Download - 慢性房颤的导管消融治疗 -- 何时柳暗花明?
慢性房颤的导管消融治疗-- 何时柳暗花明?
刘少稳刘少稳上 海 市 第 一 人 民 医 院上海交通大学附属第一人民医院 心内科
--Mechanisms of AFib (1)
① Electrical Reconnection of PV and LA
② Atrial substrate modification
③ Non-PV drivers or firing foci are
important for acute termination of AFib
and for long-term success. --Miyazaki S, et al. Long-term clinical outcome of extensive PVI-based
catheter ablation therapy in patients with paroxysmal and persistent AF.
Heart. 2011;97(8):668-673.
Reasons of Recurrence After AFib Ablation
Afib pathophysiologyAfib pathophysiology
AFib:AFib: a developmental disease! a developmental disease!
Factors account for the progression of AFib: New Triggers, More extensive atrial myocardium fibrosis (Substrate), Changing of Autonomic tone
Patients with first AFib and comorbidities are at higher risk for rapid progression to permanent AFib. Age, diabetes, and heart failure are independent predictors. Pappone C, Radinovic A, Manguso F, et al. AFib progression and management: a 5-year prospective follow-up study. Heart Rhythm. 2008;5(11):1501-1507.
--Mechanisms of AFib (1)
Reasons of Recurrence After AFib Ablation
--Mechanisms of AFib (1)
Reasons of Recurrence After AFib Ablation
N=3966 (PAF 36%, PsAF 20%, LSP 44%) , Redo N=987(PAF 29%, PsAF
20%, LSP 51%) , LAA firing: 266 (27%) (PAF 18%, PsAF 23%, LSP 58%)
Freed
om from
A
F/A
TMonths
Di Biase and Natale. LAA: an underrecognized trigger site of AF. Circulation. 2010;122(2):109-118
>500 bpm
88 bpm170 bpm340 bpm380 bpm
>500 bpm
400 ms100 msI
II
V1
SVC1
SVC2
SVC3
SVC4
SVC5
SVC6
HRA
MRA
LRA
CSp
CSd
A B
SVC-P
SVC-P
SVC-P
SVC-P
A AA
Afib AT Sinus rhythm
SVC Isolation in patients with PsAF
--Mechanisms of AFib (1)
Paroxysmal (n=46) and persistent (n=14) AF patients
without structural heart disease who underwent
CPVI.
SVC sleeve length >30 mm and maximum amplitude
of SVC potential >1.0 mV strongly predicted an SVC
focus of AF (100% sensitivity, 94% specificity). Higuchi K, et al. SVC as initiator of AF: factors related to its
arrhythmogenicity. Heart Rhythm. 2010;7(9):1186-1191.
Reasons of Recurrence After AFib Ablation
确定肺静脉外起源异位兴奋灶 -SVC
Tube PV
PV Antrum
Becker A et al.JCE 2001
--Related to Ablation Approaches (2)
Reasons of Recurrence After AFib Ablation
Parkash R, et al. Catheter Ablation Technique of PAF and PsAF: A Meta-Analysis of the Randomized Controlled Trials. JCE. 2011;18:1540-8167.
Haissaguerre M, et al. The "venous wave" hypothesis.JACC. 2004;43(12):2290-2292
CPVA+PVI plus additional linear ablationLA roof line1,2, MA isthmus3,4, RA5,6
• Willems S, et al. Substrate modification combined with PVI improves outcome of ablation in PsAF: a prospective randomized comparison. Eur Heart J 2006;16:16.
• Hocini M, et al. Techniques, evaluation, and consequences of linear block at the left atrial roof in PAF: a prospective randomized study. Circulation 2005;112:3688-96.
• Fassini G, et al. Left mitral isthmus ablation associated with PVI: long-term results of a prospective randomized study. JCE 2005;16:1150-6.
• Pappone C, et al. Prevention of iatrogenic atrial tachycardia after ablation of AF: a prospective randomized study comparing CPVA with a modified approach. Circulation 2004;110:3036-42.
• Calo L, et al. LA ablation versus biatrial ablation for persistent and permanent AF: a prospective and randomized study. JACC 2006;47:2504-12.
• Takahashi Y, et al. Clinical characteristics of patients with persistent AF successfully treated by LA. Circ Arrhythm Electrophysiol. 2010;3(5):465-71
Additional linear ablation in patients with persistent AFib
右心房消融线 ---在 PVI的基础上增加右心房消融线:右房后壁和间隔部连接上下腔静脉的消融线,以及上腔静脉电隔离,可使慢性房颤术后14月的复发率由 39% 降到 15% ( p=0.02 ) --Calo L, et al. LA ablation versus biatrial ablation for persistent and permanent AF: a prospective and randomized study. JACC 2006;47:2504-12. Takahashi Y, et al. Clinical characteristics of patients with persistent AF successfully treated by LA. Circ Arrhythm Electrophysiol. 2010;3(5):465-71.
三尖瓣狭部线性消融在经导管消融治疗慢性持续性房颤中的作用? !
Shanghai First People’s Hospital, Jiao Tong University
CFAE ablation provided only benefit for persistent AFib when combined with antral PVI (RR 0.55). Adjunctive CFAE ablation increased procedural, fluoroscopy, and RF application times, and the risk/benefit profile of adjunctive CFAE ablation deserves further evaluation.1. Kong MH, Piccini JP, Bahnson TD. Efficacy of adjunctive ablation of CFAEs and PVI for the treatment of AF: a meta-analysis of randomized controlled trials. Europace. 2011;13(2):193-204.2. Parkash R, et al. Approach to the Catheter Ablation Technique of Paroxysmal and Persistent AF: A Meta-Analysis of the Randomized Controlled Trials. JCE.. 2011;18:1540-8167.3. Li WJ, et al. Additional Ablation of CFAEs After PVAI in Patients with AF: A Meta-Analysis. Circ Arrhythm Electrophysiol. Feb 8 2011. 4. Hayward RM, et al. PVI with CFAE Ablation for Paroxysmal and Nonparoxysmal AF: A Meta-
Analysis. Heart Rhythm. 2011;9.
CAFE ablation in patients with
persistent AFib
Mechanisms of CFAE
Shanghai First People’s Hospital, Jiao Tong University
In human, CFAEs indicate localized rapid AFib sites in a
minority of cases. The majority of CFAEs reflect far-field
signals, AFib acceleration, or disorganization. Narayan SM, et al. Classifying fractionated electrograms in human AF using
MAP and activation mapping. Heart Rhythm. 2011;8(2):244-253.
AF patients have a higher prevalence of CFAE and short
CL activation within the proximal CS than control patients
with nonclinical AF. No difference in the DF during AF was
seen. CS CFAEs are common in controls with induced AF.Teh AW, et al. Prevalence of CFAE in the CS: comparison between patients
with PsAF or PAF and a control population. Heart Rhythm. 2010;7(9):1200-
1204.
GP ablation CFAE Ablation.In CFAE ablation, targeting peripheral sites may only destroy axons and may be cause for failure -target cell bodies (GP) for highest success!Armour JA, Murphy DA, Yuan BX, et al. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec, 1997,247:289-298.Zhou J, Scherlag BJ, et al. Gradients of atrial refractoriness and inducibility of AFib due to stimulation of ganglionated plexi. J Cardiovasc Electrophysiol, 2007,18(1):83-91.
Arrhythmia Research Institute
University of Oklahoma
Mechanisms of AFib
Afib pathophysiologyAfib pathophysiology
Trigger
Substrate Nerve
Ectopy to start Afib
Conduction properties of atria to sustain Afib
Conditions that increase the likelihood of Afib induction or maintenance
Vagal & sympathetic
Substrate: Maze, Linear Abl, CFAE, CPVA
Trigger: PVI, Ablation of AFL, AT, PACs
Autonomic Nerve: GP Abl 、 CPVA
CPVATriggersSubstrateNerve
12
① Cooled-tip catheter has a superior long-term outcome than the 4-mm-tip catheter in CPVI, which may be associated with the efficacy of transmural block
Chang SL, et al. Comparison of cooled-tip versus 4-mm-tip catheter in the
efficacy of acute ablative tissue injury during circumferential pulmonary
vein isolation. J Cardiovasc Electrophysiol. 2009;20(10):1113-1118 ② The image-integration guided catheter ablation of
paroxysmal or persistent AFib may provide a superior efficacy of over the long term
Della Bella P, et al. Image integration-guided catheter ablation of AF: a
prospective randomized study. JCE. 2009;20(3):258-265.
--Related to Ablation Techniques (3)
Reasons of Recurrence After AFib Ablation
PASupRL LL
Individualized CPVA Line
Shanghai First People’s Hospital, Jiao Tong University
Recurrences After
AFib Ablation
n=226
n=240
n=107
The use of 3D Image Integration improves
single-procedure efficacy of PV isolation for
AF. Variant PV anatomy was associated with
a lower single-procedure success rate.
Hunter RJ, et al. Impact of variant pulmonary
vein anatomy and image integration on long-
term outcome after catheter ablation for atrial
fibrillation. Europace. 2010 Sep 7;2010:7.
③Contact sensing provides a highly accurate means to titrate RF ablation lesion depth and may provide clinically valuable information regarding the efficacy of RF ablation lesions. (electrical coupling index, EnSite) Holmes D, et al. J Cardiovasc Electrophysiol. 2010(29):1540-8167.
④ Real-time lesion assessment using high-frequency ultrasound integrated into an ablation catheter is feasible and allows differentiation between true necrosis and hemorrhage. Wright M, et al. Real-time lesion assessment using a novel combined ultrasound and RF ablation catheter. Heart Rhythm. 2011;8(2):304-312.
--Related to Ablation Techniques (3)
Reasons of Recurrence After AFib Ablation
O'Neill MD, et al. Long-term follow-up of persistent AF ablation using
termination as a procedural endpoint. Eur Heart J. 2009;30(9):1105-1112.
PATIENT FLOW CHART
Reasons of Recurrence After AFib Ablation--Impact of Ablation procedure end-point (4)
49%
69%
95%
52%
85%
15%
Left isthmus AT Cavotricuspid isthmus AT
235 356
Cavotricuspid isthmus AT Left isthmus ATFocal AT on the septum AT Macroreentry AT-LA roof
Transition to a second AT occurs frequently in the
ablation of AT in PsAF patients. This transition
occurs most commonly abruptly within the range of a
single CL of the original AT (79.4%). This is best
explained by a continuation of AT that was "present"
simultaneously with the pre-transition tachycardia,
being "entrained" (for a reentrant tachycardia) or
"overdriven" for an automatic focal tachycardia.
Transition was followed by a macro-reentrant AT
related to MA/TA in 26% and followed by focal or roof
related macroreentry AT in 74%.
Tachycardia Transition During Ablation of PsAF. JCE. Arantes L & Haïssaguerre M et al. Nov 29 2010(29).
AFL2
AFL1 AFL3
AP
陈 , M , 54 岁,房颤持续近 1 年心超: LA 33mm , EF 58%
Failed 3 Shocks: 300J-360J-360J
Mapping of AT
AP LL
Periodogram of AFib recorded in the CS at baseline (A), 3 minutes prior to conversion (B), and the frequency of AT (C). At baseline, the dominant frequency (DF) of AF is 6.60 Hz (A). Ablation of CFAEs results in a decrease in DF of AFib; however, there is no change in the frequency of the spectral component (B, arrow). After termination of AFib to AT, the frequency of AT (4.84 Hz) is similar to the frequency of the spectral component identified in the periodogram of AF (C). The mechanism of AT was mitral isthmus– dependent flutter in this example. Yoshida K, et al. Relationship between the spectral characteristics of AF and AT that occur after catheter
ablation of AF. Heart Rhythm. 2009;6(1):11-17.
Elimination of spectral components of AF by targeted linear ablation suggests that spectral components may indicate site-specific ATs that coexist with AF despite a lower frequency than the DF of AF Yokokawa M, et al. Effect of linear ablation on spectral components of AF. Heart Rhythm. 2010;7(12):1732-1737.
Baseline
Antral PVI
Linear ablation
Effect of antral PVI and linear ablation on the prevalence of spectral components in the left atrium, coronary sinus, and right atrium.
① Type of Afib1,2,5 , duration of permanent AFib7
② LA volume ( 145ml ) 2,3,6, LA strain4, fibrillatory wave amplitude on surface ECG7,8
1. Bhargava M, et al. Impact of AF type and repeat catheter ablation on long-term freedom from AF: Results of multicenter study. Heart Rhythm. 2009;9:9.
2. Abecasis J, et al. LA volume calculated by multi-detector CT may predict successful PVI in catheter ablation of AF. Europace. 2009;23:23.
3. Hof I, et al. Does LA volume and PV anatomy predict the outcome of AF ablation? JCE. 2009;20(9):1005-1010.
4. Hwang HJ, et al. LA strain as predictor of successful outcomes in catheter ablation for AF. J Interv Card Electrophysiol. 2009;16:16.
5. Bhargava M, et al. Impact of type of AFib and repeat catheter ablation on long-term freedom from AFib: Results of multicenter study. Heart Rhythm. Jun 9 2009;9:9.
6. McCready JW, et al. Predictors of recurrence following radiofrequency ablation for PsAF. Europace. 2011;13(3):355-361.
7. Matsuo S, et al. Predictors of catheter ablation outcome for PsAF. JACC.2009;54(9):788-795.
8. Nault I, et al. Clinical value of fibrillatory wave amplitude on surface ECG in patients with PsAF. J Interv Card Electrophysiol. 2009;30:30.
Reasons of Recurrence After AFib Ablation--Impact of the patient’s characteristics (5)
Pre-procedural elevated levels of NT-proBNP1, Endothelin-12, Interleukin-63, hCRP4 and conventional markers of the inflammatory cascade such as WBC count, as well as hypertension and increased BMI were significantly associated with AFib recurrence3,5.
1. Hwang HJ, et al. Incremental predictive value of pre-procedural NT-proBNP for short-term recurrence in AF ablation. Clin Res Cardiol. 2009;19:19.
2. Nakazawa Y, et al. Endothelin-1 as a predictor of AFib recurrence after PVI. Heart Rhythm. 2009;6(6):725-730.
3. Henningsen KM, et al. Prognostic impact of hs-CRP and IL-6 in patients undergoing RFCA for AFib. Scand Cardiovasc J. 2008;31:1-7.
4. Kurotobi T, et al. A pre-existent elevated C-reactive protein is associated with the recurrence of atrial tachyarrhythmias after catheter ablation in patients with AF. Europace. 2010;12(9):1213-1218.
5. Letsas KP, et al. Pre-ablative predictors of atrial fibrillation recurrence following pulmonary vein isolation: the potential role of inflammation. Europace. 2009;11(2):158-163.
Reasons of Recurrence After AFib Ablation--Impact of the patient’s characteristics (5)
3D Delayed Enhancement MRI3D Delayed Enhancement MRI
Staging of AF by DE-MRIStaging of AF by DE-MRI
Oakes RS, et al.
Detection and
quantification of LA
structural remodeling
with delayed-
enhancement MRI in
patients with AF.
Circulation. 2009;
119(13):1758-1767
DE-MRI based Staging of AFDE-MRI based Staging of AF
Stage 1(Mild enhancement)
Stage 2(Moderate enhancement)
Stage 3(Extensive enhancement)
Oakes RS, et al. Detection and quantification of LA structural remodeling with delayed-enhancement MRI in patients with AF. Circulation. 2009;119(13):1758-1767
Relationship of Pre-ablation Delayed Enhancement (Disease Stage) and Procedural Outcome
Relationship of Pre-ablation Delayed Enhancement (Disease Stage) and Procedural Outcome
Oakes RS, et al. Detection and quantification of LA structural remodeling with delayed-enhancement MRI in patients with AF. Circulation. 2009;119(13):1758-1767
Staging AF by DE-MRIStaging AF by DE-MRI
Stage 1 Stage 2
Stage 3
Paroxysmal 49%
Persistent 43%
Persistent 57%
Paroxysmal 36%
Permanent 7%
Permanent 7%
Persistent 77%
Paroxysmal 9%Perm
anent 14%
Oakes RS, et al. Circulation. 2009;119(13):1758-1767
Reasons of Recurrence After AFib Ablation
Recurrence of AFib may related to:
Mechanisms of
AFib Ablation approaches and techniques
Procedure end-points
Characteristics of patients with AFib
如何提高慢性房颤导管消融治疗的成功率
选择合适的房颤消融患者;优化消融方法、技术和手术终点;对于复发患者根据具体情况选择再次消融、药物或其它治疗
Thanks!