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9/14/2019
1
Ablation of Persistent AF: What to do Beyond PV Isolation
Aman Chugh, MDSeptember 13, 2019
CHRSSan Francisco, CA
Disclosures
• Biosense-Webster – research support
• Boston Scientific – research support
• Abbott– Fellows education course
Outline
• Pathophysiologic differences b/w paroxysmal (PAF) and persistent (Ps) AF
• Evidence for mapping and ablation outside the PVs in patients with Ps and longstanding (LS) Ps AF
• Present an intuitive, evidenced-based approach to catheter ablation of Ps AF
Permanent AF
Increasing AF
No AF
Platonov JACC 2011
Fibrosis and fatty infiltration correlated w/ lymphocyte infiltration (ie, inflammation)Fibrosis – cause or consequence of AF?
PAFPs AF
9/14/2019
2
0
5000
10000
15000
20000
25000
30000
1LAA
2Base
3Ridge
4LtAntrum
5RtAntrum
6Anterior
7Posterior
8Roof 9
9aMI
9bInferior
9cCS
p
c
‡ ‡
§
§
‡¶
¶
¶ ¶
ap
pe
nd
age
ba
se
of
LA
A
rid
ge
an
terio
r w
all
po
ste
rio
r w
all
roo
f
se
ptu
m
mitra
l is
thm
us
infe
rio
r w
all
CS
left
PV
A
rig
ht P
VA
LA regions
Paroxysmal
Persistent
0.75
1.50
2.25
Am
plit
ud
e (
mV
)
NS
† †
Structural differences b/w Ps and PAF
Yoshida…Chugh Heart Rhythm 2010
5.5
5.6
5.7
5.8
5.9
6
6.1
6.2
6.3
6.4
Paroxysmal AF Persistent AF
DF
(H
z)
Paroxysmal AF
Persistent AF
P=0.0006
Electrical remodeling – faster drivers
Paroxysmal AF
(N=18)
Persistent AF
(N=40)
P
Age 58±8 59±10 0.71
Gender (M/F) 14/5 33/7 0.44
Body mass index (kg/m2) 27±3 32±5 0.0001
Sleep apnea syndrome 3 (17%) 7 (18%) 0.94
Hypertension 6 (32%) 25 (63%) 0.03
Diabetes 1 (6%) 2 (5%) 0.93
Period from the first diagnosis of
AF (month)
54±38 53±47 0.96
Duration of continuous AF (month) N/A 26±19 -
LA pressure (mmHg) 10±4 18±5 <0.0001
LA diameter (mm) 38±4 48±6 <0.0001
LA volume indexed (ml/m2) 43±10 68±20 <0.0001
Ejection Fraction (%) 64±7 (during
SR)
58±7 (during
AF)
-
Yoshida…Chugh HR 2010
Ghanbari et al HR 2014
Is PAF really different from Ps AF?
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3
0 3 6 9 12 15 18 21 24 27 30 33 36 39
Months
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Cu
mu
lati
ve P
rop
ort
ion
Fre
e f
rom
AF
Freedom from Recurrent AF after PV Isolation
Paroxysmal AF (234)
Persistent AF (20)
P<0.001
Oral et al Circ 2001
Cu
mu
lati
ve P
rop
ort
ion
Fre
e f
rom
AF
Longstanding Ps AF - PVI alone was able to
establish long-term SR in only 24% (49 of 202)
Tilz et al JACC 2012
Sanders et al JCE 2006
ms ms
Ps AF – no Δ in global AF CL with PVI PAF – progressive increase in AF CL with PVI
DF of PVs: 8.8 HzDF of LA: 6.9 Hz
∇ : 1.9 Hz
DF of PVs: 11 HzDF of LA: 5.8 Hz
∇ : 6.2 Hz
Why aren’t PVs enough in persistent AF?
PV-LA gradient (∇ )STAR AF 2: PV isolation is all you need for Ps AF?
Verma NEJM 2015
With or without AAD
PVs alone – 41% after one procedure
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4
STAR AF 2
Takeaways
• Unproven adjuncts
– automated “CFAE” algorithms – “lack of pathophysiologic
relevance” (Lau et al HR 2015)
• Ambiguous endpoints (linear ablation/procedural)
• If AF →AT, cardioverted at operator discretion
• Did additional ablation do anything to AF?
– Was AF slowed? If not, targets were not identified
• Excellent single center results not reproducible
• 20% of patients presented in sinus rhythm – how
applicable to patients presenting in AF? * ** **
180250
Septal LAd
II
Septal LAp
Septal RA
180 80?
CS
V1
LA
180
LAd
V1
RFA
Continuous electrical activity - specific but uncommon
Most ”CFAEs” are generated by far-field activity (Narayan et al HR 2010)
Our eyes are appear to be better than algorithms in ascertaining FF EGMs/local activation rates
@ inferior LA
Linear block across mitral isthmus? s/p endo/epi (CS) RFA and EtOH VOM
CS3-4
CS5-6
CS1-2
CS7-8
Abld
Ablp
V1
CS9-10
S
RidgeLAA
S
145
S S
Ridge – RFA endo MI
180
Avoid mitral isthmus
O.K., So what then
• Approach must be
– Evidenced-based – proven
– Unambiguous
– Intuitive
– Practical, with conventionally available tools
9/14/2019
5
Case
• 50 yo man with LS Ps AF since 2013
• AVR for congenital AS
• CV – SR for seconds
• Ef 35% and CHF
• RFA on 1/2015
– PVI for rapid PV tachycardia
– AF persists
CSd
CSp
Abld
V1
RAA
RFA @ low posterior LA
Last f/u 2/2019–SR without AADEf 50%
CSd
CSp
Abld
V1
RAA
AF terminates to SR
What’s next after PVI?
Posterior Wall Isolationprovenunambiguousprevents roof dependent atrial flutter
(Heart Rhythm 2016;13:132–140)
Bai et al
Conclusions – “ePVAI+LAPW is still associated with a significant high incidence of very late recurrence of atrial tachyarrhythmia.”
Abld
V1
LAA
CSd
V1
Abld
PV
LIPV
Abld
Ablp
V1
Case
• DK
BaselineLAA CL 178
LAA<LIPV
AF Persists despite PVI
OK, LA is driver but how to target? PVs/Posterior LA – out; CS – slow→ LAA driver
CS
LAA
V1
RAA
Post PVI/PWILAA=162 ms
RAA=200 ms
∇
V1
RAA
CSd
CSp
* AF terminates to AT during RFA around LAA
9/14/2019
6
V1
II
aVF
CSd
CSp
V1
Abld
Ablp
ECG – AT 240
RFA at posterior RA, Eustachian ridge, and finallyat CTI terminates AT
Endpoint of LAA RFA – AF terminationSR without AAD for 4 years
Case
• 52 yo man with permanent AF since 2013
• DC CV 1995
• PVI 2010 at OSH – PV stenosis
• “Mini-maze” 2013
• Worsening effort intolerance
• RFA 11/2018
Posterior LA
LAA 137
V1
CS
LA
LA
V1
CS
LA
LA
V1
CS
LAA
LAA
Septum–slow activity
640
150
V1
CS
LAA
LAA
LAA
After extensive ablation around LAA, entrance block into LAA
Endpoint of LAA RFA – slowing of conduction into LAALAA no longer driving AFLAA as driver – proven and unambiguous*
LAA
RAA
CSd
CSp
178
161
III
V1
∇
Case-
• 54 yo man Ps AF
• AF persists post PVI, PWI, LAA RFA
• RA to LA gradient
9/14/2019
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Where to ablate in RA? SVC?
AF termination sites in RA
Hocini et al JACC 2010
RAA
V1
RAA
SVC
SVC288 ms
179 ms
• 90 patients Ps AF
• 26 (29%) required RA ablation
• RA targets: RAA, lateral RA, lateral TA, RA roof
• Follow up of 21±18 months
– 53 of the 64 patients in the LA only group (83%)
– 20 of the 26 patients in the RA group (77%) in SR w/o AAD (p=0.57)
Ghannam…Chugh HRS 2014
Lateral RAAbase
CSd
CSp
V1
50 ms
Extremely fast bursts from RAA (20 Hz!)
AF terminates to AT after RFA at RAA
*CSd
CSp
V1
Abld
CSd
CSp
V1
Abld
Ablp
Termination w/o global capture @ MILinear block achieved
RAA driver – intuitive, evidence-based
SR w/o AAD for 6 yrs
230 230
S S S S
230
LAA
RAA
SVC
Tricuspid
valve
CS
LPV
Cut-Sew Maze
Anatomically based
9/14/2019
8
CASE
• 76 yo woman with persistent AF since 2013
• Recurrence despite cardioversion and propafenone
• s/p stenting of RCA
• RFA 10/2015
CSd
CSp
V1
III
LIP
V
Right PVs isolated
AF terminates to SR during RFA of L PVs
What would you do next?A. Linear ablation at LA roofB. Linear ablation at mitral isthmusC. Nothing moreD. Linear ablation at CTI
Noninducible with isoproterenol and rapid pacing
SR w/o AAD x 4 years
Procedural details
• Persistent AF - 2-3 procedures
• RF duration 60-80 minutes
• If AF terminates to AT, map and ablate
• Procedure time 4-5 hours
• AT/”atypical atrial flutter” is unavoidable in most patients
• If AF recurs after first procedure – Likely RA ablation (30% of patients)
• Emphasis on AF termination during 2nd procedure
• 80% without antiarrhythmic medications
• Complications 1%
• No perforation during LAA/RAA RFA
• Secondary prevention measures
Summary
• Ps and LS Ps AF – more structural and electrical alterations cf. PAF
– Calls for a measured, more aggressive approach than PVs
• Mapping during AF – identification of drivers; not possible during SR
• Tailored to patient
– if AF terminates with PVI – no reason to do more
– If AF terminates during LAA RFA, don’t need to isolate LAA
• ATs are unavoidable in most if we wish to get rid of AF
• Whichever approach →must show that fibrillatory process was affected – was AF slowed or terminated?
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