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Atrial Fibrillation Ablation
Cardiology SymposiumDecember 6, 2004
Paul R. Steiner, M.D.Cardiac Electrophysiology
Case Background:Case Background:
46 yr old athletic woman (cyclist, runner) 3 yr h/o increasingly frequent rapid
palpitations paroxysmal AF Often immediately following exercise More recently may occur randomly
No other medical conditions
Initial Evaluation:Initial Evaluation:
ECG : Sinus bradycardia at rest 54 bpm, normal morphology
Labs : T4, TSH, lytes, etc. are WNL Echo : Structurally normal heart Holter : Frequent APCs, occas PVCs; salvos
of AT and AF, some that are associated w/ symptoms on the patient log.
Heart rate range (in sinus): 46 – 138 bpm
Treatment History:Treatment History:
Rate control strategy: Digoxin β – blockers CCBs
Rhythm control strategy: Propafenone (Rhythmol) Flecainide
What next?What next?
Question:Question:
What would you do next to effectively treat her life-style altering paroxysmal AF?
[ A ] Trial of a class IA drug (ex. quinidine).[ B ] Amiodarone treatment (with regular
careful monitoring).[ C ] Referral for AV junction ablation and
high-quality pacemaker [ D ] Refer for atrial defibrillator implant[ E ] Refer for catheter ablation of AF
Atrial Fibrillation AblationAtrial Fibrillation Ablation(What we did…)(What we did…)
FOR WHOM?FOR WHOM? ((Paroxysmal Paroxysmal or or PersistentPersistent))1. AF w/ “significant symptoms” associated2. Refractory to AADs3. Absence of severe structural heart dz.
[ E ]
Left AtriumLeft AtriumPosterior Basal ViewPosterior Basal View
R. superior pulmonary vein
R. inferior pulmonary vein
Coronary sinus
L. inferior pulmonary vein
L. atrium
L. superior pulmonary vein
L. auricle
L. pulmonary artery
R. pulmonary artery
Netter F. Atlas of Human Anatomy. 1989;Plate 202.
Nathan, Circ Res, 1969?
Left Atrium, Posterior WallLeft Atrium, Posterior WallVariable Anatomy (Common)
RIPV
RSPV
LIPV
LSPV
IVC
SVC
LAARAA
Left Atrium, Posterior WallLeft Atrium, Posterior Wall
Atrial FibrillationInitiation Mechanism – PV Triggers
Nathan, Circ Res, 1969?
Left Atrium, Posterior WallLeft Atrium, Posterior WallPulmonary Vein Isolation
MediastinumMediastinumAxial Superior ViewAxial Superior View
Netter F. Atlas of Human Anatomy. 1989;Plate 230.
Esophagus
Right Pulmonary
Veins
Left Pulmonary Veins
Aorta
Azygous Vein
Left AtriumRight
Atrium
T8 Axial ViewT8 Axial View
Courtesy of M. Ramsey, PhD, CEO CardioCommand
Right PVs Left PVs
Esophagus Aorta
LeftVentricle
Atrial Fibrillation AblationAtrial Fibrillation AblationTechniqueTechnique
Combined ModalityCombined Modality ImagingImaging
1. Fluoroscopy (biplane, for rapid 3-D estimates)
2. High resolution gated CT or MRI3. 3-D electroanatomic mapping 4. Intracardiac echo
In the future: Multi-modality image co-registration combining
real-time anatomy and function…
Cur
rent
Left Atrium (LA) andLeft Atrium (LA) andPulmonary Vein AnatomyPulmonary Vein Anatomy
3-D CT Reconstruction
(Extreme PA Cranial View)
LA Roof
Esophagus
Left PVs
Right PVs
LA Appendage
Side-by-Side GeometrySide-by-Side GeometryElectroanatomic Map & 3-D CT: Cranial ViewElectroanatomic Map & 3-D CT: Cranial View
ESI Nav-X 3-D Geometry 3-D CT via CardEP
(Cranial View)
LA Roof
Esophagus
Left PVsRight PVs
LAA
ESI Nav-X 3-D Geometry 3-D CT via CardEP
Side-by-Side GeometrySide-by-Side Geometry RF catheter pointing RF catheter pointing awayaway from esophagus from esophagus
Pulmonary Vein IsolationPulmonary Vein IsolationSegmental ApproachSegmental Approach
Haïssaguerre, M. et al., Circulation. 2000;102:2463–2465.
Going…Going… Going…Going… Gone !Gone !
LA Mapping and Catheter AblationLA Mapping and Catheter AblationVisualizationVisualization:: Intracardiac UltrasoundIntracardiac Ultrasound
Facilitate transeptal access to LA Visual guidance of catheters at PV ostium RF energy delivery titration via “bubble” monitoring Doppler PV flow (assess for size and stenosis) Direct visualization of:
PV ostial size Anatomic abnormalities Pericardial effusion Thrombus
Left Atrial Mapping and Catheter AblationLeft Atrial Mapping and Catheter AblationVisualizationVisualization:: Intracardiac UltrasoundIntracardiac Ultrasound
Transeptal Access to LATranseptal Access to LA
Tenting of theintra-atrialseptum duringtranseptalcatheterization
AcuNav 10 Fr Phased Array Diagnostic Ultrasound Catheter (by Acuson)
Left Atrial Mapping and Catheter AblationLeft Atrial Mapping and Catheter AblationVisualization Visualization : : Intracardiac UltrasoundIntracardiac Ultrasound
Optimizing Catheter Placement at PV OsOptimizing Catheter Placement at PV Os
CautionCaution
STOP !STOP !
Marrouche N and Natale A. Electromedica 70 (2002) no. 1
PV Isolation by RF LesionPV Isolation by RF Lesion
Before …
Electronically Isolated PVElectronically Isolated PV
After …
FOR WHOM?FOR WHOM? ((Paroxysmal Paroxysmal or or PersistentPersistent))1. AF w/ “significant symptoms” associated2. Refractory to AADs3. Absence of severe structural heart dz
HOW?HOW?1.1. Electrical isolation of pulmonary veinsElectrical isolation of pulmonary veins2.2. Atrial tissue substrate modificationAtrial tissue substrate modification3.3. Accomplished via catheter ablation combined w/ Accomplished via catheter ablation combined w/
multiple imaging modalitiesmultiple imaging modalities
SUMMARYSUMMARYAtrial Fibrillation AblationAtrial Fibrillation Ablation