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Substrate Ablation (CAFE)A Promising or Vanishing Technique
Substrate Ablation (CAFE)A Promising or Vanishing Technique
Walid I. Saliba, M.D.Walid I. Saliba, M.D.
Director, Atrial Fibrillation Center
Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine
THE CLEVELAND CLINIC FOUNDATION
Cleveland, Ohio
Director, Atrial Fibrillation Center
Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine
THE CLEVELAND CLINIC FOUNDATION
Cleveland, Ohio
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Goal
To confuse you
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Paroxysmal
Self terminating AF episodes
Permanent
Sinus cannot be maintained
Persistent
Sinus can be restored electrically
or chemically
“AF begets AF”Atrial remodeling:
↓Refractory Period ↓ Conduction velocity
Favors Arrhythmia
Trigger initiation
Substrate maintenance
Natural History of AF Dual Substrate Model
Ablation of Triggers
Modification of Substrate
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Alternative Strategies
More Ablation
Where?
Why?
How much more?
CAFEDominant
FrequencyGanglionic PlexiStepwise/TailoredAF NestSVC / CS / Septum
/ CristaLAA, LoMFlutter? CTILines, circles …
Primary therapy
Adjunctive therapy to PVI
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What are CAFÉ’s EGMs with CL < 120 ms
EGMs with continuous electrical activity
EGMs with low amplitude and more than 2 deflections
EGMs with CL shorter than in the CS or LAA
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Mechanisms Underlying CAFE Pathological anisotropic conduction Slow conduction , Pivot and anchor points or Collision of
the wavelets (Alessie 1996)
Focal microreentry (Gardner/Alessie 1985)
Wave break and fibrillatory conduction at the Borderzone of the mother rotors and areas of dominant frequencies. (Kalifa et al Circ 2006)
Calcium transient triggering activities from hyperactive autonomic ganglionic plexi with shortening of the RP (Scherlag et al. 2004)
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CAFÉ’s in Atrial Fibrillation Ablation
Stand Alone Targets ( Nademaneee)
Hybrid approach with PVI
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Substrate-Guided Ablation: CAFÉ’s
Rationale Target key atrial regions responsible for perpetuating AF
rather than targeting the triggers in the PV’s
End Points Complete elimination of areas with CFAE’s Conversion of AF to SR
Nademanee et al, JACC 2004
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Substrate-Guided Ablation: CFAE
Nademanee et al, JACC 2004
Fractionated electrograms composed of 2 deflections or more and continuous deflection of baseline
Atrial EGMs with very short CL <120 msec
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Substrate-Guided Ablation: CFAE’s
60% patients had CFAEs clustered around PV’s 87% patients had CFAEs clustered around septum and
roof, close to PVs.Nademanee et al, JACC 2004
Median RF lesions: 64
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Nademanee et al, JACC 2004
121 pts (51 PAF, 64 Chronic AF)
91% of pts free of arrhythmia
23% required a 2nd. Ablation13% on AAD
Substrate-Guided Ablation: CFAE’s Only
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Ablation of CAFÉ’s as part of a stepwise approach to achieve conversion to SR
Rationale: Structures contributing to initiation and maintenance of
AF are sequentially targeted
With increasing ablation of left atrial structures, there is a cumulative increase in AFCL resulting in “AF termination” with each ablation step performed.
Stepwise Ablation ApproachHaissaguerre et al. JCE 2005
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The Stepwise Ablation Approach
Lasso Guided PV Isolation
Roof Line Ablation
Ablation of CS & Complex LA activities
Mitral Isthmus Ablation
Right Atrial / SVC Ablation
Cardioversion
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EGM Based Ablation
Haissaguerre et al. J CardiovascElectrophysiol2005;16:1125-37
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• 87% (52) had AF termination during ablation (SR:7 ; AT:45)
• 60% success rate with a single procedure(40% required repeat ablation)
• 95% success rate with multiple procedures• Sinus rhythm at 11±6 months f/u ,without AAD’s • Good atrial transport function
Stepwise Ablation Approach
Haissaguerre et al., J C E, Vol. 16, pp. 1138 Nov 2005
60 pts with Non-PAF
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Some Observations The greatest magnitude of prolongation of
fibrillatory cycle length occurred during ablation at the PV-LA junction (Antrum) Coronary sinus Anterior LA
Almost half of the residual atrial tahycardias originated these same sites.
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Circulation.2007;115:2606
100 pts with Chronic AF RF ablation of CAFÉ’s in PV’s, LA and CS End point: All CAFÉ’s eliminated or AF termination
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CAFÉ’sCFAEs EGM: • CL< 120 msec• CL < CL n CS• Fractionated and/or continuous electric activity
• 1 PV 46%• CS 55%• Septum/roof All
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Results
33% in SR after a single ablation procedure
Repeat ablation in 44% CAFÉ’s in antrum, PV tachycardia, Macroreentrant
flutter and circuits……
57% in SR at ~1 year follow up.
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“The modest efficacy attained in this study despite extensive ablation of left atrial and coronary sinus CFAEs suggests either that CFAEs do not accurately identify sites that are critical to the maintenance of chronic AF or that ablation of CFAEs is not sufficient to eliminate the driving mechanisms of chronic AF in a large proportion of patients.”
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A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF
Oral et al. J Am Coll Cardiol 2009;53:782–9)
• Group A: • Termination with PVAI (n=19)
• Group B: • No Termination→Cardioversion (n=50)
• Group C: • No termination →CFAE* (n=50)
n=119
*LA and CS for up to 2 hrs additional ablation
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CAFÉ: LA sites
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A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral PV Isolation for Long-Lasting Persistent AF
Oral et al. J Am Coll Cardiol 2009;53:782–9)
• Group A: • Termination with PVAI (n=19)• Group B: • No Termination→Cardioversion (n=50)• Group C: • No termination →CFAE (n=50)
SR at 10 months
36%
34%
79%
P=0.84
Up to 2 h of additional ablation of CFAEs after PVAI does NOT appear to improve clinical outcomes in patients with
long-lasting persistent AF.
After a single Ablation
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Repeat Ablation in 34 randomized patients.
Oral et al. J Am Coll Cardiol 2009;53:782–9)
• Group B: • No Termination→Cardioversion (n=50)• Group C: • No termination →CFAE (n=50)
SR at 9 months
68%
60%P=0. 4
No Difference even with repeat ablation
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Methods 144 patients with permanent AF randomized to:
1. Group I: Pulmonary Vein Antrum Isolation .(PVAI) n=48
2. Group II: Hybrid approach. (CFAE’s + PVAI) n=49• Initial defragmentation: targeting bi-atrial and CS CFAE,
and started randomly in the right or left atrium followed by PVAI
3. Group III: Large area circumferential ablation. (LACA) n=47• Targeting voltage reduction using electroanatomic
mapping. (CARTO)
Elayi et al. ;Heart Rhythm. 2008 5(12):1665
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PVAIN=48
Defragmentation ONLY
N=49
Defragmentation +PVAI N=49
P value
SR 3(6%)
0 (0%)
2(4%)
NS
AT 18 (38%)
1 (2%)
34(70%)
P<0.001
AF 27 (56%)
48(98%)
13(26%)
P=0.01
Acute Results Group I Group II
1. Defragmentation alone did not have a significant effect on AF organization.
2. Defragmentation as an adjunctive strategy to PVAI increases the rate of conversion from AF to organized arrhythmias.
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Long Term Results
Group I PVAIn=48
Group II CFAE+PVAI
n=49
Mean follow-up (months) 11.4 ± 1.1 11.2 ± 1.2
Patients in sinus rhythm after a single procedure
42% 61%
Patients in sinus rhythm after two procedures and with AAD if needed
83% 94%
Better success rate when defragmentation was performed in conjunction with PVAI
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LAA
Cristal Terminalis
CS Pre RF CS Post RF
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LSPV
Presenting for Ablation
Post Antral Isolation
Post CS & LA-CAFEAT Ablation
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Substrate vs. Trigger Ablation for Reduction of AF: An International, Multicenter, Randomized Trial (STAR-AF)
• Comparison of 3 strategies of AF ablation: • (n=100 pts, 35% persistent)
–CFE ablation alone–PVI ablation alone–PVI+CFE hybrid ablation
Verma et al, HRS LBT 2009
Fre
edom
fro
m A
F 74%
47%
29%
In high-burden paroxysmal/persistent AF, PVI+CAFE has the highest freedom from AF versus PVI or CAFE alone after one procedure.
CAFE alone has the lowest procedure success rates
with a higher incidence of repeat procedures
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Outcomes of Different Ablation Approaches That Incorporated CFAE Ablation in Patients With Persistent AF
N AF CAFÉ only PVI only PVI + CAFÉ
Nademanee et al (2004) 121 P+C 91%
Oketani et al (2008) 410 P+C 81%
Verma et al (2007) 40 C 82%
Star AF (2009) 100 P+C 29% 47% 74%
Haissaguerre (2005) 60 C 95% *
Orale at al.(2009) 50 C 60%
Orale et al.(2006) 100 C 57%
Meulet et al.(2007) 96 C 67% 66%
Elayi et al. (2008) 97 C 83% 94%
After 1-2 ablations F/U ~1 year
60% 66% 83%
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Does CAFÉ substrate modification offer additional success?
• Different techniques, Different Operators, Different Skills, Different interpretations, Different endpoints, different experiences, different follow up’s: – Can we generalize the information
– Can we trust the data: Is this Science?
• Significance of CAFÉ: Active vs Passive role?
• Is it just more Controlled Debulking? (CEDCA)
• I will let you draw your own conclusion
Conclusion
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PV Antrum Isolation
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Overlap of CFAE and PVI? Majority of ablated CFAE in tailored approach were in the LA
Extensive “fixed” PV antral isolation includes most areas of CAFÉ.
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Is More ablation better?
• More Ablation: Potential for More atrial Flutter• More ablation: Compromise LA mechanical function• More ablation: Interatrial / intraatrial dyssynchrony• More ablation: More fluoro / More potential complications
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Angioplasty in Acute MI
We were overzealous with the angiojet. Let us fly her to Boston for a body transplant
بكفيCAFE
OK, butwhat else
can we ablate?…
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END