73
Young&Hoon Kim, MD Arrhythmia Center, KUMC www.korea&heartrhythm.com Korea University Medical Center Seoul, Korea Procedural Endpoints and Predictor s of Long&term Outcome after Persi stent AF Ablation 2015 Venice Arrhythmia

Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

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Page 1: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Young&Hoon(Kim,(MD

Arrhythmia(Center,(KUMC( www.korea&heartrhythm.com(

Korea(University(Medical(Center(Seoul,(Korea(

Procedural(Endpoints(and(Predictors(of(Long&term(Outcome(after(Persi

stent(AF(Ablation(

2015(Venice(Arrhythmia

Page 2: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

AF#Ablation#

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#####(B)(Standard(lesion(set(Circumferential(antral(PV(ablation(lines(around(ipsilateral(PV(pairs(Additional(ablation(points(at(the(carina(No(linear(ablations(for(PAF(unless(induced(or(clinical(atrial(flutter(((C)(Standard(endpoints(Electrical(pulmonary(vein(isolation(Electrically(unexcitable(ablation(line(Absence(of(dormant(conduction(with(rapid(administration(of(adenosine(Confirm(non&PV(foci(are(no(longer(induced(

KUMC#Standard#Approach#for#PAF#

Page 4: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

AF#Ablation:###Other#than#PVI,#it#does#not#have#an#indisputable#mechanistic#basis.##It#is#empirical,#not#truly#individualized#on#the#basis#of#mechanism.##

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Heart#Rhythm#2008;5:1658#–1664

Page 6: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Heart#Rhythm#2008;5:1658#–1664

Freedom#from#Recurrent#AF/AT#after#2#Ablations#in#the#Absence#of#AADs

Page 7: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Circ Arrhythm Electrophysiol. 2014;7:841-852

Page 8: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Circ Arrhythm Electrophysiol. 2014;7:841-852

Page 9: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Circ Arrhythm Electrophysiol. 2014;7:841-852

Page 10: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Circ Arrhythm Electrophysiol. 2014;7:841-852

Page 11: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia
Page 12: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Perhaps#neither#complex#electrograms#nor#lines#are#the#correct#supplemental#targets#for#ablation.##More#selective#targets#may#be#needed#to#better#characterize#an#individual#patient’s#specific#arrhythmic#substrate.

Page 13: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

STAR#AF#II#Confirms#PVI#is#not#sufficiently#effective#in#treating#persistent#AF#(60%#of#freedom#from#AF).##AF#termination#with#CFAE#ablation#was#achieved#in#only#45%,#which#may#explain#the#poor#prognosis#in#this#group.##Standard#unipolar#ablation#do#not#reliably#produce#the#permanent#transmural#and#longitudinally#continuous#lesions.#####

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Circulation. 2009;119:1758-1767

MRI EAM

Minimal DE

Moderatel DE

Extensive DE

Page 15: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

!  Late gadolium enhancement (LGE) of Cardiac MR (CMR) is accepted as a powerful tool for detecting atrial fibrosis.

!  Utah group (CARMA Center) demonstrated that the amount of LGE had an excellent correlation with clinical outcome.

Circulation+2009;119:1758–67

J+Cardiovasc+Electrophysiol+2011;22:16–22

Implication#of#cardiac#MR#in#AF

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The#extent#of#late#gadolinium#enhancement#of#entire#LA#wall#surface#was#58%.

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Lee#DI,#HRS#2015,#Unpublished

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Lee#DI,#HRS#2015,#Unpublished

LA#DE#MRI###

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Biatrial#ABL#failed#to#terminate#AF.##AF#recurred##6#months#after#ablation.

LA#DE_MRI#is#of#value#to#predict#ablation#success#and#follow#up#outcome.##

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Freedom(from(AF(after(Catheter(Ablation(in(Recent(Study

0#

20#

40#

60#

80#

100#

Paroxysmal(AF(

85%

54% 66%

0#

20#

40#

60#

80#

100#

Persistent(AF(

MANTRA(&PAF(

NEJM(2012

RAFFT&2(JAMA(2014

Wilber(et(al(JAMA(2010

Calkins(et(al(Circ(2009

SARA(EHJ(2014

STAR(AF&II(NEJM(2015

57% 60% 59%

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Circ#Arrhythm#Electrophysiol.#2014;7:281_287.

Page 22: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

CHA2DS2_VASc,#R2#CHADS2#score#were#associated#with#clinical#outcome.##

Circ#Arrhythm#Electrophysiol.#2014;7:281_287.

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Page 24: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

DC#energy#parameters#for#successful#CV#before#RFCA#were#useful#predict#the#long_term#outcome.##

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Pre&Ablation(Evaluation(

Predictors#of#Long_term#Outcome#

1.#AF#duration##

2.#Clinical#type##

3.#LA#size#and#volume#

#

#

#

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Pre&Ablation(Evaluation(

In#addition,#!  The#extent#of#LGE#on#MRI,##!  Stroke#stratification#schema#(CHA2DS2_V

ASc,#R2_CHADS2#score)##!  DC#energy#parameters####can#be#used#to#predict#successful#ablation.#####

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During(Ablation((

Page 28: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Heist############143#####PeAF+LSPeAF SR:25%######################################################################################################AT:75%

Recurrence#during#F/U

AF#term#(+):#48%#AF#term#(_):##58%,#p<0.05

66%# Visual#or#C#or#NavX

Authors##########n###########Subjects###############CFAE#########ABL####AF#termination

S#or#M

Zhou###########200####PeAF+LSPeAF S# SR:16%######################################################################################################AT:47%

63%# Visual AF#term#(+):#46%#AF#term#(_):##57%,#p=0.15

Elayi############306#####LSPeAF Visual S#or#M SR:3%######################################################################################################AT:97%

58%# AF#term#(+):#17%#AF#term#(_):##18%,#p=ns

Yoshida######100#####PeAF Visual S# SR:3%######################################################################################################AT:97%

39% AF#term#(+):#38%#AF#term#(_):##52%,#p<0.01

Fiala#############194#####PAF+PeAF+####################################LSPeAF

Linear#(_)#CFAE

S# SR:34%######################################################################################################AT:66%

##50%# AF#term#(+):#30%#AF#term#(_):##63%,#p<0.05

Elayi,###########144#####LSPeAF##CPVA,#47######2008###########################################PVAI,#48##########################################CFAE+PVAI,#49#Visual

M 13%#44%#74%

72%#17%##6%###########################P<0.001

2010

Estner###########35#####PeAF Visual M# SR:35%######################################################################################################AT:65%

AF#term#(+):#22%#AF#term#(_):##34%,##p=ns

66%#

Park############140######LSPeAF NavX_3D####S############68% SR:24%######################################################################################################AT:76%

AF#term#(+):#45%##AF#term##(_):#69%,#P<0.01

Relationship(of(AF(Termination(with(Clinical(Outcome((

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J#Cardiovasc#Electrophysiol,#Vol.#23,#pp.#1051_1058,#October#2012

Termination#of#AF#during#catheter#ablation#is#associated#with#a#better#clinical#outcome.##

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#Clinical#Predictors#

of#Termination#and#Clinical#Outcome#of#Catheter#Ablation#

for#CAF##

Matsuo#S#et#al.#J#ACC#2009;54:789_95#

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1

0.8

0.6

0.4

0.2

0

0 0.2 0.4 0.6 0.8 1

142(msec

21(months

Sens

itivity

1(&(Specificity

(Surface(AFCL(

(

Area(under(the(ROC(curve(=(0.880(Standard(error(=(0.039(95%(CI(=(0.795(to(0.939(P((Area(=(0.5)(<(0.0001(

(Duration(of(AF(

(

Area(under(the(ROC(curve(=(0.844(Standard(error(=(0.068(95%(CI(=(0.752(to(0.912(P((Area(=(0.5)(<(0.0001(

Predictors#of#AF#Termination�

! (Surface(ECG(AFCL(>142(ms(! (Duration(of(continuous(AF(>21(months(

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M/54,#AF#for#5#years,#LA#=#51.0mm###

High(RA

LA

Mean(CL(=148ms

Mean(CL(=210ms

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Mean(AF(CL(=(averaging(30(consecutive(cycles(measured((at(high(RA(and(LA

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AF(termination(during(stepwise(ablati

on

AF(termination(during(PVI

AF(termination(during(LA(ablation

AF(termination(directly(to(SR

Longer#AF#cycle#length#can#predict##better#success#with#minimal#ablation.###

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M/50#,#1st#AF#ablation#for#PAF

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#One#year#after#ablation

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no#reconnected#all#PVs

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J+Cardiovasc+Electrophysiol,+Vol.+26,+pp.+739D746,+July+2015

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Trigger#Evaluation,##IRAF#after#DC#shock#under#Isoproterenol#

SVC

RSPV

LSPV

Isoproterenol#10#~#20#ugm

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Lasso((

SVC(

Page 41: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Lasso((

SVC(

Effective(Trigger(test(can(uncover(the(origin(of(AF.

HRA

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"  It#remains#to#be#determined#whether#######the#“inducibility#test#after#termination”#of#long_######lasting#persistent#AF#improves#the#outcome.#

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Clinical#Significance#of#Induced#AT#After#Termination#of#Longstanding#Persist

ent#AF#Using#a#Stepwise#Approach

Nagamoto#and#Kim,#JCE#2012

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AT

Entrainment(mapping(Electroanatomical(mapping(

Catheter(ablation

Sinus(Rhythm

Induction((Burst(pacing(with/without(ISP

Inducible

Ablation#for#Long_lasting#Persistent#AF

Stepwise(approach((1.(PVI+(2.(CFAE(map(guided(biatrial(ablation((

Endpoint(of(the(procedure

Non&inducible

Page 45: Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome ... · Procedural(Endpoints(and(Predictor s(of(Long&term(Outcome(after(Persi stent(AF(Ablation(2015(Venice(Arrhythmia

Post&PVI,(CFAE(Guided(AF(Ablation(

Nagamoto#and#Kim,#JCE#2012

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Pa#ents(with(LPAF((underwent(((

AF(abla#on((n=194)

Figure(2(

converted(AT(

(n=75,(39%)( AF(

(n=119,(61%)(

Induced(AF((

(n=49, 25%) NonHinducible(

(n=37,(19%)(

Inducibility(test(

Induced(AT(

(n=108,(56%)(

SR(

Clinical#Significance#of#Induced#AT#After#Termination#of#Longstanding#Persistent#AF#Using#a#Stepwise#Approach

Nagamoto#and#Kim,#JCE#2012

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# RFCA(targeted(induced(ATs(with(longer(CL((((((((>270(ms)(after(termination(of(PeAF(decreased((((((recurrence(rate(of(AF/AT.((

Inducibility(test(after(termination(of(long&lasting(persistent(AF(

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Persistent(AF(Ablation Post(4PVs(Isol

ation 4PVs+(LA(CFAE(

+(RA(CFAE

AF#sustained

49%((converted#AT#or#SR

51%((AF#sustained

56%(AF#sustained#LA#Vol.#127.1#±#40.6########RA#Vol.#142.2#±#50.2

≒72%#converted#AT#or#SR

4PVs+(LA(CFAE

44%(converted#AT#or#SR#LA#Vol.#119.9#±#35.0##################RA#Vol.#122.4#±#37.9

Chen%and%Kim.%J%Cardiovasc%Electrophysiol,%2013;24(9):949_57

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RA(volume(145(mm3(predicting(AF(termination(during(RA(CFAE((ablation.(Sensitivity(of(51%(and(Specificity(of(73%.(

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No.(at(Risk AF(termination(((((((46((((((((((((((27((((((((((((((17((((((((((((((12(((((((((((((((7((((((((((((((((2((((((

No(AF(termination(47((((((((((((((21((((((((((((((13(((((((((((((((7((((((((((((((((5((((((((((((((((2((

Months after Blanking Period

AF

or A

T fr

ee s

urvi

val (

%)

AF termination during RA ablation

No AF termination

Log Rank p=0.004

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# RA#CFAE#clustered#at#specific#anatomical#structures#####such#as#the#RAA#and#crista#terminalis,#and#that#####additional#RA#CFAE#ablation#terminated#AF#in#≈50%#of#####patients#with#LPeAF#in#whom#LA#ablation#alone#was#####unsuccessful.##

Kim(YH.(Circ(J(2012;(76:(1299(–(1306�

Automated(CFAE(Guided(RA(Ablation(

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Contact#force#catheter

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•  Thirty_two#patients#with#PAF#underwent#PVI#using#cat

heter#with#a#CF#sensor#(TactiCath#Set).#

•  They#were#followed#for#12#months.#

EFFICAS#I,#II#:#CF#guided#ablation#improved#efficacy.#

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Heart#Rhythm2015;12:1990–1996#

9#studies#(#2#RCT,#7#observational),#1148#patients

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From(technical(standpoint,(to(achieve(transmurality(remains(great(challenges.

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Achievement(of(Transmurality

Gen%Thorac%Cardiovasc%Surg((2014)(62:428–433

0#

20#

40#

60#

80#

100#

<1.0# 1.0_2.0# 2.0_3.0# 3.0_4.0# 4.0_5.0# >5.0#

Transmurality

Single# Double# triple#

Wall##Thickness##[mm]

Tran

smural#Lesions

#[%]

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The(Success(rate(of(Catheter(Ablation(is(Lower(than(that(of(Surgical(Treatment

1.  (Difficulty(of(transmural(ablation(

2.  (Disparity(between(epicardial(and(endocardial(potential(

3.  (Gap(and(conduction(recovery(of(linear(ablation(

#

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The(Limitation(of(Linear(Ablation(

$  Achievement(of(complete(conduction(block(remains(challenging(and(conduction(recovery(is(common.##

JCE%.%2006.%vol.%17,%pp.%1106D1111

$  Conduction(recovery(in(previous(LA(linear(ablation

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Hybrid(Percutaneous(Epicardial(Catheter(Ablation(with(Endocardial(

Ablation(of(AF((

Hybrid(endo&(and(epicardial(catheter(ablation(via(subxiphoid(puncture(is(relevant(and(feasible(in(patients(with(high(risk(for(left(side(pulmonary(vein(stenosis(and(those(with(suspicious(intra&

cardiac(mural(thrombus.((((((((((((

(((((((((((H&N(Pak(&(Y&H(Kim(et(al.(JCE(2007;18:917&23(((((((((((((J&I(Choi,(H&N(Pak((&(Y&H(Kim(et(al.(Circ(J.(2009;73(2):384&7(

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During(Ablation((

•  AF#cycle#length#before#ablation#influences#the#result#of#procedure.###

•  Trigger#test#can#uncover#the#origin#of#AF#outside#PVs.##•  Clinical#outcome#is#better#in#patients#with#AF#terminati

on#during#ablation.#•  New#technology#(CF)#and#ablation#strategy#(epi_endoca

rdial#ablation#and#hybrid#ablation)#can#improve#the#clinical#outcome.#

#

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In#a#considerable#instances,#AF#is#mere#result#of#risk#factor#

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3743#patients#AF

The(result(of(AF(ablation(is(poor(in(patients(with(OSA(and

(can(be(improved(by(CPAP(in(those(patients.(

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•  BP#<#130/80#mmHg#in#office#a

nd#24_h#ambulatory#BP#meas

urements#

•  High#protein#and#low#glycemi

c#index#food#%#weight#decre

ase#up#to#10%#

•  Lieft#style#modification#of#sta

tin#%#LDL#<#100#mg/dl##

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Risk#factor#reduction#facilitate#the#rhythm#control#st

rategies.#

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Post(Ablation((

•  Risk#factor#reduction#including#(HTN,#DM,#OSA,#obesity….)##is#important#after#AF#ablation.#

#

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Pre&Ablation(Evaluation(

In#addition,#!  The#extent#of#LGE#on#MRI,##!  Stroke#stratification#schema#(CHA2DS2_V

ASc,#R2_CHADS2#score)##!  DC#energy#parameters####can#be#used#to#predict#successful#ablation.#####

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•  AF#cycle#length#before#ablation#influences#the#result#of#procedure.###

•  Trigger#site#evaluation#can#uncover#the#origin#of#AF#outside#PVs.##

•  Clinical#outcome#is#better#in#patients#with#AF#termination#during#ablation.#

•  New#technology#(contact#force#catheter)#and#ablation#strategy#(epi_endocardial#ablation#and#hybrid#ablation)#can#improve#the#clinical#outcome.#

#

During(Ablation((

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•  Risk#factor#reduction#including#(HTN,#DM,#OSA,#obesity….)##is#important#after#AF#ablation.#

#

Post(Ablation((

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•  The#clinical#outcome#can#be#predicted#successfully#based#on#several#pre_,#during#and#post_ablation#parameters.#

•  Tailored#ablation#approach#based#on#these#predictors#can#effectively#improve#the#result#of#AF#ablation.###

#

Pre&Ablation(Evaluation( During(Ablation(( Post(Ablation((

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Korea#University#Medical#Center