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Cardiovascular Surgery and Electrophysiology: Where are the
opportunities for a Combined Interdisciplinary approach in Atrial
Fibrillation?Felix Yang, MD, FACC, FHRS, CCDS
Associate Director, Cardiac ElectrophysiologyDepartment of Cardiology
Maimonides Medical Center
11/2018Philadelphia
Relevant Disclosures
• Consulting fees from Atricure, BiosenseWebster, Boston Scientific, Abbott
Paroxysmal AF Success Rates
PVI alone ~70% Success
PVI plus more extensive ablation ~70-80%
Catheter Ablation ofLong-Standing Persistent Atrial Fibrillation5-Year Outcomes of the Hamburg Sequential Ablation Strategy
Roland Richard Tilz, MD, Andreas Rillig, MD, Anna-Maria Thum, Anita Arya, MD, Peter Wohlmuth, Andreas Metzner, MD, Shibu Mathew, MD, Yasuhiro Yoshiga, MD, Erik Wissner, MD, Karl-Heinz Kuck, MD, Feifan Ouyang, MD
Hamburg, Germany
JACC Vol. 60, No. 19, 2012
Last ablation
First ablation
Catheter Ablation ofLong-Standing Persistent Atrial Fibrillation5-Year Outcomes of the Hamburg Sequential Ablation Strategy
Roland Richard Tilz, MD, Andreas Rillig, MD, Anna-Maria Thum, Anita Arya, MD, Peter Wohlmuth, Andreas Metzner, MD, Shibu Mathew, MD, Yasuhiro Yoshiga, MD, Erik Wissner, MD, Karl-Heinz Kuck, MD, Feifan Ouyang, MD
Hamburg, Germany
Journal of the American College of Cardiology Vol. 60, No. 19, 2012
AF <2 yrs
AF > 2 yrs
Multipleprocedure success
Limitations of Catheter Ablation Beyond PVINeed to Address Chronic Progressive Disease
High Late Recurrence Rate (VLR) in Successfully ablated patients (e.g. SR off AADs @ 1 year). • Persistent patients recur at a much higher rate than paroxysmal. • Patients with multiple risk factors also have a much higher recurrence rate.
Steinberg JS. Very long-term outcome after initially successful catheter ablation of atrial fibrillation. Heart Rhythm2014;11:771–776.
10 yrs
Parox
Persistent
HTN & persistent
PAF, no HTN
HTN or Persistent
Approaches to Catheter Ablation for Persistent Atrial Fibrillation
Atul Verma, M.D. et al for the STAR AF II Investigators
N Engl J Med 2015; 372:1812-1822
Singleprocedure success
What is the best method to deal with persistent atrial fibrillation?
Clinical factors associated with limited efficacy of AF ablationLong standing persistent AF
AF ablation can also be offered to those with persistent and long standing persistent AF but the expected efficacy is less.
Sleep apnea
Increased left atrial size (> 5.5 cm)
Increased age (> 70 yrs)
Severe obesity
“Frequently the factors that limit use of standard catheter ablation most often occur in patients who need the ablation the most”
HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation. Calkins H et al. Heart Rhythm 2007; 4(6): 816-61
Methodologies of AF ablation• A: The circumferential ablation lesions that are
created in a circumferential fashion around the right and the left PVs. The primary endpoint of this ablation strategy is the electrical isolation of the PV musculature.
• B: Some of the most common sites of linear ablation lesions. These include a “roof line” connecting the lesions encircling the left and/or right PVs, a “mitral isthmus” line connecting the mitral valve and the lesion encircling the left PVs at the level of the left inferior PV, and an anterior linear lesion connecting either the “roof line” or the left or right circumferential lesion to the mitral annulus anteriorly. A linear lesion created at the cavotricuspid isthmus is also shown.
• C: Also shows additional linear ablation lesions between the superior and inferior PVs resulting in a figure of 8 lesion set as well as a posterior inferior line allowing for electrical isolation of the posterior left atrial wall. An encircling lesion of the superior vena cava (SVC) directed at electrical isolation of the SVC is also shown.
• D: Some of the most common sites of ablation lesions when complex fractionated electrogramsare targeted (these sites are also close to the autonomic GP).
Importance of the Posterior Wall
Substrate
The problem is that much substrate exists on the posterior wall
Common regions of fibrosis
Adapted from Cochet et al. J Cardiovasc Electrophysiol 2015; 26: 489.
Schematic of Progressive Atrial Remodeling
Panel A: Schematic of progressive atrial remodeling. Pericardial reflections (green lines), their attachments to the posterior left atrium, and their relation to proposed high stress regions. Panel B: Ganglionated plexi (yellow) and epicardial fat (green). Left superior ganglionated plexi (LSGP), left inferior ganglionated plexi (LIGP), right anterior ganglionated plexi (RAGP), right inferior ganglionated plexi (RIGP), aortocaval ganglionated plexi (ACGP)
There are also additional factors that contribute to the AF substrate
The Risks of Posterior wall collateral injuryBut how can we safely treat
this substrate?
Convergent vs Thoracoscopic AF Ablation Lesion Set
Panel A: Schematic of the Convergent procedure lesion pattern relative to the high stress regions. Panel B: Thoracoscopic hybrid AF ablation lesion set. Hybrid AF ablation utilizing a thoracoscopic approach commonly involves pulmonary vein isolation, a roof line, posterior box line, exclusion of the left atrial appendage (blue lines). Endocardial ablation is performed to confirm bidirectional block across the lines and create a cavotricuspid isthmus line (red dotted line). Additional ablation may be performed to create an intercaval line, mitral line, and at ganglionated plexi.
How is convergent AF ablation performed?
EPi-Sense® SystemTips & Techniques
EPi-Sense® Coagulation Device Preshape device distal end so deflects along pericardium to reach roof pericardial reflections• Connect device vacuum connection to -400 to -450 suction• Always turn vacuum “off” when moving device• Place device above cannula guidewire to separate device from pericardium Always ensure arrows and dots extending from heel of electrode are facing epicardium Make sure saline is flowing from unpressurized bag of saline prior to initiation of RF energy delivery
Dots identify direction of heating
Arrows identify direction of heatingAblation coil electrode
Sensing electrodes
Vacuum openings
Advantages of the Convergent ApproachEndocardial Ablation of Reflections Eliminates Dissections
Ablating Posterior Left AtriumNo Dissecting of Reflections
Ablating RIPV @ Reflections Ablating Reflections to Complete Isolation of PVs
EPi-Sense® Directs Heating into Epicardial SurfaceProtects Collateral Anatomy by Cooling Device
20
30
40
50
60
70
80
90
100
110
0 10 20 30 40 50 60 70 80 90
Tem
pera
ture
(C)
Time (sec)
Endocardial vs Epicardial Ablation Heating ProfileTemperature Reached Along Pericardium
[Myocardial Wall Thickness: 0.7 - 3.0mm]Catheter Ablation -
25Watts Max Tip Pressure 15g
Catheter Ablation -35Watts Max Tip Pressure 15g
Catheter Ablation -45Watts Max Tip Pressure 15g
Epicardial Ablation -nContact Device @ 30Watts
Collateral Heating, EPi-Sense Device
EPi-Sense Guides Epicardial AblationElectrogram Sensing & Pacing
Benefits
• Confirm target anatomy to ablate
Atrium vs Ventricle vs Pericardium
LAA vs Anterior Left Atrium
• Confirm lesion completeness
Visualize drop in electrogram signal
Pacing to confirm inability to capture
• Ensures posterior left atrium is ablated
No electrograms or inability to capture
Map posterior under endoscopic vision
Evaluation of Lesion CompletenessPre nContact Ablation
Post nContact Ablation
Electrophysiology portion of Convergent AF ablation
Efficacy of Convergent epicardial AF ablation. Confirmation of dense scar using endocardial electroanatomic mapping
Batul, S, Plawes, Z, Kupferstein, E, Israel Jacobowitz, IJ, Yang, F, Greenberg, Y. Maimonides Medical Center
Age 63.5 +8.9Lesions 40+6.6La size 4.77LA volume carto 162 +51BMI 33+6Dense Superior Scar 45.7%Dense Inferior Scar 52.5%Overall Dense Scar 47.68%
The Effect of Hybrid Ablation for AF on Left Atrial Function
Patel, JA, John, J, Greene, M, Chen, O, Greenberg, Y, Jacobowitz, IJ, Yang, F, Sadiq, A, Saxena, A.
Maimonides Medical Center
Pre and post-procedural echocardiograms of patients who underwent the Convergent AF ablation were evaluated for parameters of LA size and function using a rhythm independent Left Atrial Function Index .30 patients who underwent the Convergent AF ablation, 19 patients had pre and post-procedural echocardiograms where LAFI was calculated.
LA ESV Mean LAFI
Pre-procedure 104.5 ml pre-procedure 0.11
Post-procedure 92.2 ml post-procedure 0.13
p=0.048, 95% CI: 0.1 - 23.6
p=0.93, 95% CI: -0.065 - 0.060
Maimonides Persistent AF: A Difficult Substrate
• Mean age 62• Mean BMI 35.3• ~90% HTN• ~30% Diabetic• ~25% CAD• Mean CHADS 2.44• Mean LA Size 4.6cm• Mean LVEF 52%• Mean Time from First AF Dx 6.1 yrs• 18/100 with prior ablation
We had a much sicker populationThan STAR AF 2!
STAR AF2@1 year;Freedom From AF +/- AA
~50-60%
~25-30%~20-25%
~52%
Ganesan et al meta-analysis @1 year;Arrhythmia Free +/-AA; JAHA 2013
Hamburg@1 year;Arrhythmia Free +/- AA
~35%
Gaita et al@2 year;AF Free (34% on AA); Europace3/2018
~50%
Hamburg@2 year;Arrhythmia Free +/- AA
~40%
Gaita et al@3 year;AF Free (34% on AA); Europace3/2018
83%93%
OPE
N C
HEST
COX
IV
OPE
N C
HEST
COX
IV
OPE
N C
HEST
COX
IV
OPE
N C
HEST
COX
IV
73%85%
OPE
N C
HEST
COX
IV
OPE
N C
HEST
COX
IV
82%77%
Lawrence, Damiano et al; Annals of Cardiothoracic Surgery, Jan 2014
Hamburg@3 year;Arrhythmia Free +/- AA
The LAA
Watchman/Lariat
• Good data for Watchman for stroke prevention but doesn’t provide electrical isolation
• Lariat electrically isolates the LAA but more challenging to place
• Incidence of device related thrombus in patients with LAA imaging was 7.2%/year
27% of repeat ablation procedures had LAA firing
56%
28%
76%
56%
WITH LAA ISOLATION WITHOUT LAA ISOLATION
single procedure repeat procedure
Freedom From AF at 12 months
Atriclip : LAA Closure
Pro2
ProV
LAA Closure with Atriclip
Additional reasons to Close the Appendage
LAA Neurohormal interactions
• ANP is secreted by myocytes throughout the atria, with the LAA/RAA accounting for 30% of sources
• More ANP storage granules in RAA>LAA• LAA is innervated by parasympathetic and sympathetic fibers
(but not as densely as the LA posterior wall or pulmonary veins)
• Significant findings:– Persistent decline in epinephrine, norepinephrine,
renin, and aldosterone lasting at least 3 months with Lariat device
– Sustained and significant decrease in systolic and diastolic pressures of 15% and 12%
• Possible mechanisms:– Natriuretic peptide pathway (mostly short term effects)– Neurally mediated pathway
• Possibly by interruption or modification of neural reflexes by destruction of afferent fibers within the LAA or injury to peri-LAA ganglionated plexi during Lariat ligation
Combined Convergent with AtriclipEarly experience at Maimonides
• 29 patients• Age 61.5± 7.4yrs• Male 72%• BMI 34.2• CHADS2-VA2Sc 2.2 ± 1.1• Post procedure TEE performed in 12 patients
RESULTS• After 3 month blanking period only 1 patient on sotalol for VT. • 1 patient died 9 months post procedure due to MI• 5/29 discontinued a/c due to low CHADS-VASc score or increased
bleeding risk• Zero strokes / TIA• Mean f/u time 10.4 months
020406080
100
AF/AT free ±AA
AF/AT free offAA
97% 89%
Freedom from Arrhythmia
Freedom from Arrhythmia
Convergent + LAA AtriClip Closure
0
10
20
30
40
50
60
70
80
90
100
Freedom from AF off AA Freedom from ATA off AA % on AA at last follow-up
86%
14%
49 average burns / patientMean follow up time: 499 days
Average Age = 6316 Female/35 Male
7/8 recurrences were AF1/8 Atrial Tachycardia
84%
51 Patients
Updated Results