Ablation of Left Atrial Tachycardia
Transcript of Ablation of Left Atrial Tachycardia
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Ablation of Left Atrial Tachycardia
Ahmed Abdelaal, MD
Department of Cardiology – University Hospital Nancy, France
Critical Care Medicine Department – Cairo Univerity Hospital, Egypt
Cairostim Nov 2008
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Arrhythmogenic substrate of left atrial tachycardia
EP mechanisms of left atrial tachycardia
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Arrhythmogenic substrate of left AT
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Linear catheter ablation of atrial fibrillation
Years 1994 – 1997
RA linear lesions- Success without drugs = 13%- Success with drugs = 27-40%
LA linear lesions - Success without drugs = 47%- Success with drugs = 87%
- High prevalence of post ablationreentrant atrial tachycardias related to gaps within the RF lines
Haïssaguerre M et al. JCE 1996
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Follow-up after ablation of atrial fibrillation
Occurrence of atrial flutter and other atrial tachyarrhythmias should be considered as treatment failures
HRS/EHRA/ECAS Expert Consensus - Europace 2007;9:335-79Shah D et al. J Cardiovasc Electrophysiol 2006;17:508-15
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Atrial tachycardia after surgicalablation of atrial fibrillation
Magnano AR et al. JCE 2006;17:366-73
20 patients
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Magnano AR et al. J Cardiovasc Electrophysiol 2006;48:1405-9
Atrial tachycardia after surgicalablation of atrial fibrillation
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Mapping and ablation of LA flutters
Jaïs P et al. Circulation 2000;101:2928-34
22 patientsHistory of open heart surgery in 4 patients
Presence of silent left atrial areas (voltage <0.05mV) in 11/22 patients
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Jaïs P et al. Circulation 2000;101:2928-34
22 patientsHistory of open heart surgery in 4 patients
Presence of 32 zones of conduction block (>1 /patient)
Mapping and ablation of LA flutters
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Jaïs P et al. Circulation 2000;101:2928-34
Mapping and ablation of LA flutters
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Jaïs P et al. Circulation 2000;101:2928-34
Mapping and ablation of LA flutters
Ouyang F et al. Circulation 2002;105:1934-42
Isthmus barriersScar = 32/42 LAMRTMitral valve = 10/42 LAMRTPulmonary vein = 17/42 LAMRT
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Spontaneous left atrial tachycardiaIatrogenic left atrial tachycardia
Mostly related to presence of ‘natural’ zones of scar, usually located on the posterior LA wall
Prevalence higher and even increasing in relation withthe number of AF ablation procedures performed worldwide Mesas CE et al. J Am Coll Cardiol 2004;44:1071-9 incidence = 4.7%
Chae S et al. J Am Coll Cardiol 2007;50:1781-7 incidence = 8.5%
Ouyang F et al. Circulation 2005;111:127-35 incidence = 29.0%
Incidence higher with circumferential or linear LA ablation ascompared to PV ostium or PV antrum ablation: 17% vs. 1%(Katritsis et al. JICE 2006;16:123-30)
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EP & arrhythmia mechanisms
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‘Non re-entrant AT’ ‘Re-entrant AT’
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Reentrant or not reentrant: that may NOT be the question !
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Focal or not focal :that is the question !
for arrhythmia ablation purpose …
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How to ablate reentrant left atrial tachycardia ?
Where is the arrhythmia ‘weak point’ ?
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LAT inVirgin Atria
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Case Study #1
- 36 year-old woman / no structural HD
- No evidence of documented AF.
- Symptoms = dyspnea on exercise
- Drug-refractory atrial tachycardia
- Patient referred for atrial tachycardia ablation
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12-lead ECG during atrial tachycardia
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Step 1 : check for ECG characteristics
The sensitivity and specificity of a positive P wave in lead V1 in predicting a left atrial focus was 93% and 88%
(Tang etal JACC Nov 2008-11-05)Leads II, III and aVF :differentiates superior from inferior foci.
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Step 2 : Mapping during AT
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Step 3 : Ablation of AT
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LAT inNon-Virgin
Atria
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Case Study #2
- 46 year-old man / no structural HD
- Persistent atrial fibrillation for 6 years
PV isolation + roof line + CS line + CFAE ablation …
- 9 months later … referred for left AT ablation
- Symptoms = dyspnea on exercise
- Drug-refractory = amiodarone + flecainide
- Patient referred for atrial fibrillation ablation
Atrial fibrillation transformed into AT cardioversion
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12-lead ECG during atrial tachycardia
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Spontaneously induced & self-terminating episode
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Episode induced and terminated by programmed atrial stimulation
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Step 1 : check whether PV conduction has recovered
LSPV LIPV
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LSPV
LIPV
RSPV
Step 2 : PV isolation
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After the LSPV was disconnected …
LSPV
LAA
LAA pacing CS pacing
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… SR resumed and AT was no longer inducible
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Comments
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Why should PV be the first target ?
PV musculature may be involved in the circuit or may be bystander and then fool the physician !
Mapping (and understanding !) a PV circuit is difficult, even with a multipolar array catheter
Epidemiology: Hamburg paper on PV ‘responsibility’ in AT following atrial fibrillation ablation
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Case Study #3
- 64 year-old man / no structural HD
- Paroxysmal atrial fibrillation for 10 years
Circumferential PV ablation
- 6 months later … referred for left AT ablation
- Symptoms = palpitations & fatigue
- Drug-refractory = amiodarone + flecainide
- Patient referred for atrial fibrillation ablation
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12-lead ECG during atrial tachycardia
Looks like atrial fibrillation, is not it ?
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Step 1 = PV isolation (here: all 4 veins)
No change: tachycardia goes on
Step 2 = 3D mapping of the tachycardia
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LA mapping during AT
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Comments
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Macroreentry:1. Circuit involving 3 or more segments of the atrium 2. 80 to 100% of the CL is mapped along the circuit3. Good PPI in 3 or more segments
Shah D et al. J Cardiovasc Electrophysiol 2006;17:508-15
Definition proposed by the Bordeaux group
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Example of entrainment of a peri-mitral circuit
Shah D et al. Heart Rhythm 2005;2:1153-7
Pacing site = anterior mitral annulus Pacing site = close to the RSPV
PPI = TCL PPI > TCL
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12-lead ECG analysis
Gerstenfeld EP et al. Heart Rhythm 2007;4:1136-43
Limitations:Many other possible macro-reentry Influence of previous RF sites ++ (patient dependent)
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Case Study #4
- 53 year-old man / Ischaemic HD
- Paroxysmal atrial fibrillation for 4 years
Circumferential PV isolation (Ablation Frontier system)
- Incessant left AT during PV isolation.
- Symptoms = dyspnea & fatigue
- Drug-refractory = amiodarone + B-blockers
- Patient referred for atrial fibrillation ablation
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Step 1: PV Isolation
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Step 1: LA mappingPeri-mitral atrial tachycaria
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Step 2: LA mapping remappingRPV related focal LAT
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Comments
From macro-reentry to ‘small-loop’ reentry
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Case Study #5
- 73 year-old woman / no structural HD
- Recurrent atrial tachycardia for 2 years
Diagnosis = commun atrial flutterTreatment = cavotricuspid ablation
- Recurrences of AF/ atrial tachycardia episodesDiagnosis = ‘atypical’ atrial flutterEPS study consistent with a LA origin
- Patient referred for left AT ablation
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LA mapping during SR
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LA mapping during SR
Isochronal step = 20ms
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Step 1 = PV isolation
Left veins
Right veins
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ECG changes during PV isolation…
300ms
980ms
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LA mapping during AT
Isochronal step = 20ms
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LA mapping during AT
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Ablation at endocardial breakthrough site
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ECG changes after RF application ???
300ms 300ms
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LA re-mapping during ATIsochronal step = 20ms
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Ablation at new endocardial breakthrough site
First RF application zone
Second RF application zone
25mm
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ECG changes after RF applicationat this second site ???
300ms 310ms
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LA re-mapping during AT
Isochronal step = 20ms
slow conduction
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Ablation at new endocardial breakthrough site
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ECG changes after RF application at this third site ???
310ms 400ms
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LA re-mapping during AT
Isochronal step = 20ms
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LA re-mapping during AT
Isochronal step = 20ms
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Ablation at new endocardial breakthrough site
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ECG changes after RF application at this fourth site ???
400ms 400ms
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LA re-mapping during AT
then ablation at earliest site
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ECG changes after RF application at this fifth site ???
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To summarize …
‘Hunting’ a changing arrhythmia …
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Comments
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+50 +80+0
Focal Tachycardia:
1. Centrifugal activation to the other segments 2. Less than 70-80% of CL is recorded3. PPI increases with increasing distance from the focal source
Definition proposed by the Bordeaux group
+0
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Focal AT is common in patients with history of documentedatrial fibrillation
It is frequently (30-40%) observed during a chronic atrial fibrillation ablation procedure, after atrial fibrillation has been ‘organized’ by extensive RF applications
Not so easy to ablate when running after a ‘moving’ target !
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Conclusions
1. Precise mapping is very important for effective ablation of LAT.
2. Accurate mapping starts from surface ECG (especially for idiopathic LAT), aided by classic entrainment and PPI measurements, and using 3-D mapping systems (for delineation of arrhythmogenic substrate).
3. In LAT following AF ablation, stepwise diagnostic approach, starting by ensuring PV isolation, excluding macroreentarnt circuits and hunting the focal ones is the road map to successful ablation.
4. Be patient !
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Stanislas Square - Nancy
Thank you