“Conoscere il risultato a lungo termine dopo ablazione FA...

“Conoscere il risultato a lungo termine dopo ablazione della FA è pre‐requisito per indicazioni appropriate”

Prof. Fiorenzo Gaita ‐ Università di Torino, Dipartimento di Cardiologia Asti

Key points:• 1‐What does it mean efficacy for AF ablation at the present today?• 2‐Which are the long‐term results of AF ablation?• 3‐Which are the predictors of long‐term failure of AF ablation?

Atrial Fibrilation

CMP?

valvularidiopathic

vagal

focal

SSS adrenergic

pericarditis

conduction delay

Disorganized atrial electrical activuty in only one region of the atria

F. Gaita et al. JACC 2001;37:534

Paroxysmal AF Persistent AF

Disorganized atrial electrical activity in more than one region of the atria

Long-lasting and Permanent AF

Disorganized atrial electrical activity in all the regions of the atria

Clinical Classification and substrate of AF

Different AF ablation methods

Tsai Circulation 1999; Jais Circulation 2000; Schreieck J Cardiovasc Electrophy 2002

RF ablation catheter

4 mm 4 mm 8 mm

RF ablation cooled catheter

RF ablation catheter

Evolution of AF catheter ablation strategy over the years (Oct. 1994 /Nov. 2009) = 2052 pts

11%

35%

0

20

40

60

80

100

Paroxysmal

1994–97RA Lines

Pts = 35

Complications =

0%

1998“Culprit” PV

17%

9%

0

20

40

60

80

100

Paroxysmal

Pts = 25

Complications =

13,0%

1999-2001All PV + Carto

0

20

40

60

80

100

Paroxysmal

58%

23%

Pts = 245

36%

24%

Pers

/Perm

Complications =

1,4%

2002-2005PV + 7 lines +RM

+Carto

0

20

40

60

80

100

Paroxysmal

78%

10%

Pts = 746

55%

24%

Pers/

Perm

Complications =

0,7%

2006-07PV + 7 lines

+Merge

0

20

40

60

80

100

Paroxysmal

82%

8%

Pts = 500

Complications =

0,6%

65%

21%

Pers/

Perm

Success w/o drugsSuccess with drugs

2008-09PV + 7 lines

+Merge

0

20

40

60

80

100

Parossistica

85%

6%

Pts = 501

Complications =

0,5%

74%

18%

Pers/

Perm

Procedure duration

6 h.

Procedure duration2,30 h.

Procedureduration

4 h.

Procedureduration4,30 h.



RX: 88’ RX: 94’ RX: 62’ RX: 44’ RX: 15’ RX: 8’

F-up:

1 year

“7” scheme ablationPPVV electrical disconnection validated by multipolar mapping

Three ablation options: a) Isolation of PVb) Isolation of other thoracic veins (SVC and CS)c) Ablation of fractionated atrial potentials

Haissaguerre et al. JCE 2005: 16; 1125-1137

Multifaceted approach in persistent long-lasting AF60 pts with long-lasting persistent AF (Mean duration of AF 17±27 months)

F-up: 11±6 monthsSuccess rate:SR w/out drugs: 53/60 (89%)SR with drugs: 57/60 (95%)

Success outcome: absence of all documented arrhythmia beyond the 2nd month after ablation

Complications: 1 cardiac tamponade

2 right phrenic nerve damage

1st STEP:randomization of one of the three options

2nd STEP:1° step +

randomization of the two remaining options

AF termiantion?

AF termiantion?

no

3rd STEP:adding of the

last option

no

4th STEP:adding Linear left atrial ablation

STOP

yesyes

AF termiantion?

yesno23pts (38%) required a

second procedure and 4

(7%) pts required a third

procedure

20

17

12

3

0

5

10

15

20

25

1 2 3 4

Cumulative incidence of AF termination

5% 25% 53% 87%

1• WHAT DOES IT MEAN EFFICACY FOR AF ABLATION

Gaita F. Clinical Pacing 2000 CEPR 2002;6:401.

BENUSSI 77%

RF

RF Cooled RF

RF

Cryo Cryo

Cryo

COX 93%

DENEKE 82%

MELO 69% SUEDA 68%

GAITA 80% KOTTKAMP 82% GAITA 85%

Surgical cryoablation: results with drugsPt

s in

SR w

ith d

rugs

U 7

PV

105 pts (3 groups of 35 pts)

Chronic AF and Valvular Heart Disease

Gaita et al. Circulation 2005:18;111:136

PV

Weeks

Sinus rhythm

Gaita et al. Circulation 2005. 18;111:136

…without knowing if the intended surgical lines were obtained

without drugs

20%

57%

with drugs

59%

90%

Missingsegment


The line between RIPV-MA was missing in

all the pts with “U” lesion; 41% of them also showed other patterns of incomplete

“7” lesion


In 35% of the pts with “7” lesion, the surgically intended lesion was not

achieved


PV isolation:PV potentials were recordable at least in one vein in 29% of t

Pts i

n SR

with

out d

rugs

U7

PV

Chronic AF and Valvular Heart Disease


PV

Surgical cryoablation: results without drugs and with proof of complete lesions

PV isolation + LA linear lesionsPV Isolation Fractionated

electrograms

7182

67 7469

83 83

78

87

83

0

20

40

60

80

100

Gaita 2004

Nademanee 2004

Pappone 2001

Oral 2003

Haissaguerree 2004

Oral 2003

Haissaguerre 2000

90 pts 179 pts 40 pts 35 pts

Haissaguerre 2004

40 pts 35 pts 84 pts

Hocini 2005

Hocini 2005

45 pts 45 pts

%

73%

Mean

389 pts

83%

57 pts

F-up: 36mos

82%

Mean

204 pts

PAROXYSMAL AF: efficacy at 1 year of transcatheter ablation (without drugs)

48

22

37

68 71 74 76

0

20

40

60

80

100

PV isolation + LA linear lesions

Gaita 2004

Nademanee 2004

Pappone 2001

PV Isolation

Oral 2002

Haissaguerree 2004

Fractionated electrograms

Oral 2006

72 pts 12 pts 58 pts 77 pts135 pts

Wei Lim 2006

51 pts

%

36%

Mean

135 pts

Mean

71%

270 pts

76%

60 pts

PERS/PERM AF: efficacy at 1 year of transcatheter ablation (without drugs)

2•LONG-TERM EFFICACY

Katritsis Europace 08

PVI (segmental ablation Lasso)*Antral ablation (Lasso + ICE)*Circumferential ablation (Carto)* more effective

Last procedure65% 2 or more

procedures

93% at 1y

21% at 2y

73% at 1y

35% at 2y

Long-term follow-up after PV segmental ablation for paroxysmal atrial fibrillation (39 pts)

I procedure

Transcatheter ablation of Paroxysmal AFPVI vs PVI + linear lesions

PVI + linear lesions

PVI

Gaita et al. CIRCULATION Arrhythmia Electrophysiol. 2008;1:269-275

Maintenance of SR during 36 months:


PVI

After one procedure After redo procedure

53%

29%

62%

85%

Transcatheter ablation of Persistent/Permanent AF PVI vs PVI + linear lesions


PVI

Gaita et al. CIRCULATION Arrhythmia Electrophysiol. 2008;1:269-275

Maintenance of SR during 36 months:


PVI

After one procedure After redo procedure

41%

75%

39%19%

3•PREDICTOR OF LONG-TERM FAILURE

Univariate analysisVariables Postablation AT Successes Unajusted OR P value

(95% CI)Age (years) 57,88 ± 11,25 58,57 ± 9,96 0,99 (0,96-1,03) 0,702Gender [n (%)]

F 8 (16%) 13 (13%)M 42 (84%) 86 (87%) 0,79 (0,31-2,06) 0,635

BMI (kg/m2) 27,52 ± 2,11 24,34 ± 2,13 2,11 (1,63-2,73) <0,001AF type [n (%)]

Paroxysmal 24 (48%) 84 (85%)Persistent 26 (52%) 15 (15%) 7,35 (3,05-17,7) <0,001

AF age of onset (years) 49,62 ± 10,64 51,2 ± 10,09 0,99 (0,95-1,02) 0,374AF duration (years) 68 ± 55,35 59,03 ± 42,78 1 (1-1,01) 0,277Previous cardioversions (CV/pts) 1,58 ± 1,72 0,88 ± 1,37 1,34 (1,07-1,68) 0,010Hypertension [n (%)] 22 (44%) 35 (35%) 1,44 (0,72-2,88) 0,306Structural heart disease [n (%)] 15 (30%) 10 (10,1%)

Dilated cardiomyopathy 2 (4%) 2 (2%) 1 (0,03-29,81) 1,000Hypertrophic cardiomyopathy 7 (14%) 5 (5%) 1,4 (0,07-28,12) 0,826

Valvular heart disease 5 (10%) 2 (2%) 2,5 (0,1-62,6) 0,577Congenital heart disease 1 (2%) 1 (1%)

Left atrial volume (ml) 209,82 ± 37,61 122,07 ± 32,01 1,1 (1,06-1,14) <0,001Right anatomical variants [n (%)] 26 (52%) 13 (13%) 7,17 (3,2-16,03) <0,001Left anatomical variants [n (%)] 16 (32%) 13 (13%) 3,11 (1,35-7,16) 0,008Dysthyroidism [n (%)] 13 (26%) 16 (16%) 1,82 (0,8-4,17) 0,155Fluoroscopy time (min) 53,82 ± 26,28 47,91 ± 24,2 1,01 (1-1,02) 0,175Rhythm at the beginning of the procedure [n (%)]

SR 29 (58%) 69 (70%) 0,6 (0,3-1,22) 0,157AF 21 (42%) 30 (30%)

Continuous variables are given as mean ± SD.CI = confidence interval; OR = odds ratio. In Press JCM 2010

Role of the left atrial volumeR

isk

of

recurr

ence

165 ml

225 ml

In Press JCM 2010

Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein

ablation

Berruezo A. et al. European Heart J (2007) 28, 836-841

148 pts, Paroxysmal AF 60%,M 82%, mean age 52±11,

Hypertension 33%,

Multivariable analysis:indipendent predictors of AF recurrence

after ablation procedure

Linear relationship with the increase LAD and AF

recurrences.

Hypertension increase the mean predicted proportion of pts with AF

recurrences at each LAD

Long-term efficacy for Segmental Pulmonary Vein Isolationin pts with Paroxysmal Atrial Fibrillation

Sawhney N et al.Am J Cardiol 2009;104:366-372

86% at 1 y79% at 2 y

56% > 5 y

LONG-TERM EFFICACY AFTER ONEPROCEDURE OFF ANTIARRHYTHMIC DRUGS

71 Pts with paroxysmal AF who uderwent PVI; 31 pts (44%) underwent ≥ 1 repeat ablations.

After multiple procedures 58 pts (81%)were free of symptomatic AF off antiarrhythmic drugs at 63± 5 months after their initial ablation

Age 60±9, M 77%, Hypertension 37%, Structural Heart dis. 10%, CHADS2 score 0.5, Duration of AF (y) 4.5±1.2

Sawhney N et al.Am J Cardiol 2009;104:366-372

Five-Years Outcomes After Segmental Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation

RISK FACTOR DEVELOPING RECURRENT ATRIAL FIBRILLATION

HYPERTENSION WAS AN INDIPENDENT PREDICTOR OF AF

RECURRENCE

NO HYPERTENSION

HYPERTENSION

Bertaglia E et al. Europace 2009

229 pts, drug refractory AF 177 (78%) free from any arrhythmia during a 12 months FU

CLINICAL CHARACTERISTIC LONG-TERM EFFICACY

55% at 6 y

87% at 2 y

65% at 4 y

Circumferential PV ablation

Impact of type of atrial fibrillation and repeat catheter ablation on long-term freedom from atrial fibrillation:

Results from multicenter study

Bhargava M et al. Heart Rhythm 2009; 6: 1403-1412

383 (27%) LONG-STANDING AF

1404 pts, 76% Men, mean age 55±11 y

676 (52%) PAROXYSMAL AF

293 (21%) PERSISTENT AF

Follow-up mean duration 59±16 months

Bhargava M et al. Heart Rhythm 2009; 6: 1403-1412

AFTER REDO ABLATION

Freedom from AF/AT:-PAF 89%

-PERSISTENT 71%-LONG-STANDING 68%

Impact of type of atrial fibrillation and repeat catheter ablation on long-term freedom from atrial fibrillation:

Results from multicenter study

153 pts, age 56±10, M 85%, Long-lasting persistent AF 54%Mean duration sustained AF 21.8 ±33 months

23 pts (15%) non-termination130 pts (85%) procedural termination (108 via intermediate AT- 22 DC to SR)

64/130 (49%) pts repeat Procedures (6 AF and 58 AT)

15/23 (65%) pts repeatprocedures (9 AF and 7 AT)

Median Follow up 34 months

Long-term Follow-up of persistent atrial fibrillation ablation using termination as a procedural endpoint

O’Neill M., Haissaguerre M et al European Heart Jourtnal (2009) 30,1105-1112

O’Neill M. Haissaguerre M. et al European Heart Journal (2009) 30:1105-1112

124/130 (95%)

12/23 (52%)

ATRIAL FIBRILLATION TERMINATION AND LONG-TERM FOLLOW UP (34 months)

AFTER ONE PROCEDURE

79/153 (52%) pts uderwentrepeat procedures

8/23 (35%)

66/130 (51%)

AFTER THE LAST PROCEDURE

O’Neill M. et al European Heart Journal (2009) 30:1105-1112

90%

54%50%

100%

Long-term Follow-up of persistent atrial fibrillation ablation using termination as a procedural endpoint

Duration of persistent AFprior to the ablation procedure

AF cycle lenght measured in the left atrial appendage

Variable HCM(n = 26)

Other cardiopathies(n = 26)

idiopathic (n = 26)

Total 64% 65% 77%PAF 77% 77% 85%FA

Perst/Perm 50% 54% 69%

Success

Total population : 78 pts

AF radiofrequency catheter ablation results in patients with HCM, other cardiomyopathies and idiopathic AF

Gaita et al, Am J Cardiol 2007;99:1575–1581

F-up: 19±10 months

24/41 pts (59%) with redo procedure

PAF 25 (71%) - Pers/Perm 16 (61%)

Mean F-up34±16

months

Final success rate41/61 pts (67%)

Cardiology Department – Asti , Florence and Bordeaux

32/61 total pts (52%) with redo

procedure

Major complications: none

Long term f-up results in patients with HCM and AF RFCA

0

10

20

30

40

50

60

70

I I I I I I

NYHA Functional Class

p=0.02

RFC

A Fa

ilure

(%)

0

10

20

30

40

50

60

Parox Persist Perm

p=0.44

Type of AF

RFC

A Fa

ilure

(%)

0

10

20

30

40

50

60

70

<130 130-150 >150

p<0.001

Left Atrial Volume (ml)

RFC

A Fa

ilure

(%)

Predictors of outcome

In Press Europace 2010

•In a long term follow-up the “PVI + linear

lesions” scheme is significantly more

effective than the “PVI alone” , but often

multiple ablation sessions are required

•Absence of recurrences at 12 month follow up

can not be considered permanent success sinceAF recurrences are possible in the long-termespecially utilizing the “PVI” ablation scheme.

CONCLUSIONS

Duration of continuous AF

FAILURE SUCCESS

Increased Left Atrial Size

CONCLUSIONS

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