, Herrera C, Hindricks G, Jaïs P,
Nakagawa H, Lambert H, Shah DC.
• CONCLUSIONS: Catheter ablation using real-time CF
technology is safe for the treatment of SVT and AF. High
CFs may occur during catheter manipulation and not just
during ablation, suggesting that measuring CF may
provide additional useful information to the operator for
safe catheter manipulation. In the future, CF-sensing
catheters may also increase the effectiveness of RF
ablations by allowing better control of the RF lesion size
Paroxysmal AF catheter ablation with a contact force sensing catheter: results
of the prospective, multicenter SMART-AF trial.
Natale A1, Reddy VY2, Monir G3, Wilber DJ4, Lindsay BD5, McElderry HT6,
Kantipudi C7, Mansour MC8, Melby DP9, Packer DL10, Nakagawa H11,
Zhang B12, Stagg RB12, Boo LM12, Marchlinski FE13.
• CONCLUSIONS: The SMART-AF trial demonstrated that
this irrigated CF-sensing catheter is safe and effective
for the treatment of drug refractory symptomatic PAF,
with no unanticipated device-related adverse events.
The increased percent of time within investigatortargeted CF ranges correlates with increased freedom
from arrhythmia recurrence. Stable CF during
radiofrequency application increases the likelihood of 12month success.
Atrial Fibrillation Mechanisms
meccanismi operativi
TRIGGERS
SUBSTRATO
GANGLI VAGALI
RF
ROTORI
triggers dalle Vene Polmonari
RF
Firing VPSL
Haissaguerre,
NEJM ‘’98
Dominant source of triggers
Role in the maintenance
• Firiing focali a scarica continua (Jaïs)
• Firiing focali intermittenti (O’Donnell, Kumagai,
Oral)
• Rientro (Arora, Hocini, Wu, Mansour, Jais)
One shot to PVI
Risultati ablazione FA parox
• Considerando i risultati dei vari studi
pubblicati negli ultimi 10 anni la
percentuale di successo nel trattamento
della fibrillazione atriale parossistica,
inteso come mantenimento stabile di ritmo
sinusale si attesta tra il 70 ed il 90% in
assenza di terapia antiaritmica
Come aumentare la percentuale di
successo
• Mappaggio accurato
• Ricerca foci extrapolmonari
• Validare stabilità del risultato mediante
adenosina e/o isoprenalina
• Controllo blocco in uscita ed entrata
• Utilizzo tecnologia contact force
• Evitare jump durante rogazione
J Cardiovascular Electrophysiol Vol 16 November 2005
Conclusions
Termination of long-lasting
persistent
AF can
be
achieved in 87% of patients
by catheter ablation.
Contemporary Challenges of Catheter Ablation for Atrial
Fibrillation.
Weerasooriya R1, Shah AJ2, Hocini M2, Jaïs P2, Haïssaguerre M2
•
•
•
The use of contact force-sensing technology, adenosine testing after
ablation, and pace capture-guided ablation all have the potential for
achieving more durable ablation. Selection of patients suitable for ablation
of persistent AF may be improved by assessing the extent of atrial fibrosis
with delayed enhancement imaging with cardiac magnetic resonance or by
assessing the pattern of atrial electrical activity with the use of complex
atrial electrograms. Advances in treatment are likely to result from the
recognition of localized rotors and focal sources as primary sustaining
mechanisms for all types of human AF and in the use of noninvasive
mapping for their identification. Linear ablation to supplement PVI may
improve the results of AF ablation.
IMPLICATIONS:
Rapidly unfolding advances in the techniques of AF ablation and the
understanding of mechanisms of AF hold promise for improving the
durability of PVI and for extending the technique to carefully selected
patients with persistent AF.
Pulmonary veins to left atrium cycle length gradient
predicts procedural and clinical outcomes of persistent
atrial fibrillation ablation.
Pascale P1, Shah AJ2, Roten L2, Scherr D2, Komatsu Y2, Ramoul K2, Daly M2,
Denis A2, Derval N2, Sacher F2, Hocini M2, Jaïs P2, Haïssaguerre M2
• BACKGROUND:
• Rapid pulmonary vein (PV) activity has been shown to
maintain paroxysmal atrial fibrillation (AF). We evaluated
in persistent AF the cycle length (CL) gradient between
PVs and the left atrium (LA) in an attempt to identify the
subset of patients where PVs play an important role.
• CONCLUSIONS:
• The PV to LA CL gradient may identify the subset of
patients in whom persistent AF is likely to terminate after
PV isolation or limited substrate ablation and better longterm outcomes are achieved
Tailored Atrial Substrate Modification Based On
Low-Voltage Areas in Catheter Ablation of Atrial
Fibrillation.
Rolf S1, Kircher S2, Arya A2, Eitel C2, Sommer P2, Richter S2, Gaspar T2,
Bollmann A2, Altmann D2, Piedra C2, Hindricks G2, Piorkowski C2.
• CONCLUSIONS: -LVAs can be found at preferred sites
in 10% of patients with paroxysmal AF, and in 35% of
patients with persistent AF. This is the first clinical report
describing a consistent voltage-based approach for
substrate modification in addition to circumferential PVI
irrespective of AF type. Application of this limited
individualized approach may have the potential to
compensate for the impaired 12-months outcome of
patients with endocardial structural defects.
Randomized ablation strategies for the
treatment of persistent atrial fibrillation:
RASTA study.
Dixit S1, Marchlinski FE, Lin D, Callans DJ, Bala R, Riley MP, Garcia FC, Hutchinson MD, Ratcliffe SJ, Cooper JM,
Verdino RJ, Patel VV, Zado ES, Cash NR, Killian
•
CONCLUSIONS
• These data suggest that additional
substrate modification beyond PVI does
not improve single-procedure efficacy in
patients with persistent AF
The atrial fibrillation ablation pilot study: a European Survey
on Methodology and results of catheter ablation for atrial
fibrillation conducted by the European Heart Rhythm
Association.
• Success without antiarrhythmic drugs was achieved in 40.7% of
patients (43.7% in paroxysmal AF; 30.2% in persistent AF; 36.7% in
long-lasting persistent AF). A second ablation was required in 18%
of the cases and 43.4% were under antiarrhythmic treatment. Thirtythree patients (2.5%) suffered an adverse event, 272 (21%)
experienced a left atrial tachycardia, and 4 patients died (1
haemorrhagic stroke, 1 ventricular fibrillation in a patient with
ischaemic heart disease, 1 cancer, and 1 of unknown
•
CONCLUSION: The AFib Ablation Pilot Study provided crucial information
on the epidemiology, management, and outcomes of catheter ablation of
AFib in a real-world setting. The methods used to assess the success of the
procedure appeared at least suboptimal. Even in this context, the 12-month
success rate appears to be somewhat lower to the one reported clinical
trials.
A-Fib vs. EP Labs