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Novel ablation• Contact
– Smart touch/Tacticath/VerisenseContiguous lesion• Endoscopic ablation systems
– laser balloon– virtual electrode catheter
• Mayo balloon
Deeper lesion• Bipolar ablation• Infusion needle RF catheter
Laser balloon• First human case published by Reddy et al. Circulation 2009 Jul 7;120(1):12-20
Dukkipati SR et al.Circ Arrhythm Electrophysiol. 2010,3:266-73
Chronic Histology (10 PVs/120 sections)
Circumferentiality 100%
96.7% of sections were transmural
• Multicentre non-randomised trial with 200 patients
• ‘PV isolation can be achieved in virtually all patients using a single VGLA catheter with an efficacy similar to radiofrequency ablation’. Dukkipatti etal, Circ EP 2013
Europace. 2014 Jul 16. pii: euu168
194 patients between Jan 2009 & May 2013
• Multicentre non-randomised trial with 200 patients
• ‘PV isolation can be achieved in virtually all patients using a single VGLA catheter with an efficacy similar to radiofrequency ablation’. Dukkipatti etal, Circ EP 2013
• Heartlight study (NCT01456000)
• Prospective randomised against RF
• 150 patients 5 European centres
Direct endocardial visualization catheternow ceased-Voyage Medical no longer
Journal of Cardiovascular ElectrophysiologyVolume 23, Issue 1, pages 88-95, 13 SEP 2011
Heart Rhythm 2011 8, 361-367
Saline acts as virtual electrode rather than conducting heat– DEV greater surface area -16W 2xRF – no difference in depth– no difference in transmurality– 12W ablation same as 30W RF
RF 30W vs DEV catheter 14W&16W
Ablation in patients
Heart Rhythm 2011 8, 361-367
Desimone et al Translational Research July 2014
• Pace• Ablate with RF or DC energy• Drug elution – antiproliferative
agent• DC energy for electroporation
(7.5mA, 7kHz, 60-300sec)
• 2 balloons – inner inflated with air, outer with heparinised saline
• Ablation 30-50W
Desimone et al Translational Research July 2014
Deeper lesions
Korean Circ J 2014;44(4):210-217
Bipolar ablationCatheter ablation of the ventricular septum with radiofrequency energyRing et al. Am Heart J. 1989 Jun;117(6):1233-40.
Unipolar ablation
Bipolar ablation no-contact 50W
Bipolar ablation 50W
Bipolar ablation 20W
Bipolar ablation misaligned 50W
Pacing and Clinical ElectrophysiologyVol 33;1:pages 16-26, 28 DEC 2009
Heart Rhythm Volume 9, Issue 12, Pages 1932-1941 (December 2012)
Koruth et al Bipolar irrigated radiofrequency ablation: A therapeutic option for refractory intramural atrial and ventricular tachycardia circuits
• Basal LV free wall max thickness• Unipolar 50W 25ml/min• Bipolar 50W 25ml/min
All bipolar ablations achieved transmurality
Gizurarson S et al. Europace 2014 Feb 19
Unipolar n=9
Bipolarn=4
Depthmm
6.1 (+/-1.7) 14.8(+/-0.5) P<0.001
Widthmm
7.8(+/-3.4) 9.8(+/-1.9) P=ns
9 explanted human hearts
Some small series, all patients with failed unipolar ablation
Teh et al• 4 patients• 24-45K PVCs/day• RVOT & Ao root pre QRS
• Initially failed unipolar ablation at earliest sites
J Cardiovasc Electrophysiol. 2014 Jun 2
20mm between ablation tips
Patient 1 2 3 4
Median 4/12 f/u
No PVCs EF 44-62%No PVCs
EF 30-44%PVCs 0.6%
failed
Heart Rhythm 2012 9, 1932-1941
Koruth et al Bipolar irrigated radiofrequency ablation: A therapeutic option for refractory intramural atrial and ventricular tachycardia circuits
No. pts
No. circuits targeted w bipolar abl
Circuits terminated
Pts w recurrence
Pts requiring repeat proc
Pts w recurrence after last proc
Afl 3 5 5 3 3 1(AF)
Septal VT 4 6 5 2 1 1
Free-wall VT 2 3 2 0 0 0
• 27 gauge needle• Extends to 12mm
Sapp J L et al. Circulation. 2013;128:2289-2295
Irrigated RF needle ablation
Journal of Cardiovascular ElectrophysiologyVolume 17, Issue 6, pages 657-661, 1 MAR 2006 DOI: 10.1111/j.1540-8167.2006.00439.x
Use in VT ablation
Concluding…
• New ablation technologies are getting better at forming contiguous and deeper lesions ?transmural
• Rapid introduction of new technologies makes comparison difficult
• Epicardial & hybrid approaches
• Focus on shorter procedure times with better ablation but without new or more frequent complications
Thank you
