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Hybrid AF Ablation Sequential thoracoscopic and percutaneous ablation for Lone AF Dr Guy Haywood Consultant Cardiac Electrophysiologist South West Cardiothoracic Centre Derriford Hospital Plymouth

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AF Catheter Ablation Outcomes Bordeaux 5 year follow up (PV Ostial ablns. 2001-2) 63% PAF, 22% Persistent, 14% Longstanding Pers. Recurrence = any recording of > 30 sec AF/Flutter/Tachycardia (anti-arrhythmics stopped at 1 month) 87 J Am Coll Cardiol. 2011;57(2):160-166 Longstanding Persistent recurrence rate 1.9 fold higher 40% 37% 29% 87% 81% 63% Single Procedure Last Procedure (Median of 2)

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146 Procedures (43 persistent, 103 PAF) 146 Procedures (43 persistent, 103 PAF) 115 were 1 st time procedures 115 were 1 st time procedures 80% AF Free, 90% minimal symptoms PAF 62%

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Catheter Ablation Phased RF Plymouth 146 Procedures (43 persistent, 103 PAF) 115 were 1 st time procedures 71% AF Free, 80% minimal symptoms Persistent (Continuous AF < 1 year) 55% 62%

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Plymouth Late Outcome in Persistent AF patients - Time to First Arrhythmia Single procedure

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HRS 2012 Abstracts Kuck: 5 year follow up Long Standing Persistent AF Ablation 202 pts Persistent AF with continuous AF for 4944 months (median 36 months) PVI only at first ablation, PVI + Linear lesions and/or CFAE at subsequent ablations Median 2 ablations (Range 1-5) Complications : 4.7% of procedures At 5 years of follow up success rate 20% from 1 procedure, 45% from multiple procedures. Total AF duration 2yrs 76.5% vs. 42.2% p = 0.033

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What causes recurrence? Reconnection across lines of electrical block Trigger sites outside isolated areas Degree of atrial myocardial scarring and remodelling

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Todd, D. Circulation. 2003 108:25 3108-14 The Guiraudon paper. The Box Set 14 patients with drug refractory Persistent AF Surgical and cryo ablation 3/7 EP study via epicardial wires 2 long term AF recurrences: One AF gap in cryo line found and re-ablated One flutter reablated mitral isthmus line 100% SR

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HIFU Outcomes Using Epicor device to isolate the Posterior Wall during open chest surgery. At > 2 year follow-up: 81% of previous PAF in NSR 56% of previous PsAF in NSR 18% of previous LS PsAF in NSR Davies, E. J of Card Surg. 2014. 29(1): 101-7

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When it works- why does it work? AF Maze EP Substudy (Plymouth) to investigate link between PWI and freedom from AF very late outcomes Invasive Left Atrial EP study on 2 groups of patients >4 years post surgical ablation: 1)Successful - SR post surgery 2)Unsuccessful on-going AF post surgery

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AF Maze EP Substudy Case 1 Endocardial Voltage Mapping of Epicor HIFU ablated patients at > 4 years of follow up A patient with persistent AF despite previous epicardial ablation with HIFU. The posterior wall is seen to be non-isolated Purple High Voltage Grey, Orange and yellow Low Voltage

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AF Maze EP Substudy Expandable Lasso mapping catheter on Posterior wall Lasso Mapping Catheter Coronary Sinus Catheter QRS Surface ECG Case 1

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Following DCCV; Pacing in the coronary sinus was quickly conducted to the posterior wall in a time of approx. 40ms demonstrating failure of posterior wall isolation by HIFU Pacing at Coronary Sinus Sensed endocardial signal Inside posterior wall area AF Maze EP Substudy Testing for posterior wall isolation post DC Cardioversion Case 1

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AF Maze EP Substudy Case 2 Freedom from Afib post HIFU Ablation Voltage map showing the isolated posterior wall in a patient who experienced no AF following the epicardial ablation

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AF Maze EP Substudy Results 100 patients screened 10 patients with no AF since surgery agreed to study 17 patients studied 11 with on going AF 6 no evidence of recurrent AF since surgery 11 with AF all had non-isolated post wall 6 with No AF recurrence post surgery: 4 isolated posterior wall 1 very delayed conduction (260ms from CS pacing) 1 non-isolated PW (PAF only before surgery)

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Hybrid Ablation Atricure Cobra Fusion followed by Catheter Ablation Stage 1 - Thoracoscopic Epicardial LA ablation Stage 2 (approx 2/12 later) Catheter ablation

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Hybrid Ablation Long Term Outcomes Cobra Fusion System Brescia 2013 Cobra Fusion System Brescia 2013 % PAROXYSMAL AF LA DIMENSION MEAN AF DURATION LONG TERM PERSISTENT AF LA DIMENSION MEAN AF DURATION Catheter Abln Surgical 1 STEP Only Hybrid FREEDOM FROM AF (mean FU 19.2 mth) AF Muneretto C et al. Innovations (Phila) 2012 Jul-Aug;7(4):254-8 & Muneretto C. J Thorac Cardiovasc Surg. 2012;144(6):1460-5 All persistent AF 30 month mean follow up with ILRs No complications, no ITU stay

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HYBRID ablation progress Visits to evaluate the technologies to Brescia, Italy (GH and M D-H) and Bad Neuheim, Germany (GH and AM) Governance clearance secured via internal Trust new procedures process Agreement with Plymouth Trust to start admitting patients June 2013 1 st procedure 12/9/2013

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EP Study post Thoracoscopic Cobra Ablation Patient in Sinus Rhythm Voltage map from the second stage of a hybrid case. Here we see that the posterior wall is isolated from the outset. No additional endocardial ablation was delivered. Case 1

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EP Study post Thoracoscopic Cobra Ablation Patient still in AF Voltage map from the second stage of a hybrid case. The colour on the posterior wall shows that there is continued electrical activity in that region. There is some evidence of transmural scar seen here along the floor (image on left in red). Case 2

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5-6 11-12 A fluro (x-ray) image of the circular mapping catheter placed flat on the posterior wall. The earliest signals previously seen through 5-6 show the break in the ablation line to be on the roof. This is confirmed with the latest signals being around 12-13. Case 2

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Techniques to locate the gap TactiCath (white) and A Focus II (green) are both on the posterior wall. Note on the green signals from the posterior wall, the earliest signal is from 5-6 and the latest around 11-12 Case 2

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Catheter ablation Post Wall Isolation for Persistent AF + CTI Line

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Following endocardial roof-line completion (shown here as while dots), the posterior wall becomes electrically silent here depicted as grey. Case 2

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Pacing from the TactiCath (top while line) within the isolated region is detected with a very short conduction time on the A-Focus II (green) also in the isolated region. Note that although there is local capture, this does not propagate out of the isolated region to the CS (Red) The posterior wall beats independently of the rest of the heart. Case 2

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Start of 2 nd stage hybrid pathway Patient in Sinus Rhythm Voltage map from the second stage of a hybrid case. Despite the patient being in sinus rhythm, there is persisting areas of high voltage seen on the posterior wall. Case 3

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The completion of the roof line renders the posterior wall silent. Case 3

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Hybrid Ablation - Cobra Fusion + Catheter Ablation Experience 20 Patients All persistent AF mean 31 months continuous AF duration in past 10 yrs (median 28, Max continuous 60 months) LA median diameter 47 mm CHADS VASC Median 2 2 Female, 18 Male Mean age 67 yrs 2 patients aborted due to adhesions Complications: 1 fatal CVE day 2 post surgery, 1 haemothorax 19.03.15

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Cobra Fusion experience Post 2 nd Stage Catheter Ablation 10 Completed Patients PW isolated at start of case in 4/10 Gap closed in 5 patients 1 unable to isolate endocardially but slow conduction CTI ablation at 2 nd stage procedure in all Follow-up - 10 pts Median f/u 8 months (1-15 months) 9/10 currently in SR 1/10 in persistent AF 2x failed DCCV 2 Pts AF/AT recurrence in 4/12 1 DCCV at 4/12 (SR since) 1 paroxysmal atrial tachycardia in first 4/12 but now >6/12 SR

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Initial 12 month Hybrid Experience. 50 Referred 35 Accepted 20 Surgical (1 st Stage Complete) 10 Catheter (2 nd stage complete) 9 >3/12 post Cath

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Hybrid Pathway Referral to either GAH or MDH Joint EP/CTS MDT Seen by MDH in clinic Baseline QoL questionairre 1 st Stage (surgical) Procedure 2 nd Stage (endocardial) procedure 8-12 weeks post Surgery 4 month Follow-up ECG, monitor, symptoms, QoL 12 Month Follow-up ECG, monitor, symptoms, QoL 24 Month Follow- up ECG, monitor, symptoms, QoL, Echo

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QoL Quality of life is the most important outcome in AF Built into the AF pathway The 2 scores AFEQT EQ 5D Collected at each follow-up: 4, 12 & 24 months

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To take things forward National database of non-concomitant surgical AF ablation Appointment of EP Research Fellow to liase with other centres and run Establish the minimum dataset designed by Plymouth and Brompton nationally CRF QOL analysis Future Hybrid research Ganglionic plexi GRASS stimulator Does epicardial ablation eliminate GP responses + do they endure? Catheter alone versus Hybrid Post Wall isolation for Pers AF