What is catheter ablation – is it safe and who can it help?

Hugh Calkins MD Nicholas J. Fortuin Professor of Cardiology

Professor of Medicine Director of Electrophysiology

Johns Hopkins

Disclosures: None

1998

Initiation of AF from Pulmonary Vein Focus

Haissaguerre et al, NEJM 1998; 339:659-666

1998

Atrial Fibrillation – Focal Ablation Strategy

1998

Segmental Lasso Guided Ablation

Circumferential Ablation with PV Isolation

Cryo Ablation

Efficacy of Anti-arrhythmic Drugs and Catheter Ablation in Patients with Atrial Fibrillation

34 (3,481)

40 (1,813) 18 (800)

52 (4,786)42 (3,562)

31 (2,800)

50 (4,768)

0

10

20

30

40

50

60

70

80

90

Treatment success Recurrent AF Single Procedure

Success

Off AAD

Multiple Procedure

Success

Off AAD

Single Procedure

Success on AAD

or Uncertain

Multiple Procedure

Success on AAD

or Uncertain

Patients Requiring

Repeat Ablation

AAD Catheter Ablation

Meta

-analy

zed p

roport

ion o

f patients

(%

)

Catheter Ablation Antiarrhythmic Drug

Therapy

57%

72% 71% 77%

26%

46%

Copyright restrictions may apply.

Noheria, A. et al. Arch Intern Med 2008;168:581-586.

Catheter Ablation of Atrial Fibrillation Meta-Analysis of Four Randomized Clinical Trials

15

Irrigated Diagnostic/Ablation Catheter

• Steerable, multi-electrode, deflectable

• 3.5-mm tip and 3 ring electrodes

• 6 saline ports in the tip for irrigation and cooling (open irrigation)

• A location sensor and a temperature sensor incorporated into the tip

NAVISTAR® THERMOCOOL® Trial

Freedom From Chronic Failure (FDA Protocol 1° endpoint)

• N = 159 patients • 56 + 11 years • 67% male

0 100 200 300 400 500

Days

0%

20%

40%

60%

80%

100%

Tre

atm

en

t S

uccess

Primary Effectiveness Analysis Treatment Success

Blanked for Detectable AF

vs 7.3% (SE 2.9%)

CRYO 69.9% 114 / 163

DRUG 7.3% 6 / 82

30 days

KM estimate 68.6% (SE 3.9%)

OR = 29.5 (12.0 – 72.2) p < 0.001

Outcomes in 2012

Single Procedure Efficacy Multiple Procedure Efficacy Optimal Candidate: 60-80% 70-90% Moderate Candidate 45-65% 55 – 75% Poor candidate 35 – 50% 45 – 60%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year

Co

mp

licat

ion

rat

e

Complication Rates of AF Ablation at Johns Hopkins 2001 - 2010

• No deaths.

• No atrial esophageal fistulas.

• No strokes in past 5 years.

Complications in 2012

Overall Complication Rate: 1% - 4%

Stroke /TIA – 0.5% - 1% Cardiac perforation / tamponade – 0.5% - 2% Vascular injury / bleeding – 0/5% - 1% Phrenic nerve injusy 0.2% - 1% Atrial esophageal fistula - < 1/1000 Gastroparesis – 0.2% - 0.5% Death - < 1/1000

What Can I Expect if I Have the Procedure ?

• Arrive early in the morning. • Meet with team of doctors to give informed consent. • This is your last chance to ask questions. • You may be asked to get a CT scan, an MRI scan, or a transesophageal echocardiogram before the procedure. • You will be sedated duration the procedure. • Some doctors prefer general anesthesia. • Many patients have a urinary catheter inserted – especially if using an irrigated ablation catheter. • Procedure duration 3 – 5 hours.

What Can I Expect if I Have the Procedure ?

• Discharged on a blood thinner for at least 2 months. • Recover in the hospital overnight. • Feel “beat up” for 1 – 3 days. • Chest pain is common after the procedure. • AF recurrences are common during the first three month healing phase. • On discharge given phone numbers to call if questions. • Follow-up appointment in 1 – 3 months.

Heart Rhythm, EuroPace, JICE March 1, 2012

Update on New AF Ablation Guidelines

Indications for Catheter Ablation Of Atrial Fibrillation

Patient Selection for Ablation

Courtesy of Hugh Calkins, MD.

More Optimal Patient Less Optimal Patient

Variable

Symptoms Highly symptomatic Minimally symptomatic

Class I and III drugs failed 1 0

AF type Paroxysmal Long-standing persistant

Age Younger (<70 years) Older (70 years)

LA size Smaller (<5.0 cm) Larger (5.0 cm)

Ejection fraction Normal Reduced

Congestive heart failure No Yes

Other cardiac disease No Yes

Pulmonary disease No Yes

Sleep apnea No Yes

Obesity No Yes

Prior stroke/TIA No Yes

Conclusion

• Catheter ablation of AF is an effective treatment strategy for atrial fibrillation.

• The efficacy of the procedure depends on many variables including the AF type, the patient population, the definition of success, and the intensity and duration of follow-up.

• Major complications occur in 1 to 4% of patients.

• Catheter ablation of AF is indicated in the treatment of patients with symptomatic AF refractory to at least one antiarrhythmic agent.

Thank You