Hybrid Strategies Context: Ablation in Persistent AF
“ Start with PVI”
Claudio Tondo, MD, PhD, FESC, FHRS
Heart Rhythm Centre
Department of Cardiovascular Sciences and Community Health
Monzino Cardiac Center, IRCCS, University of Milan, Milan, Italy
and
Texas Cardiac Arrhythmia Institute- Austin, Tx, USA
Potential conflicts of interest
Speaker’s name: Claudio Tondo, MD, PhD
▪ I have the following potential conflicts of interest to report:
1. Proctor fees for Medtronic, Abbotts, Biosense&Webster
2. Member of Advisory Boards of Medtronic, Boston Scientific
Daniel Scherr et al. Circ Arrhythm Electrophysiol. 2015;8:18-24
Single procedure success rate off AADs. Multiple procedure success rate off and on AADs of
PeAF ablation.
Copyright © American Heart Association, Inc. All rights reserved.
STAR AF 2 Trial
589 patients randomized 1:4:4 to the three
strategies: PVI, PVI+CFE, PVI+Lines
PVI 97%
BLOCKED LINES 74%
PVI group!!
Technology Advancement for
Atrial Fibrillation Ablation
AGENDA
- Balloon-based Technology :
1. Cryo energy
2. Laser energy
3. RF balloon
- Contact Force Technology:
1. Smart-touch Catheter
2. Tacticath Catheter
Enhanced Cooling
0,2
0,3
0,4
0,5
0,6
0,7
0,8
28 mm 23 mm
Arctic Front Uniformity Score + STDev
Arctic Front AdvanceUniformity Score + STDev
0,2
0,3
0,4
0,5
0,6
0,7
0,8
28 mm 23 mm
.33
.47
.60
.68
N = 30 N = 30 N = 30 N = 30
~47% increase in uniformity for the 23 mm ~83% increase in uniformity for the 28 mm
Refrigerant distribution comes from 4 jets
Improved surface temperature gradient
8
Arctic Front Advance-EvenCool TechnologyTM
PV Lesion Durability with RF and Cryoballoon Studies evaluating PV reconduction using repeat electrophysiology and
mapping after the index procedure
30%
23%
8%
35%
63% 67%
78%
0%
20%
40%
60%
80%
100%
GAP-AF Willems Jiang EFFICAS I EFFICAS II* Ahmed SUPIR
% of Patients without Gaps During Remapping Procedure
5
RF: Contact Sensing RF Arctic Front™
Cryoballoon
1 2 3 4
Arctic Front Advance™
Cryoballoon
6 7
* Calculated rate from manuscript data reporting 9/24 patients with gaps.
**Time between index procedure and re-mapping procedure. All patients were evaluated regardless of clinical symptoms
20 1Late Breaking Clinical Trials session I at the EHRA EUROPACE 2013 meeting in Athens, Greece 2 Williems, et al. J Cardiovasc Electrophysiol. 2010; 21(10):1079-84; 3 Jiang, et al. Heart
Rhythm. 2014;11(6):969-76; 4 Neuzil et al. Circ Arrhythm Electrophysiol. (2):327-33; 5 Kautzner, J. et al. Europace. 2015; 2015 Aug;17(8):1229-35; 6 Ahmed, et al. J Cardiovasc
Electrophysiol. 2010;21(7):731-7; 7 Reddy VY, et al. J Cardiovasc Electrophysiol. 2015 May;26(5):493-500
Patients (n) n=117 n=40 n=75 n=75 n=24 n=12 n=21
Follow-up** 3 Months 3 Months 12 Months 3 Months 3 Months 3 Months 3 Months
Pulmonary Vein Isolation Cryoablation for Persistent and Long-Standing
Persistent Atrial Fibrillation Patients. Clinical Outcomes from Real Word
Multicentric Observational Project
Short title: Cryoablation in Persistent and Long-Standing Persistent AF
Claudio Tondo 1; Saverio Iacopino2, Paolo Pieragnoli3, Giulio Molon4, Roberto Verlato5,
Antonio Curnis6, Maurizio Landolina7, Giuseppe Allocca8, Giuseppe Arena9, Gaetano
Fassini1, Luigi Sciarra10, Mario Luzi11, Massimiliano Manfrin12, Luigi Padeletti13; on
behalf of ClinicalService 1STOP project investigators.
Heart Rhythm, 2017 in press
Tondo C et al Heart Rhythm, 2017 in press
Tondo C et al Heart Rhythm, 2017 in press
Compatible with both 3D mapping system and fluoroscopy
10 irrigated electrodes to deliver RF energy from selected electrode(s), allowing segmental isolation
Spherical, compliant balloonto conform to the anatomy of Pulmonary Vein
Over-the-wire design foreasy maneuverability
FIM study (no results)- Investigators- 40 patients- MRI/ENDOSCOPY/3M CT SCAN
FIM case video- CARTO- FLURO- ICE
RF BALLOON PLATFORM
Personal data
RF BALLOON PLATFORM
Pre-PVI Post-PVI
The main ablation technique in patients undergoing first-time ablation for
persistent, but not long-standing AF was stand-alone PVI in the majority of the
centres (67%)
(A) Very Long-Term from atrial fibrillation in the CONFIRM trial for FIRM-guided ablation (blue) and conventional ablation (red; P=0.003) after 1.2±0.4 procedures;
(B) Very Long Term Single-Procedure freedom from the AF for FIRM-guided ablation (blue) and conventional ablation (red) in the CONFIRM trial. Data shows all cases (solid lines, P=0.002) and those undergoing their first ablation (dashed lines, P=0.002). AF,
atrial fibrillation; FIRM, Focal Impulse and Rotor Modulation.
How to approach Persistent Atrial Fibrillation
Personal Data
Goal(s) OF THE SURGICAL LESION
Tondo, C, Polvani GL, et al. Hybrid approach for AF; under review
Hybrid Treatment (RF surgical epicardial ablation+transcatheter endocardial ablation)
Epicardial ablation
Endocardial ablation
Follow up
under review
Final Remarks
For the time being, persistent AF is regarded as the most controversial form of the
arrhythmia to be treated
The shorter is the duration of AF, the higher is the chance to parallel paroxysmal AF in
terms of clinical outcome
PVI ablation remains the first step to be accomplished and it can be deemed the initial
approach for early persistent AF
For long-persistent AF or redo cases, searching for more functional approach (rotor-like
mapping; AQ mapping,..) can be considered. Endocardial left posterior wall isolation
might have a rationale for electrophysiologists, but hybrid approach (torascopic surgical
approach + concomitant EP) remains a valuable option for higher success rate
