Disclosures Ablation of Persistent AF: What to do Beyond - PDF document

9/14/2019 Disclosures Ablation of Persistent AF: What to do Beyond • Biosense-Webster – research support PV Isolation • Boston Scientific – research support • Abbott – Fellows education course Aman Chugh, MD September 13, 2019 CHRS San Francisco, CA Increasing AF Outline Permanent AF No AF Ps AF PAF • Pathophysiologic differences b/w paroxysmal (PAF) and persistent (Ps) AF • Evidence for mapping and ablation outside the PVs in patients with Ps and longstanding (LS) Ps AF • Present an intuitive, evidenced-based approach to catheter ablation of Ps AF Fibrosis and fatty infiltration correlated w/ lymphocyte infiltration (ie, inflammation) Fibrosis – cause or consequence of AF? Platonov JACC 2011 1

9/14/2019 Structural differences b/w Ps and PAF Electrical remodeling – faster drivers NS 30000 2.25 25000 ‡ ‡ 6.4 Amplitude (mV) 20000 1.50 § 6.3 † † c Persistent P=0.0006 ¶ 6.2 ¶ 15000 ‡ p Paroxysmal ¶ 6.1 ¶ DF (Hz) § 10000 6 0.75 Paroxysmal AF 5.9 5000 5.8 Persistent AF 5.7 0 mitral isthmus 1LAA 2Base 3Ridge 4LtAntrum 5RtAntrum 6Anterior 7Posterior posterior wall 8Roof 9 9aMI 9bInferior 9cCS 5.6 base of LAA anterior wall appendage inferior wall 5.5 right PVA left PVA septum Paroxysmal AF Persistent AF ridge roof CS LA regions Yoshida…Chugh Heart Rhythm 2010 Paroxysmal AF Persistent AF P Is PAF really different from Ps AF? (N=18) (N=40) 58 ± 8 59 ± 10 Age 0.71 Gender (M/F) 14/5 33/7 0.44 27 ± 3 32 ± 5 Body mass index (kg/m2) 0.0001 Sleep apnea syndrome 3 (17%) 7 (18%) 0.94 Hypertension 6 (32%) 25 (63%) 0.03 Diabetes 1 (6%) 2 (5%) 0.93 54 ± 38 53 ± 47 Period from the first diagnosis of 0.96 AF (month) 26 ± 19 Duration of continuous AF (month) N/A - 10 ± 4 18 ± 5 LA pressure (mmHg) <0.0001 38 ± 4 48 ± 6 LA diameter (mm) <0.0001 LA volume indexed (ml/m2) 43 ± 10 68 ± 20 <0.0001 Ghanbari et al HR 2014 64 ± 7 (during 58 ± 7 (during Ejection Fraction (%) - SR) AF) Yoshida…Chugh HR 2010 2

9/14/2019 Freedom from Recurrent AF after PV Isolation Longstanding Ps AF - PVI alone was able to 1.0 establish long-term SR in only 24% (49 of 202) Cumulative Proportion Free from AF Cumulative Proportion Free from AF 0.9 0.8 Paroxysmal AF (234) 0.7 0.6 0.5 P<0.001 0.4 Persistent AF (20) 0.3 0.2 0.1 0.0 0 3 6 9 12 15 18 21 24 27 30 33 36 39 Tilz et al JACC 2012 Months Oral et al Circ 2001 Why aren’t PVs enough in persistent AF? STAR AF 2 : PV isolation is all you need for Ps AF? PV-LA gradient ( ∇ ) Ps AF – no Δ in global AF CL with PVI PAF – progressive increase in AF CL with PVI ms ms DF of PVs: 11 Hz DF of PVs: 8.8 Hz With or without AAD DF of LA: 5.8 Hz DF of LA: 6.9 Hz ∇ : 6.2 Hz ∇ : 1.9 Hz PVs alone – 41% after one procedure Sanders et al JCE 2006 Verma NEJM 2015 3

9/14/2019 STAR AF 2 Continuous electrical activity - specific but uncommon V 1 Takeaways RFA LA d • Unproven adjuncts @ inferior LA – automated “CFAE” algorithms – “lack of pathophysiologic 80? 180 relevance” (Lau et al HR 2015) V 1 • Ambiguous endpoints (linear ablation/procedural) LA • If AF → AT, cardioverted at operator discretion Most ”CFAEs” are generated by far - field activity (Narayan et al HR 2010) • Did additional ablation do anything to AF? CS 180 – Was AF slowed? If not, targets were not identified Our eyes are appear to be better than algorithms in ascertaining FF II • Excellent single center results not reproducible EGMs/local activation rates • 20% of patients presented in sinus rhythm – how Septal LA d * * applicable to patients presenting in AF? * * * Septal LA p 250 180 Septal RA O.K., So what then Linear block across mitral isthmus? s/p endo/epi (CS) RFA and EtOH VOM • Approach must be Ridge – RFA endo MI LAA Ridge S S S S – Evidenced-based – proven V 1 – Unambiguous Abl d – Intuitive Avoid mitral isthmus Abl p – Practical, with conventionally available tools 180 145 CS 1-2 CS 3-4 CS 5-6 CS 7-8 CS 9-10 4

9/14/2019 RFA @ low posterior LA Case V 1 • 50 yo man with LS Ps AF Abl d since 2013 What’s next after PVI? • AVR for congenital AS CS d • CV – SR for seconds • Ef 35% and CHF CS p Posterior Wall Isolation • RFA on 1/2015 proven – PVI for rapid PV RAA unambiguous tachycardia prevents roof dependent – AF persists atrial flutter V 1 Abl d Last f/u 2/2019 – AF terminates to SR SR without AAD CS d Ef 50% Conclusions – “ ePVAI+LAPW is still associated with a significant high CS p incidence of very late recurrence of atrial tachyarrhythmia.” RAA Bai et al (Heart Rhythm 2016;13:132 – 140) V 1 V 1 Case LAA • DK Post PVI/PWI Abl d LAA=162 ms ∇ Baseline CS LAA CL 178 LAA RAA=200 ms RAA V 1 OK, LA is driver but how to target? PVs/Posterior LA – out; CS – slow → LAA driver Abl d Abl p V 1 LAA<LIPV LIPV * AF terminates to AT CS d during RFA around LAA V 1 Abl d AF Persists CS p despite PVI PV RAA CS d 5

9/14/2019 V 1 Case II LA • 52 yo man with Posterior LA ECG – AT 240 permanent AF since LA aVF 2013 • CS DC CV 1995 V 1 • PVI 2010 at OSH – PV stenosis V 1 RFA at posterior RA, • “Mini - maze” 2013 Eustachian ridge, and finally • Worsening effort LA V 1 at CTI terminates AT intolerance Septum – LA • RFA 11/2018 slow activity Abl d CS Abl p V 1 Endpoint of LAA RFA – AF CS d termination LAA SR without AAD for 4 years LAA 137 CS p LAA CS After extensive ablation around LAA, entrance block into LAA Case- • 54 yo man Ps AF III • AF persists post PVI, V 1 PWI, LAA RFA V 1 150 • RA to LA gradient 178 LAA 640 LAA LAA ∇ LAA CS RAA 161 Endpoint of LAA RFA – slowing of conduction into LAA LAA no longer driving AF LAA as driver – proven and unambiguous* CS d CS p 6

9/14/2019 Where to ablate in RA? SVC? Extremely fast bursts from RAA (20 Hz!) AF termination sites in RA 50 ms V 1 SVC V 1 288 ms SVC RAA Lateral RAA RAA 179 ms base • 90 patients Ps AF CS d • 26 (29%) required RA ablation • RA targets: RAA, lateral RA, lateral TA, RA roof • Follow up of 21±18 months – 53 of the 64 patients in the LA only group (83%) – 20 of the 26 patients in the RA group (77%) in SR w/o AAD (p=0.57) CS p Ghannam …Chugh HRS 2014 Hocini et al JACC 2010 SVC V 1 AF terminates to AT LAA Abl d after RFA at RAA RAA LPV CS d * 230 CS p Cut-Sew Maze Anatomically based S S S S V 1 Termination w/o global capture @ MI Abl d Linear block achieved Abl p RAA driver – intuitive, 230 230 evidence-based CS CS d SR w/o AAD for 6 yrs Tricuspid CS p valve 7

9/14/2019 CASE • 76 yo woman with persistent AF since 2013 Procedural details • Recurrence despite cardioversion and propafenone • s/p stenting of RCA • Persistent AF - 2-3 procedures • RFA 10/2015 • RF duration 60-80 minutes • If AF terminates to AT, map and ablate III Right PVs isolated • Procedure time 4-5 hours V 1 • AT/”atypical atrial flutter” is unavoidable in most patients AF terminates to SR LIPV • If AF recurs after first procedure during RFA of L PVs – Likely RA ablation (30% of patients) • Emphasis on AF termination during 2 nd procedure CS d Noninducible with • 80% without antiarrhythmic medications isoproterenol and rapid CS p pacing • Complications 1% What would you do next? • No perforation during LAA/RAA RFA A. Linear ablation at LA roof SR w/o AAD x 4 years • Secondary prevention measures B. Linear ablation at mitral isthmus C. Nothing more D. Linear ablation at CTI Summary • Ps and LS Ps AF – more structural and electrical alterations cf. PAF – Calls for a measured, more aggressive approach than PVs • Mapping during AF – identification of drivers; not possible during SR • Tailored to patient – if AF terminates with PVI – no reason to do more – If AF terminates during LAA RFA, don’t need to isolate LAA • ATs are unavoidable in most if we wish to get rid of AF • Whichever approach → must show that fibrillatory process was affected – was AF slowed or terminated? 8