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.





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


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.


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)


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


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)


PASupRL LL

Individualized CPVA Line


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)


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).

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ha%C3%AFssaguerre%20M%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ha%C3%AFssaguerre%20M%22%5BAuthor%5D

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


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!

慢性房颤的导管消融治疗 -- 何时柳暗花明？

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