©2012 MFMER | slide-1 New methods and techniques in catheter ablation of atrial fibrillation Yong-Mei Cha, MD Mayo Clinic NCF Shenyang, 2014

©2012 MFMER | slide-1

New methods and techniques in catheter ablation of atrial fibrillation

Yong-Mei Cha, MDMayo Clinic

NCFShenyang, 2014


Patient selection for cryoablation

• Patients with symptomatic AF

• FDA has approved cryoballoon catheter for patients with paroxysmal AF

• Off-label use cryoballoon for patients with persistent AF


Cryoballoon ablation

•Ablates at the point of balloon contact

• Ice formation and thawing

•Apoptosis

•Necrosis

Hypothermic Zone

Ablation Zone (sub-zero)


How Arctic Front® Balloon Catheter and AchieveTM Work

1. Accesstargeted vein

2. Inflate and position

3. Occlude and ablate (4min)

4. Assess PV isolation

4


LIPV cryo-balloon isolation


Before balloon inflation


Pre-cryo Post-cryo Adenosine


European Clinical Study Results

Neumann Van Belle Kojodjojo

Prospective study

PAF, n=293

Persistent , n=53

PAF: 74% off AAD at 1y,

Persistent, 43%

7.5% Phrenic nerve palsy; all recovered at < 1 year

No PV stenosis

Prospective study

PAF, n=141

73% off AAD at 1 year

2.8% phrenic nerve palsy; all resolved within 6 months

No PV stenosis

Prospective study

PAF, n=90

Persistent, n=34

77% off AAD at 13m

1.8% transient phrenic nerve palsy

0.8% pericardial effusion

Neumann T, et al. J Am Coll Cardiol. 2008;52:273-278. Van Belle Y, et al. Europace. 2008;10:1271-1276. Kojodjojo P, et al. Heart. 2010;96:1379-1384.


0

25

50

75

100

0 3 6 9 12 15 18

MonthsMonths

Fre

e fr

om

AF

(%

)F

ree

fro

m A

F (

%)

Koiodioio Heart 2010

Months after ablationMonths after ablation 00 66 1212 1818CryoablationCryoablation 9090 7979 6969 2626Radiofrequency ablationRadiofrequency ablation 5353 4242 3333 1212

ConventionalConventionalCryoCryo

KM free from AF


CARTO® SMARTTOUCH™ 3D Technology

•Catheter‐tissue contact is critical for effective lesion creation

•Ablating with consistent power, increase in contact force: Increases lesion size, Increases incidence of steam pop/perforations

LOCATION SENSOR* Detects micro-movement of transmitter coil

TRANSMITTER COIL Sends location reference signal

PRECISION SPRING* Provides consistent movement in response to contact force


Below Threshold Within Threshold Above Threshold<5g 5-30g >30g


•Allows to monitor the stability, consistency, and amount of contact force on the tissue

•Based on user defined parameters, display ablation data including:

Total TimeImpedance TemperaturePowerForce Over Time (NEW)Average Force (NEW)

Force Time Integral: is acalculation of force and time, in gram seconds

CARTO®SMARTTOUCH™ Technology


Minimal contact and time

Minimal contact and time

Maximal contact and time

Maximal contact and time

Increased contact and time

Increased contact and time


Contact Force Sensing for Pulmonary Vein Isolation in Paroxysmal AF

Marijon: JCE, 2014

• Randomized study

• SmartTouch Thermocool n=30

• Thermocool n=30

• Complete PVI in all patients

• Fluoro time 20 min vs 27 min

• RF time 45 min vs 65 min

• AF recurrence

• Contact force 10.5%

• Noncontact force 35.9%DaysAt risk

(no.) 0 3-mo 6-mo 9-mo 12-moCF 30 30 29 28 27Control 30 30 25 22 21

P=0.04

CF group

Control group


nMARQ™ Multi-Ablation Technology

• Combining multi-ablation capability with irrigation technology

• Uniform irrigation at the site of tissue contact. Each nMARQ™ Catheter boasts 10 irrigation holes per electrode completely surrounding the electrodes for more efficient cooling

• Multi-electrode Mapping (MEM) allows you to acquire multiple mapping points simultaneously

• Ablate with any or all of the 10 catheter electrodes

• The nMARQ™ Technology enables full visualization of the catheter loop and electrodes


Comparison of different ablation technologies used for PVI in treatment of paroxysmal AF

TechnologyAcute success (%)

Procedure time (min)

Fluoroscopy time (min)

n

Conventional RF ablation

97.6 165 24 2870

Cryoballoon ablation

97.5 160 34 905

Visually guided laser ablation

98.8 200 31 200

PVAC 100 133 30 89

nMARQ catheter

100 110 23 25

Shin DI, Heart Rhythm. 2014


• Highly accurate hybrid electroanatomical mapping system provides an optimal blend of magnetic and impedance technologies, accuracy ≤ 1-2mm

• Continuous mapping – No point-by-point acquisition collecting thousands of points

• Eliminate need for time consuming manual annotations

• Superior resolution & signal quality

• Clearly assess gaps and lesions

The Rhythmia™ Mapping System


• Open basket 64 low-noise electrodes

• 2.5 mm inter-electrode spacing 192 intracardiac channels + Surface ECG

• 8.5F, bi-directional steerability

• 8 smooth, flexible splines, variable diameter (3-22mm) for use in various anatomical

structures

• Flushing port designed to preventclot formation

• Potential lasso alternative during PVI

IntellaMap Orion™ High-Resolution Mapping Catheter


Carto System• Physician accepts each point in manual process• 30 minutes: 276 usable points

Rhythmia Medical System• Proprietary algorithm sorts inputs from 64-pole basket in real time• 10 minutes: 3,689 usable points


Find the gap

Source: Nakagawa H, Rapid high resolution electroanatomical mapping: evaluationof a new system in a canine atrial linear lesion model. Circulation Arrhythmia Electrophysiology. 2012 Apr;5(2):417-24


V3

CS

Bip1-2

Uni 1

Uni 2

Double potential

Left Atrial Activation Map During AT59M, Prior Ablation of AFx4

Channel/gap

Fractionated


Topera’s RhythmView™3D Electrophysiological Mapping System

• Multi-polar FIRMap™ catheter• Single beat mapping of the whole heart

chamber all at once • Advanced signal processing algorithms • Self referenced map• Rapidly analyze of the arrhythmia

64 evenly-spaced electrodes


Treatment of Atrial Fibrillation by the Ablation of Localized Sources: CONFIRM Trial

Narayan et al: JACC 60:628, 2012

Right Atrial Rotor, Left Atrial Focal Beat in AF

FIRM: Sinus Rhythm in 5.5 minutes


Treatment of Atrial Fibrillation by the Ablation of Localized Sources: CONFIRM Trial

Narayan et al: JACC 60:628, 2012

• 92 patients with paroxysmal or persistent AF

• Randomized to • FIRM guided + conventional• Conventional only

• AF termination 86% vs 20%

• After single procedure• AF free 82% vs 45%• Mean follow-up 9 months

Days

P=0.016 1st ablation

Freedom from Atrial Fibrillation

Eve

nt-f

ree

surv

ival

Entire Population

Population Off Anti-Arrhythmic Meds

FIRM-blindFIRM-guidedFIRM-blind, 1st ablationFIRM-guided, 1st ablation

P=0.006 all cases

P=0.015 1st ablation

P=0.003 all cases


Summary

• Both cryoballoon and RF ablation are effective technology for pulmonary vein isolation in patients with symptomatic AF

• RF ablation with contact force sensing and multi-electrodes ablation may improve RF ablation outcome, shorten procedure time and reduce complications

• Newer 3D mapping system will increase mapping efficiency (more accuracy, higher resolution/quality, shorter time…) to facilitate ablative therapy


Mayo Clinic


CARTOUNIVU™ Module Concept • Integration of Fluoroscopy images into the CARTO® 3 System

• Reducing fluoroscopy exposure

• Serve as virtual biplane fluoro monitor

• track vessel course during Complex EP procedures (AO root, congenital, CS)

• Assist in delineating PV Ostia


Pace Mapping Software (PASO)

1. Objectively and efficiently compares the 12 lead PVC/VT ECG morphology and the Pace Map

2. Calculates the correlation value3. Displays appropriate tag and color to the map

Clinical VT Pace Map (PM) VT-PM Matching


RVOT Pace Mapping (PaSo)

QRS match 64%


LVOT Left Aortic Cusp Pace Mapping (PaSo)

QRS match 98%


Acute Termination of Human AF by Identification and Catheter Ablation of Localized Rotors and Sources: 1st Multicenter

Experience of Focal Impulse and Rotor Modulation Ablation

Shivkumar et al: JCE 23(12):1277, 2012

2 Rotors and1 Focal Source in AF

FIRM at Rotors, Focal Beat(<10 min) Terminates AF

Documents

©2012 MFMER | slide-1 New methods and techniques in catheter ablation of atrial fibrillation Yong-Mei Cha, MD Mayo Clinic NCF Shenyang, 2014