1. Ablacion de Venas Pulmonares:Pasado, Presente, y Futuro 9 de Octubre, 2010 Javier E. Sanchez MD Texas Cardiac Arrhythmia Institute St. Davids Medical Center Austin, Texas

2. Texas Cardiac Arrhythmia Instituteat St. Davids Medical Center Austin, TexasElectrophysiologistsResearch Fellows/Nurses David Burkhardt MD Luigi DiBiasi MD Prasant Mohanty MD Shane M. Bailey MD Yan Wang MD Robert C. Canby MD Deb Cardinal RN Rodney P. Horton MD Chantel Scallon RN Barbara Thomas RN G. Joseph Gallinghouse MD Elva Brown RN Andrea Natale MD Jackie Kin RN Larry Price DO Karla Wolter RN Wendy Brandhorst RN Javier E. Sanchez MD Maegen Lane RN Jason D. Zagrodzky MD Cindy Williams RN 3. G. Neal Kay 4. Meta Proveer una perspectiva personal de comonuestro campo surgio, como haevolucionado, y como progresara en elfuturo cercano 5. PASADO 6. Surgical Cox Maze Procedure Cox JL. Cox J Thoracic Card Surg 1991;101:406 and J Cardiovasc Electropysiol 2004;2:250 7. Surgical Cox Maze Series 276 patients (Sept 1987-June 2003) Lone surgery on 160 Concomitant surgery on 113 MV only 33 CABG 40 Ao V + CABG 2 Others concomitant procedures on 38 J Thoracic and Cardiovasc Surg 2005;129:104 8. Success rate with Maze ProcedureJ Thoracic and Cardiovasc Surg 2005;129:104 9. Success according to duration of AFbefore surgeryJ Thoracic and Cardiovasc Surg 2005;129:104 10. Maze may not cure all Afib, but itdramatically decreases the incidence of strokesPrior stroke,No ACRisk factors,no ACPrior stroke,with ACRisk factors,with ACLone AF, ACMaze, noACJ Thoracic and Cardiovasc Surg 1999;118:883 11. Catheter Maze ProcedureThe First Catheter Ablation Procedure for AF J Swartz .Circulation 1994;90:I-335 Patient with chronic AF, CHF, and a LA of 5.8x 7.5 cm was treated with linear ablations in apattern similar to the maze surgery. Duringprocedure, arrhythmia progressively organizedand eventually converted to sinus rhythm. Later extended the series to 10 patients Never published as a full manuscript 12. Catheter Maze Procedure Swartz, Kay, Packer 1995-1996 23/29 in sinus rhythm off antiarrhythmictherapy after 2 years of follow up (79%success) Another 2 that previously had chronic AF,converted to PAF Limitations Procedure duration ~12 hrs Many complications: VF, tamponades, 2strokes, PV stenosisNever published as a full manuscript 13. Catheter Maze Procedure:First Published Series Haissaguerre JCE1996;7:1132 45 patients 3 groups in base of RA ablation pattern If AF after RA ablation, LA ablation offered Linear ablation done first. If Atrial tachycardias noted they were mapped and ablated. 14. Catheter Maze Procedure:First Published Series: Haissaguerre , JCE1996;7:1132 15. Catheter Maze Procedure:First Published Series: Haissaguerre , JCE1996;7:1132Focal ablation of atrialtachycardias done in thesuperior PVs, the highcrista and the CS os 16. Left Superior PVRight Anterior Oblique Left Anterior Oblique 3 17. Initial Linear Ablation System Designed for Catheter Maze ProcedureKay, Ellenbogen, Calkins 18. Initial Linear Ablation System Designed for Catheter Maze ProcedureKay, Ellenbogen, Calkins Am Heart J 1999; 83:227D 19. Initial Linear Ablation System Designed for Catheter Maze ProcedureKay, Ellenbogen, Calkins 20. Strategy Patients with structural heart disease;with permanent or persistent atrialfibrillation RA ablation LA ablation Focal ablation (which really meant PVablation, although it wasnt called that in initialprotocol) Calkins et al. Am Heart Journal 1999;83:227D 21. Results 49 Patients underwent RA linearablation; in 7, SR obtained 28 Patients underwent LA linear ablation In 13, sinus rhythm was obtained; in 5, AFconverted to paroxysmal PV isolation performed in 19: in 15, SR obtained; in 2, AF converted to paroxysmal; in 2, AF persisted (overall 71% success rate) Calkins et al. Am Heart Journal 1999;83:227D 22. 62% Success Rate at 8 + 6 Months 25%45% 9%16%94%(Hassaguerre M et al. NEJM 1998; 339: 659-66) 23. Aislamiento de las Venas Pulmonares(Ablacin en segmentos) Resultados clnicos mas sostenidos Menos estenosis de las VPs Resultatado en FA crnica menos de 35% 24. Circulation 2000;101:1409-1417 3 25. Segmental Ostial AblationRAO LAO 26. Ablation at 2 segmentsaround this vein achieveselectrical isolation of the PV Circulation 2000;101:1409Recordings from inside the PV 27. Basket in Right Superior PVRight Anterior Oblique Left Anterior Oblique 28. Before Segmental Ostial Ablations Circulation 2003;108:590 29. After Segmental Ostial Ablations Circulation 2003;108:590 30. An uncommon case 31. Basket in Left Superior PVRight Anterior Oblique 3 Left Anterior Oblique 32. Basket in Left Inferior PVRight Anterior Oblique 3 Left Anterior Oblique 33. Basket in Right Superior PVRight Anterior Oblique 3 Left Anterior Oblique 34. Basket in Right Inferior PVRight Anterior Oblique 3 Left Anterior Oblique 35. Basket in SVCRight Anterior Oblique Left Anterior Oblique 3 36. Ablacin Circular del Atrio Izquierdo(sin aislar las venas)Pappone et al., Circulation. 2001;104:2539 37. Registro (vs casos controles)Freedom from Atrial FibrillationJACC 2003:42;185 38. Probabilidad de Eventos AdversosDecreased incidence of strokes,CHF admissions, and deathPappone et al. JACC 2003:42;185 39. Circular Ablation Vs SegmentalOstial IsolationOral et al. Circulation 2003;108:2355 40. AF Catheter Ablation StrategiesExit (Os) FocalAntrumMore Proximal ablation: The PV Antrum 41. Atrial Esophageal Fistula Pappone et al. Circulation 2004;109:2724 42. Left atrial circular ablation achieving vein isolationwith the use of Intracardiac echo (ICE) Intracardiac echocardiography (ICE) facilitated ablation in the atrium without ablation inside of the veins Circulation. 2003;107:2710 43. ICE guided ablation-The presence of microbubbles indicates excessive heating-Decreasing ablation power when microbubbles are seenincreases safety Circulation. 2003;107:2710Circulation. 2003;107:2710 44. Improved safety and success withuse of ICE Circulation. 2003;107:2710 45. Ablation of Fractionated Electrograms(Dr Nademanee)JACC 2004;43:2044HRJ 2006;8:981 46. Lessons Learned 47. Right Atrium 48. Right Atrium 49. Considerations for AFTransseptals For the lasso: anterior is better 50. Considerations for AF Transseptals For the ablation a more inferior andposterior approach is better 51. PFO is Superior and Anterior to AFTransseptal Ideal SiteTo use the transseptal for the ablation prolongs total RF energy delivery andprocedure duration but does nor affect clinical result (JCE 2008;19:1236)For AF ablation I prefer to do 2 transseptals and not use the PFOAnother option is to use the PFO for the sheath that will have the circularmapping catheter 52. Transseptal Sheath not in PFO 53. Transseptals During RedoProcedures Tend to be a little higher Septum tends to be a little tougher May costumize needle to resemble a BRK 1 May use electrocautery or RF energyEuropace 2008;10:276 54. Bending Needle to Resemble a BRK 1 Useful PACE 2007:30:1506 55. Transseptal Needles BRKSeries Direction Arrow ~70% Pediatric UseStopcock Valve ~30% May use stylet to avoid scratching the sheath 56. RF Energy or Electrocautery For Transseptal CathetherizationCirc AE 2008;1:169 57. Evaluating PV Anatomy 58. Area of Interest 59. Area of Interest 60. Area of Interest 61. Ablation Strategy: Avoid the PVs 62. Ablation Strategy: Avoid the PVs 63. Techniques Are ComplementaryLimitations of Esophageal Temperature Probe 64. Direct Visualization with ICE Ablation Catheter on top of Esophagus 65. Mapping Facilitated by Circular CatheterLeft Pulmonary veins: Right Pulmonary veins: SVC:Low #s are anteriorLow #s are posteriorLow #s are posterior 66. Mapping Facilitated by Circular CatheterLeft Pulmonary veins: Right Pulmonary veins: SVC:Low #s are anteriorLow #s are posteriorLow #s are posteriorRecognize where far-field signals are 67. PRESENTE 68. Randomized Trial Of PAFRefractory to 1 Antiarrhythmic(multicenter)No redos Navistar Thermocool Study March 2009 69. Randomized Trial Of PAFRefractory to 1 Antiarrhythmic(single center) Redo 23 patients Jais et al. Circ 2008;118:2498 70. Ablation in Persistent AF Success rates are less Redos are more common (Complications are the same) 71. Long Standing Persistent AF PVAI + Defragmentation + Pharmacologic ChallengeSuccess after 1 procedure: 11%40% 61%Review: Cardiol Clin 2009; 27:163 Elayi et al. HRJ 2008; 5:1658 72. Long Standing Persistent AF PVAI + Defragmentation + Pharmacologic ChallengeSuccess after 1 procedure: 11%40% 61% 94% of patients in sinus after redo in 20% and 14% on AADReview: Cardiol Clin 2009; 27:163Elayi et al. HRJ 2008; 5:1658 73. Ablation of Fractionated Electrograms(Consensus opinion: limited utility as stand-alone strategy, useful as an add-on to PV isolation) PAAPNademanee HRS Afib Summit 2007Common sites where fractionated electrograms are present 74. Ablation of Long StandingPersistent AFLinz et al. J CE 2010; published ahaed of print Sept 2010 75. Linz et al. J CE 2010; published ahaed of print Sept 2010 76. Ablation of Long StandingPersistent AFLinz et al. J CE 2010; published ahaed of print Sept 2010 77. FUTURO 78. Left Atrial Appendage: An under-recognized source of AF triggers 79. Left Atrial Appendage: An under-recognized source of AF triggers(isuprel induced) 80. LAA: segmental isolation similar to a PV 81. A BC 82. LAA dissociated firingAB 83. Left Atrial Appendage: An under-recognized source of AF triggers 84. Lateral Left AtriumEHJ 2008;29, 356 85. Lateral Left AtriumEHJ 2008;29, 356 86. Increasing Complexity of AF AblationSinus RhythmOrganizedNonPVAtrial Arrhythmias Sources 86 Left Atrial Lines Atrial Fibrillation Isthmus/Roof/Antrum 82 4 PVs 70 3 PVs 50 2 PVs1 PV RA Lines1119942002 Time 87. Challenge: Need for Redo Procedures 20-40% redo rates are needed Redo procedure are done mostly tore-ablate previously ablated sites.1 Hindricks G et al, Late recurrent arrhythmias after ablation of atrialfibrillation: incidence, mechanisms, and treatment. Heart Rhythm2004;1:676683.2 Callans DJ et al, Efficacy of repeat pulmonary vein isolation procedures inpatients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol2004;15:10501055. 88. Challenge: Life-threateningComplications Remain Present JACC 2009;53:1798 89. Challenge: Life-threatening Complications Remain PresentCould some complications be avoided with contact force feedback?JACC 2009;53:1798 90. Safety: steam popsIncidence of Steam Pops in % at 40W*P 100 g offorce. (less through recently ablated tissue) Shah et al, HRS 2008 abstract (ex vivo pig heart) 93. Extreme Variability of Forces (when blinded to contact force data)Source: D. Shah, HRS 2009 94. Summary Surgical Maze remains the best singleprocedure (and it is very far from perfect) Present techniques are effective and safe forthe treatment of paroxysmal and recentlypersistent atrial fibrillation Long-standing persistent atrial fibrillationremains a challenge 95. Summary 2 major obstacles remain) Need for redo procedure to accomplishpermanent results (which hopefully willimprove with contact force information in nearfuture ) Identification of sites other than the PV antralregion 96. Gracias! 97. Termination during persistent AF HRJ 2010 ahead o print 98. Mechanism of AF (from the perspective of an ablationist) AF is initiated by sites/regions of abnormalautomaticity AF is maintained by sites/regions witheither abnormal automaticity or shortrefractory periods where local reentryoccurs (the cardiac autonomic system mayfacilitate or cause some of these areas) 99. AHA/ACC Proposed Clinical Algorithm(How to maintain sinus, sub-divided by underlying cardiac disease) Circ 2006;114:700 100. AHA/ACC Proposed Clinical Algorithm(How to maintain sinus, sub-divided by underlying cardiac disease)Ablation is an alternative to initiation of amiodarone in all patientsexcept those with CHF Circ 2006;114:700 101. What should we call the procedure? Initial concept: Focal ablation Anatomic circumferential left atrial (PV) ablation (Pappone et al) Pulmonary vein antrum isolation (Cleveland Clinic) Ablation of fractionated electrograms (Nadamanee) Tailored approach (Morady et al) Stepwise ablation: PVI plus linear plusdefragmentation plus linear (Haissaguerre et al) Probably: A Fib Ablation 102. Surgical Ablation: MazeCox JL. Cox J Thoracic Card Surg 1991;101:406and J Cardiovasc Electropysiol 2004;2:250 103. Relation Between LAAppendage and Left PVs Ho SY, et al Heart 2001;86:265 3 104. PV-Antrum and SVC DisconnectionSVC RALAMA 105. Pulmonary Vein Antrum 106. Titration of powerMicrobubble formation 107. All relevant structures visualized 108. Identifying complications Thrombus in transseptal sheathMarchlinski et al 109. Current Approach PVAI + Defragmentation + Pharmacologic ChallengePVAI+CFAE: 94% of patients in sinus after redo in 20% and 14% on AAD Elayi et al. HRJ 2008; 5:1658 110. Isoproterenol Induced CS Tachycardia 1007-1,02 111. Adenosine Induced Atrial fibrillation1007-1,03 112. Recovery of PV Conduction With Isoproterenol 113. Recovery of PV Conduction With Isoproterenol 114. Pulmonary Vein Antrum Isolation2007 115. Pulmonary Vein Antrum Isolation2008 116. Advantages of extensive PVAI Objective endpoint Practical: no arguments about how far from theostium, or about far-field versus local, orabout entrance or exit block Reproducible results among various operators Verma et al. HRJ 2007;4:1177 117. Advantages of extensive PVAI Objective endpoint Practical No arguments about: how far from the ostium far-field versus local electrograms entrance or exit block Reproducible results among various operators 118. Advantages of extensive PVAI Targets all triggers Acknowledges the reality that there will besome ablated sites that will regainconduction If a trigger regains, it will probably remainisolated If an ablation site that is part of a line of blockregains, neighboring sites are probably stillenough to accomplish block 119. Advantages of extensive PVAI Achieves complete autonomic denervation 20 patients underwent identification of vagalsites, followed by PVAI by another operator Post ablation vagal sites no longer present 22 redo patients (another unrelated group) Before ablations (in second procedure) 19/22 with no identifiable vagal sitesVerma et al. HRJ 2007;4:1177 120. The importance of AF termination(after redos in 52%) ONeill et al. Eur Heart J 2009 (in print) 121. Haissaguerre: Stepwise approach in Persistents (Predictors of termination) Duration in AF Cycle Length in LAAONeill et al. Eur Heart J 2009 (in print) 122. Basic Rules Minimize catheter manipulations If the catheter is in a place you will ablate, ablate If ablation is not having the desired effect, ablate somewhere else Recognize impossible manipulations Going from left atrial appendage to the pulmonary veins Going from one vein to another vein Avoid dangerous manipulations Never counterclock the circular catheter (always clock it) Transseptal sheaths only go from 3 oclock to 9 oclock (3-4-5-6-7-8-9; 9-8-7-6-5-4-3)