Kyoung-Ryul Julian Chun

Cardioangiologisches Centrum Bethanien (CCB)

Markus Krankenhaus, Med. Klinik III

Frankfurt am Main, Germany

How to improve procedural

outcome of cryoballoon ablation in

persistent AF – Experience from Redo

procedures

DISCLOSURES

Activity Company

Advisory Board Medtronic

Research Grant Biosense Webster

CardioFocus

Medtronic

Biotronik

Speaker‘s Honoraria Boston Sci

CardioFocus

Medtronic

1. Definition of persistent AF

2. Ablation strategies in persistent AF

3. Status Cryoballoon and PVI

4. Role Cryoballoon in Redo (persistent) AF

Persistent AF-Cryoballoon-Redo procedures

CENTRAL QUESTIONS

Kirchhof et al. European Heart J 2016

NEW AF DEFINITIONS

Persistent AF-Cryoballoon-Redo procedures

HRS/EHRA/ECAS/APHRS/SOLAECE

NEW DEFINITION 2017

Persistent AF Ablation

EARLY PERSISTENT AF

„Early persistent AF is defined as AF that is

sustained beyond 7 days but less than 3 months

in duration”

Calkins H et al. Heart Rhythm 2017

PV Trigger across AF Types (n=2168 pts)

AF Mapping, Non PV Trigger

Santangelii et al. Heart Rhythm. 2015 Oct 15. pii: S1547-5271(15)01304-1

STAR AF II

Persistent AF Ablation

Verma A et al. N Engl J Med. 2015 May 7;372(19):1812-22

Verma A et al. N Engl J Med. 2015 May 7;372(19):1812-22

Persistent AF Ablation

STAR AF II

STAR AF II, AF TERMINATION NO PREDICTOR

Persistent AF Ablation

Kochhä user et al. Heart Rhythm 2017;14:476–483

CHASE AF: PVI vs. PVI + step wise (n=153 pts)

VHF Ablation: Hochfrequenzstrom oder Ballon?

Vogler J et al. JACC 2015

ENDPOINT AF ABLATION 2017

Persistent AF-Cryoballoon-Redo procedures

Calkins H et al. Heart Rhythm. 2017

Kirchhof P et al. European Heart J 2016

J Cardiovasc Electrophysiol, 26,pp 371-377, April 2015

≥ 3 AF RFC Ablation procedures

92% (156/169) pts:

recovered PV conduction...!!

AF Ablation, ESC Guidelines 2016

METHODS, 2. Generation CB

Cyroballoon AF ablation

CCB-EP Frankfurt: CRYOBALLOON

Providencia et al. Europace 2016

FRENCH AF: CB vs. RFC

VHF Ablation: Hochfrequenzstrom oder Ballon?

EFFICACY: Durable PVI

Permanent PVI

Kuck et al 2016, GAP AF Study Reddy et al 2015, SUPIR AF

93 patients 19 patients

RFC PVI CB2 PVI

Remapping 3 months after

index procedure

Remapping 3.4 months after

index procedure

30%

70% 79%

21%

Low rate of PV reconnection

Total Parox. AF Pers. AF

91 % 56 % 34 %

0 PV Reconnected

51 56 28 50 22 65

1 PV

Reconnected29 32 21 38 8 24

2 PV Reconnected

10 11 7 13 3 9

3 PV Reconnected

1 1 0 0 1 3

4 PV Reconnected

0 0 0 0 0 0

AF REDO FINDINGS -- 2. GENERTION CB

Data @CCB Frankfurt

88

78

0

95

85

33

85

0

10

20

30

40

50

60

70

80

90

100

RIPV RSPV RCV LIPV LSPV LCPV Overall

Durable PVI rate (%) (n=91pts, 357 PVs)

Total PV PV Iso PV Reconection % Iso

RIPV 91 80 11 88

RSPV 90 70 20 78

LIPV 85 81 4 95

LSPV 85 72 13 85

LCPV 6 2 4 33

Overall 357 305 52 85

REDO FINDINGS -- 2. GENERTION CB

Data @CCB Frankfurt

8588

0

97

81

67

87

0

10

20

30

40

50

60

70

80

90

100

RIPV RSPV RCV LIPV LSPV LCPV Overall

Durable PVI rate (%) in persistent AF (n=34 pts)

REDO FINDINGS -- 2. GENERTION CB, persistent AF

Data @CCB Frankfurt

Atrial Fibrillation = Atrial Fibrillation ???

Persistent AF-Cryoballoon-Redo procedures

Marrouche NF et al. JAMA 2014

SCAR AF - Role of AF Substrate

LA Fibrosis

Marrouche NF et al. JAMA 2014

SCAR AF - Role of AF Substrate

LA Fibrosis

SCAR AF - Role of AF Substrate

LA Fibrosis

Marrouche NF et al. JAMA 2014

• Low Voltage Zone (LVZ):

• bipolar 0.1-0.4mV

• Transitional Zone (TZ):

• bipolar 0.4-1.3mV

• SR Abnormal Electrogram (SR-AE)

• >300 points LA map

SCAR AF - Role of AF Substrate

Gang Yang et al., Circulation AEP 2016

SCAR AF - Role of AF Substrate

Gang Yang et al., Circulation AEP 2016

SCAR AF - Role of AF Substrate

Gang Yang et al., Circulation AEP 2016

„Step wise“ vs. Substrate Ablation

69.8%

51.3%

Persistent AF Ablation

Bordignon S et al. DGK 2017

• Patient in SR Carto bipolar map

• Patient in AF 2 CV attempts, if no SR: exclusion

• Time to LAA in SR

• AF Cycle length in 4 PVs, LAA + CS

Seite 29

METHODS

SCAR AF Study (PAF + persistent AF)

Persistent AF Ablation

Persistent AF Ablation

PATIENTS

Bordignon S et al. DGK 2017

Persistent AF Ablation

Bordignon S et al. DGK 2017

RESULTS – PRIMARY ENDPOINT

Persistent AF Ablation

Bordignon S et al. DGK 2017

PVI: No Substrate vs. Substrate

„SMART“ Lines....

AF Substrate

Bordignon et al. DGK HT 2015

SUGGESTION

Persistent AF Ablation

PV Isolation Responder vs. PV Isolation

Non-Responder

Koektuerk B et al., Circulation AEP 2015

Cryoballoon AF

Persistent AF (n=100pts)

Laser Balloon or

Radiofrequency Ablation for

Persistent Atrial Fibrillation

Boris Schmidta, MD, Peter Neuzilb, MD, Armin Luikc, MD, Joaquin

Osca Asensid, MD, Jan Wilko Schrickele, MD, Thomas Denekef, MD,

Stefano Bordignona, MD, Jan Petrub, MD, Matthias Merkelc, MD, Lucie

Sedivab, PhD, Annemarie Klostermanna , Laura Perrottaa, MD, Oscar

Canod, MD and KR Julian Chuna, MD

aCardioangiologisches Centrum Bethanien, Frankfurt, Germany; bNa

Homolce Hospital, Prague, Czech Republic; cStä dtisches Klinikum, Karlsruhe, Germany; dHospital Universitari i Politè cnic la Fe,

Valencia, Spain; eUniversity Hospital, Bonn, Germany; fHerzzentrum, Bad Neustadt, Germany

LASER VERSUS RF IN PERS AF

Enrolled and Randomized(n = 152)

LB (n = 75) RF (n = 77)

Successful PVI (n = 72)

Successful PVI (n = 73)

- 2 screening failures (1 AT, 1 anatomic reasons)- 3 withdrew consent

- 1 screening failure (PAF)- 1 withdrew consent

12 Month follow-upcompleted

(n=68)

12 Month follow-upcompleted

(n=66)

RESULTS – STUDY FLOW

R

Schmidt B et al., … KRJ Chun LBCT DGK 2017

RESULTS – PRIMARY ENDPOINT

LASER VERSUS RF IN PERS AF

Schmidt B et al., … KRJ Chun LBCT DGK 2017

Di Biase et al. Circulation. 2010 Jul 13;122(2):109-18.

Persistent AF Ablation

Di Biase L et al. JACC 2016

BASELINECHARACTERISTICSMale 14/20(70%)

Age(years) 68±10Diagnosis

- PAF- PersAF- ATfromLAA

5/20(25%)14/20(70%)1/20(5%)

HistoryofAF(years) 3.4±3.,3

Arterialhypertension 16/20(80%)Diabetesmellitus 2/20(10%)

Historyofstroke/TIA 3/20(15%)NYHA>I 2/20(10%)

Coronaryarterydisease 7/20(35%)LAdiameter(mm) 44±7

Leftventricular(EF) 62±5Procedurenumber 2.6±1.,3

LAA Isolation in PVI Non Responder

Bordignon S. et al., …Chun KRJ submitted

Persistent AF-Cryoballoon-Redo procedures

LAA Isolation in PVI Non Responder

Bordignon S. et al., …Chun KRJ submitted

Persistent AF-Cryoballoon-Redo procedures

LAAI-PROCEDURALDATAProcedureTime(min) 67±33

FluoroscopyTime(min) 9,0±6,2LAASpikeVisualization 20/20(100%)

LAARealTimeIsolation- sustainedLAAI- nonsustainedLAAI

16/20(80%)11/16(69%)5/16(31%)

LAATimetosustainedblock(s) 94±57

LAATemperatureattimetosustainedblock(°C) -44±7LAATimetonon-sustainedblock(s) 142±64

LAATemperatureattimetonon-sustainedblock(°C) -48±3LAAtotalfreezeapplications(n) 2.0±1.6

LAAbonusapplications(n) 8/20(40%)LAAmeanocclusiongrade 3.,9±0,.2

LAAmeanminimaltemperature(°C) -50,0±54,7LAAmeanfreezeduration(s) 214±37

LAA Isolation in PVI Non Responder

Bordignon S. et al., …Chun KRJ submitted

Persistent AF-Cryoballoon-Redo procedures

Bordignon S. et al. Europace Vienna 2017

Bordignon S. et al. Europace Vienna 2017

LAA ISOLATION PATIENTS

Persistent AF-Cryoballoon-Redo procedures

Bordignon S. et al. Europace Vienna 2017

COMPLICATIONS

Persistent AF-Cryoballoon-Redo procedures

LAA ISOLATION IMPROVES RHYTHM OUTCOME

Persistent AF-Cryoballoon-Redo procedures

Bordignon S. et al. Europace Vienna 2017

• PVs are critical sites in persistent AF

• High rate of permanent PVI (1. procedure)

• After durable PVI:

– Substrate modification (EP endpoint)

– Cryoballoon LAA isolation feasible

• Durable LAA isolation linked to sinus rhythm

• The role of LAA merits investigation

CONCLUSIONS

Persistent AF-Cryoballoon-Redo procedures

Thanks for your attention!

TEAM FFM

Localized Reentry with Activity >70% AF

Cycle Length at Low Voltage Area

CL=155ms

Regional Activity >70%

AF Cycle Length

Voltage <0.5mV

in AF

0.5mV

AF Termination

120ms

Fig. S1

Jadidi et al.

SCAR AF - Role of AF Substrate

Jadidi A. et al. CircEP 2016

Selective Voltage guided Ablation of persistent AF

Jadidi A. et al. CircEP 2016

RESULTS – PRIMARY ENDPOINT

Persistent AF Ablation

STAR AF II, AF TERMINATION NO PREDICTOR

Persistent AF Ablation

Kochhä user et al. Heart Rhythm 2017;14:476–483