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Gerhard Hindricks
Fire or Ice
Radiofrequency or cryo ablation
University of Leipzig
- Heart Center -
Dept. of Electrophysiology
IDSS Tel Aviv 2015
Presenter Disclosure Information
Gerhard Hindricks/Department of Electrophysiology has received scientific grants
and research grants through the University Leipzig / Heart Center from German
Heart Foundation, ProCordis Foundation, St. Jude Medical, Biotronik, Boston
Scientific, and Volkswagen Foundation.
No personal financial relation to disclose.
• point-by-point RF ablation is standard of care for
AV-nodal reentrant tachycardia
tachycardia due to accessory pathway
ectopic atrial tachycardia
typical and atypical atrial flutter
ventricular arrhythmia
• RF ablation is the most frequent technology for
catheter ablation of atrial fibrillation
Current role of point-by-point RF ablation
Fire or Ice for AF ablation
Cryo-Balloon Cardiofocus Mesh-Ablator Ablation
Frontiers
PV-devices and alternative energy sources
HIFU
40% silent
stroke
10% PVI
rate
complications
incl. death
highly
complex,
no benefits ?
Fire or Ice for AF ablation
• Conceptual aspects and ablation strategies
• Procedural aspects (duration, fluoro time ...)
• Safety and Efficacy
• Development of future technologies
PV ablation devices and energy: What counts ?
Fire or Ice for AF ablation
• Conceptual aspects and ablation strategies
• Procedural aspects (duration, fluoro time ...)
• Safety and Efficacy
• Development of future technologies
PV ablation devices and energy: What counts ?
Fire or Ice for AF ablation
• 14 pat. with AF ablation devices (cryo, laser, HIFU)
• 3D voltage map before and after ablation
Reddy et al.; Heart Rhythm 2008
• level of PV isolation was
– distal within the PV antrum (segmental position)
– AF substrate within the PV antrum untreated
PV devices: Level of PV isolation
Fire or Ice for AF ablation
• Conceptual aspects and ablation strategies
• Procedural aspects (duration, fluoro time ...)
• Safety and Efficacy
• Development of future technologies
PV ablation devices and energy: What counts ?
Fire or Ice for AF ablation
• PV-isolation
• activation maps
• entrainment maps
• substrate maps
• CFAE maps
• rotor maps
• HD maps
Ablation strategies to approach AF: Changing paradigms
• distal PVI
• - no
• - no
• - no
• - no
• - no
• - no
Fire or Ice for AF ablation
Substrate-based AF ablation strategies
Rolf S et al.; Circulation AE 2014, in press
Fire or Ice for AF ablation
Substrate-based AF ablation strategies
Rolf S et al.; Circulation AE 2014, in press
Fire or Ice for AF ablation
Substrate-based AF ablation strategies
Rolf S et al.; Circulation AE 2014, in press
Fire or Ice for AF ablation
Assumption one:
• Cryo balloon ablation ablation is as effective as
radiofrequency ablation......
• This has never been shown by means of a
prospective randomized study performed in centers
that are experienced in the use of point-by-point RF
ablation......even not for paroxysmal atrial fibrillation.
For substrate driven AF, cryo ablation is absolutely
ineffective.
Fire or Ice for AF ablation
Non-randomized comparison of Cryo vs RF-ablation
Mubnai G et al., Am J Cardiol 2014
Fire or Ice for AF ablation
Pokushalov I et al., JCE 2013
Randomized comparison of Cryo vs RF re-ablations
Fire or Ice for AF ablation
Randomized comparison of Cryo vs RF re-ablations
Pokushalov I et al., JCE 2013
Fire or Ice for AF ablation
Assumption two:
• Cryo balloon ablation ablation is as safe or even
safer as compared radiofrequency ablation......
• No data support this assumption. Reported data
indicate that complication rates may be higher as
compared RF ablation. Let´s look to the data.....
Fire or Ice for AF ablation
Assumption three:
• Atrio-esophageal fistula does not occur after cryo
ablation.
• Unfortunately this is not true. Severe esophageal
injury as well as perforation with atrio-esophagal
fistula has been reported.
Fire or Ice for AF ablation
Assumption four:
• Cryo balloon ablation ablation is faster than
radiofrequency ablation......
Schmidt B et al., JCE 2014
n= 2850 905
Fire or Ice for AF ablation
Cryo-energy versus RF energy
• Prospective randomized studies have compared the
efficacy and safety of cryo-energy and
radiofrequency energy in the setting of
- typical atrial flutter (3 studies)
- AV-nodal reentrant tachycardia (2 studies)
• all studies confirmed superiority of radiofrequency
energy as compared to cryo energy.
• Key finding: higher recurrence rate with cryo,
same complication rate!
Fire or Ice for AF ablation
Cryoballoon versus RF energy
• Cryo RF
all types of AF no yes
individualized ablation no yes
antral ablation no yes
mapping capabilities no yes
concomitant flutter ablation
right atrium no yes
left atrium no yes
non fluoroscopic navigation no yes
Fire or Ice for AF ablation
• Why did cryo ablation not evolve as a key ablation strategy in
true high volume ablation centers?
• Because it is less effective, takes longer, and is more
expensive as compared to RF ablation.
• Point-by-point RF ablation does
• enable individualized treatment of anatomy and substrate
• enable safer and more efficacious lesion deployment
• enable innovative 3D/4D catheter navigation
• lead to procedures with
• with procedure duration < 120 min
• with fluoroscopy time < 10 min
• with clinical efficacy > 80% in PAF
Should cryo ablation be first line treatment for PAF?
Fire or Ice for AF ablation