2008 roma, convegno updating in cardiologia. l'ablazione della fibrillazione atriale
TRANSCRIPT
Stefano Nardi, MD, PhD
AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNIDIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE
UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA UNITA’ OPERATIVA DI ARITMOLOGIA CARDIACA
La terapia ablativa della La terapia ablativa della Fibrillazione AtrialeFibrillazione Atriale
L’ entusiasmo dell’ L’ entusiasmo dell’ elettrofisiologoelettrofisiologo
C O N V E G N OUPDATINGDI CARDIOLOGIA15 novembre 2008Auditorium ex I Clinica MedicaPoliclinico Umberto I - ROMA
Atrial FibrillationAtrial Fibrillationanalysisanalysis
9,6
13,4
15,3
18
25,7
28,9
49,8
0 10 20 30 40 50 60
SOLVD (I I -I I I )
V-HeFT (I I -I I I )
CHF-STAT (I I -I I I )
ATLAS (I I I )
DIAMOND-CHF (I I -I I I )
GESICA (I I -IV)
CONSENSUS (IV)
Prevalenza FA (%)
• All AFib affected pts have an increased Morbidity
• The overall increased Mortality is 1,6-2,6% (Manitoba and Framingham Studies)
• 5% year ischemic stroke
• 1/6 Cerebro-Vascular Accident (CVA)
• Framingham StudyRHD 17 X rate of CVA Risk of Stroke increased with age (1,5% 50-59 yrs vs 23,5% at 80-89 yrs)
MagnitudeMagnitude
FA
CURA controllo clinico
controllo FARipristino RS
controllo clinico
parossistica permanentepersistente
Atrial FibrillationAtrial Fibrillationdifferent strategiesdifferent strategies
L’importanza di seguirela giusta via
AFFIRM
STAFSTAF
PIAPIAFF
HOT CAFÉHOT CAFÉ
PAF-PAF-22
RACRACEE
• Paroxysmal Atrial Fibirllation 2 (PAF2) Eur Heart J ’02
• Pharmacological Intervention in AF (PIAF) Lancet ’00.
• Comparison of rate control and rhythm control in pts with AF (AFFIRM) NEJM ‘02.
• Randomized trial of rate-control versus rhythm CTR in PeAF: the Strategies of Treatment of AF (STAF) study. JACC ‘03.
• Effect of rate or rhythm control on QoL in PeAF: results from the Rate CTR vs ECV (RACE) Study. JACC ‘ 04.
• How to treat C-AF (HOT-CAFÉ`) New New DehliDehli
Atrial FibrillationAtrial FibrillationRandomized TrialsRandomized Trials
- Strategies based to maintaining SR at 1 yrs FU without AADs is <30% (recurrence between 50-70%) ....
Pooled (meta-analysis) data from PAF2,
PIAF, STAF, AFFIRM e RACE
- … however in most cases AADs based strategies are not able to prevent RECURRENCE of A Fib.
• Global acute efficacy 40-50% (reduce in long term FU)
25% interruption of treatment !
• SIDE EFFECTS– Until 20% of cases (3-5% TdP)
• Arrhythmia-free survival after ECV in pts with PeAF
Lower Curve Outcome after a single shock when no prophylactic AADs was given
Upper curve Outcome with repeated ECV in conjunction with AADs prophylaxis
Pooled (meta-analysis) data from PAF2,
PIAF, STAF, AFFIRM e RACE
The original AFFIRM STUDY
One year later…
AFFIRM revisited…AFFIRM revisited…
AFFIRM revisited…AFFIRM revisited…
AFFIRM revisited…AFFIRM revisited…
“l’importanza di usare gli STRUMENTI giusti
therapeutic Approachtherapeutic ApproachAtrial FibrillationAtrial Fibrillation
Atrial FibrillationAtrial FibrillationTherapeutic ApproachTherapeutic Approach
Electrophysiologic Electrophysiologic BackgroundBackground
Pulmonary vein anatomy
TRIGGERTRIGGER
RF
Pulmonary vein anatomy
TRIGGERTRIGGER
Haissaguerre, NEJM ’98
Action Potential, Ca++ and Contractility in AFib pts
1.1. Reduction in amplitude and increase in duration of Reduction in amplitude and increase in duration of APAP
Control Control A FibA FibAP (EAP (Emm))
[Ca[Ca2+2+]]ii
ContractioContractionn
2.2. Reduction in the upslope and downslop of the CaReduction in the upslope and downslop of the Ca++++ transienttransient
3. Parallel reduction in the upslope and downslop of the peak developed tension
ContractionContraction
[Ca2+]i[Ca2+]iAP (EmAP (Em))
Atrial Fibrillation histopathology
• Karpawich (‘90) – Canine mod.– LA myofibril disarray was found after 4
months of AFib
– Appearance of prominent cells in subendocardium, variable-sized mitochondria, and dystrophic calcification
• Adomain (‘86)– Myofibril disarray was found in 75%
of canine hearts after 3 months of pacing from AFib
• Karpawich (‘99) – Pediatric Pts– Myofibril hypertrophy, intracellular
vacuolation, degenerative fibrosis, and fatty deposits in the LA after more than 3 years of AFib
Left common trunk 3 right lower veins
Normal
Pulmonary vein anatomy
TRIGGERTRIGGER
The Antral Zone
Hocini M, Card. Res ’02, Circulation ‘02
SUBSTRATESUBSTRATE
Atrial Fibrillation ApproachAtrial Fibrillation ApproachAnatomical considerationsAnatomical considerations
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablationtranseptal puncturetranseptal puncture
Atrial Fibrillation ablationAtrial Fibrillation ablation
Inferomediale
Infero-laterale
VPIL
VPSL
Atrial Fibrillation ablationAtrial Fibrillation ablationPVs anatomyPVs anatomy
Ma qual’è l’impatto delle nuove tecnologie ?
Atrial Fibrillation ablationAtrial Fibrillation ablationPVs activity mappingPVs activity mapping
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Mandapati, Circulation `00Haissaguerre, NEJM ’98
SubstrateSubstrateTriggerTrigger
Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
Atrial Fibrillation ablationAtrial Fibrillation ablationPVs trigger ablationPVs trigger ablation
SUBSTRATE modificationSUBSTRATE modification
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablation3D Mapping System3D Mapping System
Atrial Fibrillation ablationAtrial Fibrillation ablation3D Mapping System3D Mapping System
Atrial Fibrillation ablationAtrial Fibrillation ablationAnatomical considerationsAnatomical considerations
Atrial Fibrillation ablationAtrial Fibrillation ablationAnatomical considerationsAnatomical considerations
Atrial Fibrillation ablationAtrial Fibrillation ablationAnatomical considerationsAnatomical considerations
Atrial Fibrillation ablationAtrial Fibrillation ablationduring AF ablationduring AF ablation
Circumferential lesion pathway
PVPs
Atrial potentials
Lesion Validation (Preablation)Lesion Validation (Preablation)
Incomplete lesion
Lesion Validation Lesion Validation ((AblationAblation))
Complete lesion
Lesion Validation Lesion Validation ((AblationAblation))
Atrial potentials breakdown
PVPs disappearance
Lesion Validation Lesion Validation ((PVPs PVPs AbolitionAbolition))
0.1mV
0.05mV
Validazione delle lesioniValidazione delle lesioni ((abbattimento dei abbattimento dei potenzialipotenziali))
Atrial Fibrillation ablationAtrial Fibrillation ablationVagal GangliaVagal Ganglia
Atrial Fibrillation ablationAtrial Fibrillation ablationVagal GangliaVagal Ganglia
Atrial Fibrillation ablationAtrial Fibrillation ablationPVs analysisPVs analysis
Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
137 pz (età media: 62 a)
FA parossistica o persistente
Randomizzazione a tx antiaritmica da sola o in associazione ad ablazione transcatetere (ablazione circonferenziale, lesioni lineari in AD e AS)
End-point: assenza di recidive aritmiche (>30 s) ad un f.u. di 1 anno
Recidive aritmiche: 91.3% farmaci vs 44.1% farmaci + ablazione
Complicanze maggiori: 4.4% (solo in relazione all’ablazione)
• Anatomia avversa e variabile per la realizzazione di un isolamento elettrico completo
• Rischio di recidiva di conduzione attraverso una linea di blocco INCOMPLETA
OSTACOLO CONSEGUENZA
• Difficoltà alla realizzazione di lesioni transmurali all’orifizio delle VP
• Rimodellamento elettrico
• Volume consistente di tessuto aritmogeno tra l’orifizio della VP e la linea di blocco
• Vulnerabilità all’innesco di FA in risposta a triggers non clinici (BESV da siti innocenti)
Atrial Fibrillation ablationAtrial Fibrillation ablationPITFALLPITFALL
tipo di FAtipo di FA cardiopatia sottostantecardiopatia sottostante
isolamento delle VP isolamento delle VP (ostiale, antrale, (ostiale, antrale, ecc)ecc)
ablazione ablazione circonferenzialecirconferenziale
lesioni lineari aggiuntivelesioni lineari aggiuntive ablazione in aree a ablazione in aree a
conduzione rallentataconduzione rallentata
effettivo isolamento VP
Riduzione/modifica del substrato
Δ tono autonomico
creazione di barriere elettriche complete e non
non inducibilità della FA
recidive aritmiche recidive aritmiche sintomatiche/asintomatichesintomatiche/asintomatiche
utilizzo terapia antiaritmicautilizzo terapia antiaritmica
Disomogeneità Disomogeneità delle popolazioni delle popolazioni
arruolatearruolate
Differenze della Differenze della tecnica ablativatecnica ablativa
End-point End-point procedurali non procedurali non
uniformiuniformi
Metodologia del Metodologia del follow-upfollow-up
“l’importanza di TROVARE il bandolo della matassa
181/777 181/777 Laboratori in tutto il mondo Laboratori in tutto il mondo8.7458.745 pz da 90 Laboratori pz da 90 Laboratori10.19910.199 ATC x FA (90% in ASn) ATC x FA (90% in ASn)PERIODOPERIODO:: 1995 – 2002 1995 – 2002SUCCESSO CLINICOSUCCESSO CLINICO::
52% (52% (3,866 pts) senza f. antiaritmici senza f. antiaritmici75.9% (7408 pts) con f. antiaritmici75.9% (7408 pts) con f. antiaritmici
Worldwide AFib SurveyWorldwide AFib Survey
Cappato R, Circulation ‘04
Atrial Fibrillation ablationAtrial Fibrillation ablation
Who benefits from AF ablation ?Pts selectionPts selection
Ablazione Ablazione dell’FAdell’FA
Disertori M, et al. GIAC 2006Disertori M, et al. GIAC 2006
Linee Guida AIACLinee Guida AIAC
Ablazione Ablazione dell’FAdell’FA
Disertori M, et al. GIAC 2006Disertori M, et al. GIAC 2006
Linee Guida AIACLinee Guida AIAC
What is success?
• Complete freedom of AF, off drug RX?• No symptoms, but drug Rx required?• Dramatic decrease in symptoms, but
AADs still required?• QoL• How do we detect asymptomatic
episodes?• Anticoagulation ………………...?
QUESTIONSQUESTIONS
Mickelson S, JICE ‘05
Cappato R, Circulation ‘05
In US EP believe 29% of pts with AF are candidates for RFCA
• Lower volume centres have lower success rates and higher complication rate
Atrial Fibrillation ablationAtrial Fibrillation ablation
Scientific Paper
• Results coud be Results coud be matched with matched with hystorical hystorical clinical data clinical data
Registry
“Real life” results
Clinical PracticeAcceptance degree of
randomized studies in clinical practice
Prospectic data retrived of clinical aspects in pts already implanted with a PM
Evaluation of clinical benefits due to specific PM functions (ex. Impact of special modality on several specific “end-point”)
Hp, Control groups,
economic evaluation
CLINICAL Practice VS Registries
Courtesy of Dr. Botto
TherapyTherapy
MortalityMorbidity
QoL
“l’importanza di trovare le giuste “PROPORZIONI”
Impact of AFib ablation
Atrial Fibrillation ablationAtrial Fibrillation ablationduring AF ablationduring AF ablation
Atrial Fibrillation ablationAtrial Fibrillation ablationduring AF ablationduring AF ablation
Atrial Fibrillation ablationAtrial Fibrillation ablationduring AF ablationduring AF ablation
Esophageal contiguity with LA3D mapping system in AFib3D mapping system in AFib
Atrial Fibrillation ablationAtrial Fibrillation ablationCCH ptsCCH pts
LA Medial-RPV Junction
RPV Carena
LAA-LSPV Junction
LAA-LIPV Junction
LPV Carena
LAA-LSPV Junction
MV IsthmusLSPV-LAA Junction
PRE-ABLATION POST-ABLATION
Atrial Fibrillation MechanismsAtrial Fibrillation Mechanisms
Seeking answers, but Seeking answers, but what about some what about some
questions?questions?Who benefits from
AF ablation ?
What we can do ?
Selezione dei pts che possono beneficiare
dell’ablazione dell’FA: l’importanza di fare la
SCELTA giusta
Atrial Fibrillation ablationAtrial Fibrillation ablationPVs potential ablationPVs potential ablation
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction
Atrial Fibrillation ablationAtrial Fibrillation ablation3D Mapping System3D Mapping System
Atrial Fibrillation ablationAtrial Fibrillation ablationSurface EKGSurface EKG
Atrial Fibrillation ablationAtrial Fibrillation ablationEGM 25 mmEGM 25 mm
Atrial Fibrillation ablationAtrial Fibrillation ablationEGM 50 mmEGM 50 mm
Atrial Fibrillation ablationAtrial Fibrillation ablationEGM 100 mmEGM 100 mm
Atrial Fibrillation ablationAtrial Fibrillation ablationEGM 200 mmEGM 200 mm
Who benefits from AFib ablation?
Atrial Fibrillation ablationAtrial Fibrillation ablation
Atrial Fibrillation ablationAtrial Fibrillation ablationAnatomical considerationsAnatomical considerations
Atrial Fibrillation ablationAtrial Fibrillation ablationvirtual geometry reconstructionvirtual geometry reconstruction