catheter ablation of af electrogram-based approach division of cardiology, taipei veterans general...
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Catheter Ablation of AF Electrogram-based Approach
Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
Shih-Ann Chen, M.D.Shih-Ann Chen, M.D.
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Fuster. Circulation, 2006Fuster. Circulation, 2006
Prevalence of AFPrevalence of AF
Incidence Incidence per 1000 per 1000
person-yrsperson-yrs
FraminghamFramingham MenMen
CHS MenCHS Men
Framingham WomenFramingham Women
CHS WomenCHS WomenAge Age (years)(years)
Person Person (1000)(1000)
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Fuster. Circulation, 2006Fuster. Circulation, 2006
Prevalence of AFPrevalence of AF
8%8%Incidence Incidence per 1000 per 1000
person-yrsperson-yrs
FraminghamFramingham MenMen
CHS MenCHS Men
Framingham WomenFramingham Women
CHS WomenCHS WomenAge Age (years)(years)
Person Person (1000)(1000)
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Fuster. Circulation, 2006Fuster. Circulation, 2006
Prevalence of AFPrevalence of AF
0.4-1%0.4-1% 8%8%
Incidence Incidence per 1000 per 1000
person-yrsperson-yrs
FraminghamFramingham MenMen
CHS MenCHS Men
Framingham WomenFramingham Women
CHS WomenCHS WomenAge Age (years)(years)
Person Person (1000)(1000)
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Fuster. Circulation, 2006Fuster. Circulation, 2006
Prevalence of AFPrevalence of AF
0.4-1%0.4-1% 8%8%
Incidence Incidence per 1000 per 1000
person-yrsperson-yrs
FraminghamFramingham MenMen
CHS MenCHS Men
Framingham WomenFramingham Women
CHS WomenCHS WomenAge Age (years)(years)
Person Person (1000)(1000)
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Mechanism of AFMechanism of AF
Multiple factors ?Multiple factors ?
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Idea of AF Mechanism in Earlier Idea of AF Mechanism in Earlier 20th Century20th Century
EngelmannEngelmann LewisLewis GarreyGarrey
Ectopic focusEctopic focus Single circuitSingle circuitreentryreentry
Multiple-circuit Multiple-circuit reentryreentry
Nattel. 2005
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Focal triggers leading to initiation of reentryFocal triggers leading to initiation of reentry
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Focal triggers leading to initiation of reentryFocal triggers leading to initiation of reentry
additional focal triggers and perpetuation of reentry
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Mechanisms of Atrial FibrillationMechanisms of Atrial Fibrillation( HRS/EHRS/ECAS consensus document, 2007 )( HRS/EHRS/ECAS consensus document, 2007 )
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Mechanisms of Atrial FibrillationMechanisms of Atrial Fibrillation( HRS/EHRS/ECAS consensus document, 2007 )( HRS/EHRS/ECAS consensus document, 2007 )
A. Ganglionic plexi
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Mechanisms of Atrial FibrillationMechanisms of Atrial Fibrillation( HRS/EHRS/ECAS consensus document, 2007 )( HRS/EHRS/ECAS consensus document, 2007 )
A. Ganglionic plexi B. Multiple reentrant wavelets
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Mechanisms of Atrial FibrillationMechanisms of Atrial Fibrillation( HRS/EHRS/ECAS consensus document, 2007 )( HRS/EHRS/ECAS consensus document, 2007 )
A. Ganglionic plexi B. Multiple reentrant wavelets
C. PV and non-PV triggers
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Mechanisms of Atrial FibrillationMechanisms of Atrial Fibrillation( HRS/EHRS/ECAS consensus document, 2007 )( HRS/EHRS/ECAS consensus document, 2007 )
A. Ganglionic plexi B. Multiple reentrant wavelets
C. PV and non-PV triggers D. Multiple mechanisms
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Pathophysiological adaptation of atrial substrate as the duration of AF progress Remodeling
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Pathophysiological adaptation of atrial substrate as the duration of AF progress Remodeling
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Pathophysiological adaptation of atrial substrate as the duration of AF progress Remodeling
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Indications for Catheter AF AblationIndications for Catheter AF Ablation
• Symptomatic AF ( paroxysmal and chronic ) Symptomatic AF ( paroxysmal and chronic ) refractory or intolerant to at least one Class 1 or refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication.3 antiarrhythmic medication.
• Rarely, it may be appropriate to perform AF Rarely, it may be appropriate to perform AF ablation as first line therapy.ablation as first line therapy.
• Selected symptomatic patients with heart failure Selected symptomatic patients with heart failure and/or reduced ejection fraction.and/or reduced ejection fraction.
AHA/ACC/ESC 2006, HRS/EHRS/ECAS consensus document 2007AHA/ACC/ESC 2006, HRS/EHRS/ECAS consensus document 2007
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Catheter Ablation of AFCatheter Ablation of AF
Evolution of TechniqueEvolution of Technique
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Distribution of AF triggerDistribution of AF trigger
Haissagurre et al. NEJM 1998Haissagurre et al. NEJM 1998 Chen et al. Circulation 1999Chen et al. Circulation 1999
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Lesion Sets for Catheter Ablation of AF Lesion Sets for Catheter Ablation of AF ( Consensus Document HRS/EHRS/ECAS, 2007 ) ( Consensus Document HRS/EHRS/ECAS, 2007 )
A. PV Isolation B. PVI, Roof line, CTI
C. PVI, Roof, CTI, Carina, SVCI D. DF and CFAE
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Lesion Sets for Catheter Ablation of AF Lesion Sets for Catheter Ablation of AF ( Consensus Document HRS/EHRS/ECAS, 2007 ) ( Consensus Document HRS/EHRS/ECAS, 2007 )
A. PV Isolation B. PVI, Roof line, CTI
C. PVI, Roof, CTI, Carina, SVCI D. DF and CFAE
Make sure to complete isolationMake sure to complete isolation
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Lesion Sets for Catheter Ablation of AF Lesion Sets for Catheter Ablation of AF ( Consensus Document HRS/EHRS/ECAS, 2007 ) ( Consensus Document HRS/EHRS/ECAS, 2007 )
A. PV Isolation B. PVI, Roof line, CTI
C. PVI, Roof, CTI, Carina, SVCI D. DF and CFAE
Make sure to complete isolationMake sure to complete isolation Complete line blockComplete line block
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Lesion Sets for Catheter Ablation of AF Lesion Sets for Catheter Ablation of AF ( Consensus Document HRS/EHRS/ECAS, 2007 ) ( Consensus Document HRS/EHRS/ECAS, 2007 )
A. PV Isolation B. PVI, Roof line, CTI
C. PVI, Roof, CTI, Carina, SVCI D. DF and CFAE
Make sure to complete isolationMake sure to complete isolation Complete line blockComplete line block
Find the residual PVP or non-PV ectopyFind the residual PVP or non-PV ectopy
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Lesion Sets for Catheter Ablation of AF Lesion Sets for Catheter Ablation of AF ( Consensus Document HRS/EHRS/ECAS, 2007 ) ( Consensus Document HRS/EHRS/ECAS, 2007 )
A. PV Isolation B. PVI, Roof line, CTI
C. PVI, Roof, CTI, Carina, SVCI D. DF and CFAE
Make sure to complete isolationMake sure to complete isolation Complete line blockComplete line block
Find the residual PVP or non-PV ectopyFind the residual PVP or non-PV ectopy AF substrate mappingAF substrate mapping
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AF Ablation Techniques (1)AF Ablation Techniques (1)
1. Complete PV isolation is the cornerstone for most AF ablation procedures.
2. Careful identification of the PV ostia is mandatory to avoid ablation within the PVs.
3. If a non-PV trigger is identified at the time of an AF ablation procedure, it should be targeted, if possible.
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AF Ablation Techniques (2)AF Ablation Techniques (2)
4. If additional linear lesions are applied, line completeness should be demonstrated by mapping or pacing maneuvers.
5. Ablation of the cavotricuspid isthmus (CTI) is recommended only in patients with a history of typical atrial flutter (AFL) or inducible CTI dependent AFL.
6. If patients with longstanding persistent AF are approached, ostial PV isolation alone may not be sufficient.
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Pure pulmonary vein isolation (PVI) Pure substrate modification without PVI PVI with adjunctive substrate modification
Anatomic approach: linear ablation Electrogram-guided approach: based on
fractionation mapping and/or frequency
mapping.
Current Catheter Ablation Techniques for Chronic AF
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CFAE AblationCFAE Ablation
Adjunctive procedure ? Adjunctive procedure ?
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Substrate Modification: Substrate Modification: Target the Fractionated ElectrogramsTarget the Fractionated Electrograms
121 patients (age 63 yrs, 57 121 patients (age 63 yrs, 57
paroxysmal, 64 chronic) under paroxysmal, 64 chronic) under
CARTO mapping during AF. CARTO mapping during AF.
Target the complex electrograms Target the complex electrograms
at LA (mostly septum), RA, and at LA (mostly septum), RA, and
CS.CS.
Acute termination in 115/121 Acute termination in 115/121
(95%), one year F/U 63 % without (95%), one year F/U 63 % without
drug, 28 % with ibutilide, overall drug, 28 % with ibutilide, overall
91 % successful rate.91 % successful rate.
Nademanee et al, JACC, 2004
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Substrate Modification: Substrate Modification: Target the Fractionated ElectrogramsTarget the Fractionated Electrograms
121 patients (age 63 yrs, 57 121 patients (age 63 yrs, 57
paroxysmal, 64 chronic) under paroxysmal, 64 chronic) under
CARTO mapping during AF. CARTO mapping during AF.
Target the complex electrograms Target the complex electrograms
at LA (mostly septum), RA, and at LA (mostly septum), RA, and
CS.CS.
Acute termination in 115/121 Acute termination in 115/121
(95%), one year F/U 63 % without (95%), one year F/U 63 % without
drug, 28 % with ibutilide, overall drug, 28 % with ibutilide, overall
91 % successful rate.91 % successful rate.
Does CFAE represent the atrial substrate ?? Does CFAE represent the atrial substrate ?? What are the mechanisms of CFAE ??What are the mechanisms of CFAE ??
Nademanee et al, JACC, 2004
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Clinical Outcome of High Risk Group of AF Underwent CFE Ablation
674 patients (67±12 yrs,
40%=PAF, 60%=non-
paroxysmal).
Mean LA=45±6 mm,
LVEF<40% in 22%.
Complication rate 0.8%; 81%
remained in SR after mean
follow-up period of 2.3 years,
only 13% with AAD.
SR after AF ablation is a
marker of relatively low
mortality and stroke risk.Nademanee et al. JACC 2008
CFAE approach
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Is Pure CFAE Ablation Enough to Treat CAF?
100 patients with CAF
underwent CFAE ablation in
LA/CS, 16% with AF
termination during the
procedure.
Follow up ( 14 Mo ), only
33% were in SR, 44% need
second procedures
Oral et al. Circulation 2007
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Is Pure CFAE Ablation Enough to Treat CAF?
100 patients with CAF
underwent CFAE ablation in
LA/CS, 16% with AF
termination during the
procedure.
Follow up ( 14 Mo ), only
33% were in SR, 44% need
second procedures
Controversial Results !!
Oral et al. Circulation 2007
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How to Detect CFAÉ ? Visual inspection
Automatic algorithmCARTO XP
NavX system 7.0
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Low amplitude, multicomponent potentials (0.05-0.25 mV) that are either continuous or separated by short isoelectric interval (< 120 msec), over a 10 seconds period.
Nademanee et al. JACC 2004Nademanee et al. JACC 2007
Operator-Determined CFEs
PV 67%LA roof 61%
Inter-atrial septum 83%
PCS 59%
CTI 31%
Mitral 29%
Low RA, SVC
Type I:CFAE
CFAE Distribution
Type II: CFAF
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Complex Fractionated Atrial Complex Fractionated Atrial Electrograms (CFAE)Electrograms (CFAE)
Non-CFAEs: Discrete Eg with isoelectric segment and CL >120 ms.
Type IIa : Fractionated Eg with continuous activity.
Type IIb : Fractionated Eg with isoelectric segment and the CL < 120 ms.
Taipei VGH 2008
CFAE: potential AF substrate sites and target sites for CFAE: potential AF substrate sites and target sites for AF ablation.AF ablation.
CFAE are electrograms with highly fractionated CFAE are electrograms with highly fractionated potentials or with a very short cycle length (120 ms). potentials or with a very short cycle length (120 ms).
CFAEs usually are low-voltage multiple potential signals CFAEs usually are low-voltage multiple potential signals between 0.06 and 0.25 mV.between 0.06 and 0.25 mV.
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Complex Fractionated Atrial Complex Fractionated Atrial Electrograms (CFAE)Electrograms (CFAE)
Non-CFAEs: Discrete Eg with isoelectric segment and CL >120 ms.
Type IIa : Fractionated Eg with continuous activity.
Type IIb : Fractionated Eg with isoelectric segment and the CL < 120 ms.
Taipei VGH 2008
CFAE: potential AF substrate sites and target sites for CFAE: potential AF substrate sites and target sites for AF ablation.AF ablation.
CFAE are electrograms with highly fractionated CFAE are electrograms with highly fractionated potentials or with a very short cycle length (120 ms). potentials or with a very short cycle length (120 ms).
CFAEs usually are low-voltage multiple potential signals CFAEs usually are low-voltage multiple potential signals between 0.06 and 0.25 mV.between 0.06 and 0.25 mV.
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Figure 1
msec
msec
(A)
(B)
120 125
55 40
Fractionation inteval is based onthe mean interval between multiple, discrete local
deflections (-dV/dt) during AF
How to identify the most continuous fractionation with consistency
(The CFE algorithm)
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Difference in the Automatic Algorithm of CFEs in 3D Mapping System
NavX CARTO
Detection AlgorithmInterval analysis ● ●
CFEs event frequency X ●
Electrogram characteristics detectionAdjustable mapping duration ● XAdjustable refractory period ● ●
Low voltage detection thresholds ● ●
High voltage cut off thresholds (avoid far field) X ●
Exclude far-field by Eg width (avoid far ield)
● X Taipei VGH, 2009
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The requirement of long-term recording in CFE mapping in 3D mapping
Continuous CFEs
Not continuous CFEs
Not CFEs sites
0 second
Different recording duration
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The requirement of long-term recording in CFE mapping in 3D mapping
Continuous CFEs
Not continuous CFEs
Not CFEs sites
0 second
Different recording duration
1 second
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The requirement of long-term recording in CFE mapping in 3D mapping
Continuous CFEs
Not continuous CFEs
Not CFEs sites
0 second
Different recording duration
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The requirement of long-term recording in CFE mapping in 3D mapping
Continuous CFEs
Not continuous CFEs
Not CFEs sites
0 second
Different recording duration
2.5 second
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The requirement of long-term recording in CFE mapping in 3D mapping
Continuous CFEs
Not continuous CFEs
Not CFEs sites
0 second
Different recording duration
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The requirement of long-term recording in CFE mapping in 3D mapping
Continuous CFEs
Not continuous CFEs
Not CFEs sites
0 second
Different recording duration 5 second
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Effect of Duration on the Consistency
Lin YJ and Chen SA et al Heart Rhythm 2008
Non-CFEs
CFEs 50-120
CFEs < 50
N=1248, in 27 patients
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Effect of Duration on the Consistency
Lin YJ and Chen SA et al Heart Rhythm 2008
Non-CFEs
CFEs 50-120
CFEs < 50
The most continuous CFEs:
FI < 50 msec, longer than 5 seconds
N=1248, in 27 patients
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What Is The Mechanism of CAFÉ ?
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0 Hz
4 Hz
8 Hz
AF Termination While Targeting CFAE
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0 Hz
4 Hz
8 Hz
AF Termination While Targeting CFAE
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0 Hz
4 Hz
8 Hz
AF Termination While Targeting CFAE
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0 Hz
4 Hz
8 Hz
AF Termination While Targeting CFAE
Unipolar electrograms showed rapid repetitive QS wave in termination site
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
CFAE
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
CFAE
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
CFAE CFAE
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
CFAE CFAE
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
CFAE CFAE
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Simultaneous Mapping of Unipolar and Bipolar Electrograms Ensite Noncontact Mapping
RSPVRSPV
RIPV
LSPV
LIPV
LSPV
RIPV
CFAE CFAE
S wave predominance !!
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S wave predominance Non S wave predominance
Unipolar Morphology Analysis in Bipolar CFAE
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12 consecutive AF (Paroxysmal 8) received Ensite Array 12 consecutive AF (Paroxysmal 8) received Ensite Array mapping, 87 sites analyzed (26 CFAE, 61 non-CFAE)mapping, 87 sites analyzed (26 CFAE, 61 non-CFAE)
S wave predominance Non S wave predominance
Unipolar Morphology Analysis in Bipolar CFAE
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12 consecutive AF (Paroxysmal 8) received Ensite Array 12 consecutive AF (Paroxysmal 8) received Ensite Array mapping, 87 sites analyzed (26 CFAE, 61 non-CFAE)mapping, 87 sites analyzed (26 CFAE, 61 non-CFAE)
S wave predominanceS wave predominance (>50%) in CFAE sites (24 of 26 (>50%) in CFAE sites (24 of 26 bipolar CFAE sites)bipolar CFAE sites)
S wave predominance Non S wave predominance
Unipolar Morphology Analysis in Bipolar CFAE
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12 consecutive AF (Paroxysmal 8) received Ensite Array 12 consecutive AF (Paroxysmal 8) received Ensite Array mapping, 87 sites analyzed (26 CFAE, 61 non-CFAE)mapping, 87 sites analyzed (26 CFAE, 61 non-CFAE)
S wave predominanceS wave predominance (>50%) in CFAE sites (24 of 26 (>50%) in CFAE sites (24 of 26 bipolar CFAE sites)bipolar CFAE sites)
Non S wave predominanceNon S wave predominance ( ( 50%) in non-CFAE sites 50%) in non-CFAE sites (56 of 61 bipolar non-CFAE sites).(56 of 61 bipolar non-CFAE sites).
S wave predominance Non S wave predominance
Unipolar Morphology Analysis in Bipolar CFAE
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Activation Pattern in CFAE SitesActivation Pattern in CFAE Sites
Eleven (Eleven (43%43%) of the 26 located over ) of the 26 located over arrhythmogenic PVarrhythmogenic PV..
Eleven (Eleven (43%43%) of the 26 located over ) of the 26 located over pivot pivot points with wavefront turningpoints with wavefront turning..
Four (posterior wall, RSPVos) showed Four (posterior wall, RSPVos) showed multiple wavelet pass through.multiple wavelet pass through.
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Arrhythmogenic LIPV with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
6
7
8
9
LIPV
RSPV
RIPV
LSPV
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Arrhythmogenic LIPV with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
6
7
8
9
LIPV
RSPV
RIPV
LSPV
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Arrhythmogenic LIPV with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
6
7
8
9
LIPV
RSPV
RIPV
LSPV
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Arrhythmogenic LIPV with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
6
7
8
9
LIPV
RSPV
RIPV
LSPV
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Arrhythmogenic LIPV with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
6
7
8
9
LIPV
RSPV
RIPV
LSPV
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Arrhythmogenic LIPV with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
6
7
8
9
LIPV
RSPV
RIPV
LSPV
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Arrhythmogenic LIPV with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
6
7
8
9
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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6
7
8
9
LIPV and RSPV Ectopy Turning at Roof with negative predominant wave in Bipolar CFAE sites (Unipolar Virtual 6)
LIPV
RSPV
RIPV
LSPV
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Before PV isolation After PV isolation After linear ablation
Circulation-Arrhythmia/EP, Lin YJ, 2009
Functional CFAE
Functional CFAE
Consistent CFAE
Final termination site
The Effect of PVI and lines on CFE distribution
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Before PV isolation After PV isolation After linear ablation
Circulation-Arrhythmia/EP, Lin YJ, 2009
Functional CFAE
Functional CFAE
Consistent CFAE
Final termination site
The Effect of PVI and lines on CFE distribution
The timing of CFEs mapping may affect the CFEs; Persistent presence of CFEs
are important
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Complex fractionation electrogram50-70% area of total atria
Culprit CFEs Bystander CFEs
Relate to procedural termination
Higher dominant frequency
Continuous over time
Not relate to procedural termination
Peripheral to the high DF
Not continuous over time
How to identify the important CFEs How to identify the important CFEs
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When to Stop the CAFÉ Ablation Procedure in Chronic AF ?
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ReferencesCFAE Definition/
ChamberEnd points for
CFAE site
Nademanee et al. (JACC 2004)
Visual/ LA, CS, RA <0.05 mV bipolar V AF termination
Oral et al. (Circulation 2007)
Haissaigurre et al. (JACC 2008)
Natale et al. (HRS abstract 2007)
Catheter Ablation in Non-Paroxysmal AF
Chen et al. (HR 2009)
NavX automated algorithm, LA, CS
Estner et al. n=36 (AJC 2008)
End points for procedure
AF termination/ elimination of CFAE
AF termination/ elimination of CFAE
AF termination/ elimination of CFAE
<0.1 mV bipolar V
FI > 120 msec AF termination/ elimination of CFAE
Discrete Eg, slower than CL of LAA
Visual/ LA, CS
Visual/ LA, CS, RA
Visual/ LA, CS, RA
Visual/ LA, CS Elimination of CFAE
Elimination of CFAE
AF termination/ elimination of CFAE
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ReferencesAblation procedure Termination
rate without AADNademanee et
al. (JACC 2004) Pure CFAE ablation 76%
Oral et al. (Circulation 2007)
Haissaigurre et al. (JCE 2005)
Natale et al. (HRS abstract 2007)
Catheter Ablation in Non-Paroxysmal AF
Chen et al. (HR 2009)
Estner et al. n=36 (AJC 2008)
Long-term success rate
16%
53%
52%
85%
23%
Before linear lines
To sinus rhythm
To sinus rhythm
To sinus rhythm
To sinus rhythm
Mostly to AT
70%
33%
75% / 11 mons
(single procedure)
76% / 19 mons
(multiple procedures)
61%
12 months
14 months
11 months
95%(multiple procedures)
Pure CFAE ablation
Adjunctive CFAE ablation
Adjunctive CFAE ablation
Adjunctive CFAE ablation
Adjunctive CFAE ablation
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ReferencesAblation procedure Termination
rate without AADNademanee et
al. (JACC 2004) Pure CFAE ablation 76%
Oral et al. (Circulation 2007)
Haissaigurre et al. (JCE 2005)
Natale et al. (HRS abstract 2007)
Catheter Ablation in Non-Paroxysmal AF
Chen et al. (HR 2009)
Estner et al. n=36 (AJC 2008)
Long-term success rate
16%
53%
52%
85%
23%
Before linear lines
To sinus rhythm
To sinus rhythm
To sinus rhythm
To sinus rhythm
Mostly to AT
70%
33%
75% / 11 mons
(single procedure)
76% / 19 mons
(multiple procedures)
61%
12 months
14 months
11 months
95%(multiple procedures)
Can procedure termination predict long-term
outcome?
Pure CFAE ablation
Adjunctive CFAE ablation
Adjunctive CFAE ablation
Adjunctive CFAE ablation
Adjunctive CFAE ablation
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Predictors of Procedural Termination Predictors of Procedural Termination (N=88, PAF and CAF) (N=88, PAF and CAF)
Predictors of termination
Predictors of recurrence
Significant factors from univariate Analysis
AF duration, heart failure, LA size, cycle length of CS, shortest FI, DF gradient, mean LA voltage
LA size (P=0.037)
High DF in RA (p=0.009)
Significant factors from multivariate Analysis
LA size (P=0.037)
RA non-PV ectopies (p=0.009)
LA size (p=0.02)
RA non-PV ectopies (p=0.01)
Insignificant factors Age, Sex, underlying disease, degree of fractionation and DF in the LA
Age, Sex, underlying disease, degree of fractionation and mean DF of RA and LA, and AF termination (P=0.07)
Taipei VGH, Heart Rhythm 2009
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Ablation Technique of Chronic AF (Taipei VGH)
PVI with electric isolation & CFE mapping
Linear ablation (Roof + mitral lines)
Non-PV foci, SVC isolation
AF stop
AF stop
AF stop
SR: Reconfirm PVI, CTI linear ablation
SR: Reconfirm PVI, CTI linear ablation
SR: Reconfirm PVI, CTI linear ablation
Organize AT
Organize AT
Organize AT
Map and ablate
AT
Map and ablate
AT
Map and ablate
AT
Cardioversion
AF continue
AF continue
Target continuous CFEs in the LA/CS
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Efficacy of stepwise ablation procedureEfficacy of stepwise ablation procedure
87 8880
42
0
20
40
60
80
100
step 1 step 1-2 step 1-3 withouttermination
Mai
nte
nan
ce o
f S
R
(%)
Procedural AF termination
P= 0.01
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Procedural AF Termination and Long-term Outcome (N=85, follow-up 13 months)
Lo et al, HR 2009
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Conclusion
Combination of PVI and adjunctive substrate
modification improve success in treatment of
chronic AF.
Both frequency and fractionation mapping may
provide the information to plan our ablation
strategy.
Achieving procedural termination with extensive
LA modification may not be appropriate for all CAF
patients.
Effects should be directed to identify the AF
sources with minimal ablation in individual patient.
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Prevalence and Distribution of CFEsRapid activities (I) and Continuous activities (II)
Taipei VGH, 2006, 2007 HRS abstract
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Prevalence and Distribution of CFEsRapid activities (I) and Continuous activities (II)
Taipei VGH, 2006, 2007 HRS abstract
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Prevalence and Distribution of CFEsRapid activities (I) and Continuous activities (II)
Taipei VGH, 2006, 2007 HRS abstract
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Prevalence and Distribution of CFEsRapid activities (I) and Continuous activities (II)
Taipei VGH, 2006, 2007 HRS abstract
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Characterization of CFEs by FFT
Paroxysmal AFParoxysmal AF
Persistent AFPersistent AF