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AF Ablation- A Mandatory Job Dr. Moataz A. Zaki, MD Lecturer of Cardiology - Medical Research Institute – Alexandria University. Member -Editorial Board of Egyptian Cardiac Rhythm Association. Fellow EP lab, Spedali Civili di Breschia, Italy. M-EAPCI, M-EHFA


Electrophysiological mechanisms of AF  Focal Activation Initiating focus lies within region of PVs The resulting wavelets represent fibrillatory conduction

 Multiple –Wavelet Reentry Wavelets randomly reenter tissues previously activated

by them or another wavelet


Mechanism of AF


Inter-atrial fascicle Main circular fascicle

Myocardial sleeves Transverse fascicle

Vertical fascicle (Nathan and Eliakim, Hadassah University Hospital, Israel, 1966)


PV

LA

Myocardium

Myocardial sleeve


t al., 1999

PV LA

Relatively long ERP Slow conduction Decrimental conduction


PV

LA


AF Ablation  Rate control AV nodal ablation.

 Rhythm control Linear atrial ablation (trans-catheter Maze technique). Pulmonary vein ablation. Pulmonary vein + LA isthmus ablation.


His Bundle Ablation

Transvenous Catheter Ablation

Permanent Ventricular Pacing


Focal Origin of Atrial Fibrillation Hassaiguerre M, NEJM, 1998

RA

LA

 94% of AF triggers from

Pulmonary Veins  “90 – 95% of all AF is initiated by PV ectopy”

SVC

17

31

FO Pulmonary Veins

6

IVC CS

11


Lasso™ Guided PV Isolation Before Ablation

During Ablation

After Ablation

I PV-d CS-p CS-7/8 CS-5/6 CS-3/4 CS-d HRA PV-1/2 PV-2/3 PV-3/4 PV-4/5 PV-5/6 PV-6/7 PV-7/8 PV-8/9 PV-9/10 PV-10/1

100 ms

A PV

A PV

A


Left Atrium, Posterior Wall Pulmonary Vein Isolation

Nathan, Circ Res, 1969?


AF TREATMENT GOALS  Treatment goals in symptomatic pts  ↓ frequency of recurrences  ↓ duration of recurrences  ↓ severity of recurrences

 Minimize risk of tachycardia induced

cardiomyopathy  Safety is primary concern


Catheter ablation vs AAD


Risk analysis AA Drugs, AVJ Ablation AF Ablation

Interventional risk Embolism, 0.3% Tamponade, 1%; PV stenosis, ? Atrio oesophogeal fistula

Longer-term risks , 2-3%/yr; Hemorrhagic risks of Anticoag. 1.8% Adverse effects of AADs (Pacemaker dependence)


PV Ablation Options • Sequential point by point

ablation

• Simple • Individual optimisation of lesion

delivery possible • Obligatorily time consuming • Finite irreducible rate of gap occurrence

• Circular lesion making

devices

• Unfamiliar, more complex design • Difficult to optimize contact/to

generate consistent lesions • Still do not achieve rapid, one-shot isolation


3 Dimensional Electroanatomical Mapping CARTO


Cryoballoon Ablation Pre-Cryo

LSPV Image courtesy V. Reddy

Post-Cryo

Location of conduction recovery at redo


Linear Ablation Technologies

PV ablation times: segmental PVI: 35+15 min Hocini et al. and CPVA: 37+11 min Oral et al. PVAC: Boersma et al. 27+7 min, & Scharf et al. 32+12 min


Visually-Guided Ablation Using Laser

Aiming Beam

“Static” Blood in LSPV LIPV

LA

A


Remote Navigation Systems • Magnetic Navigation: Fixed Magnets (Stereotaxis) • ) • Robotic Navigation (Hansen Medical)

Fixed Magnetic Nav

Robotic Nav Electro-Magnetic Nav


Arya et al, Europace 2010 e-pub


robotic arm

3D mouse Sensei™ Robotic Catheter System


Rotational Angiography


Catheter Ablation as First-Line Treatment of AFib • Young very

symptomatic patients

• Endurance athletes with

paroxysmal AF

• who refuse long term

AADs and anticoagulation

• Young patients with

parox/persistent AF and sinus node dysfunction

Padanilam, et al, Circulation 2005, 112, 12239

• Brady-tachy syndrome

and parox AF


PV isolation cases 2005 - 2012  150 cases Cairo University  100 cases Ain Shams  100 cases NHI


Future technology for AF Ablation • New technology should

simplify ablation • Shorten the procedure by reducing ablation times • Provide rapid and reliable endpoint verification • Result in durable, nonproarrhythmic lines of isolation

Current standard of reference…


AF Ablation Dr. Moataz A. Zaki, MD Lecturer of Cardiology - Medical Research Institute – Alexandria University. Member -Editorial Board of Egyptian Cardiac Rhythm Association. Fellow EP lab, Spedali Civili di Breschia, Italy. M-EAPCI, M-EHFA


SHA24/082004