Michalis Efremidis Electrophysiological LAB Second Department … · 2017-09-15 · Michalis...
Transcript of Michalis Efremidis Electrophysiological LAB Second Department … · 2017-09-15 · Michalis...
Michalis EfremidisElectrophysiological LABSecond Department of Cardiology‘‘Evangelismos’’ Hospital Athens
PAF Without atrial myopathy
PAF With atrial myopathy
Persistent AF Without atrial myopathy
Persistent AF With atrial myopathy
• 14.5% of the pts with AF Recurrence had all PVs
isolated
• 58.6% of the pts with SR maintenance had at least
1 PV reconnected
J Am Coll Cardiol EP 2016;2:723–31
26 patients had persistent PVI out of 63 pts undergoing redo procedure
(41%) [in 300 pts with initial AF ablation 41% pers AF]
N Engl J Med 2015;372:1812-22Atul Verma
N Engl J Med 2015;372:1812-22Atul Verma
1st Limitation
Not all CFAEs are the same
CFAEs characterized by the following EGMs:(1) low-voltage (range0.04–0.25 mV) signals that
have multiple potentials with continuousdeflection of a prolonged activation complex
(2) stationary CFAEs that have temporal andspatial stability
(3) short–cycle length (CCL 50–120 ms) EGMsthat occur repeatedly with a relatively stablefrequency with or without multiplepoten-tials as CFAEs
Oketani et al Heart Rhythm 2016
2nd Limitation
The common CFAE sites of STAR AF II arelocated in the posterior wall close to the roofand in the middle of the posterior wall; theseare not the usual sites we ablate. Our commonsites are typically at the antra of PVs, septalwall, posterior mitral annulus, mouth or atrialappendage, and coronary sinus.
Oketani et al Heart Rhythm 2016
Randomized studies using operators who perform the technique regularly in their laboratories to compare this technique with other ablative approaches
3nd Limitation
4th Limitation: At the time of ablation, 79% of patients were in spontaneousatrial fibrillation
5th Limitation: For the group assigned to isolation plus lines, all patients had therequired lines performed, with 74% showing complete conduction block acrossboth lines
6th Limitation: Complex fractionated electrograms were successfully eliminated in80% of patients
7th Limitation: Rates of freedom from atrial fibrillation after two ablationprocedures, with or without antiarrhythmic medication, were not significantlydifferent among groups
N Engl J Med 2015;372:1812-22Atul Verma
There was a significant difference in AF termination between randomization arms: 5% for PVI, 40.2% for PVI plus CFAE, and 17.2% for PVI plus linear ablation (P 0.001).
Simon Kochhäuser Heart Rhythm2017;14:476–483
Heart Rhythm2017;14:476–483 Simon Kochhäuser
CONCLUSION Acute AF termination and prolongation in AFCL did not consistently predict 18-month freedom from AF.!!!! Presence of SR before orearly during the ablation was the strongestpredictor of better outcome
If AF terminated in to atrial tachycardia or atrial flutter during ablation, the decision to map and ablate the tachycardia or cardiovert was left to the investigator’s discretion ????
J Am Coll Cardiol 2015;66:2743–52
!!!!!!!!
Τhe longest episode of continuous AF had been <12 months in most patients.
Circ Arrhythm Electrophysiol. 2016
Heart Rhythm2016;0:1–7
Initial ablation procedure: The termination site was the PV antrum (24pts 18%), LA (35pts 26%), and RA 10 pts 7%
Circ Arrhythm Electrophysiol. 2015;8:18-24.Daniel Scherr
AF termination in Persistent atrial fibrillation
ablationEvangelismos EP Lab
PVAI is effective in pts with Pers AF presenting with SR without atrial
myopathy
PVAI + extra PV ablation is the optimal approach for pts with Pers AF
presenting with AF, without atrial myopathy
AF termination with PVAI + LA and RA substrate modification is the
optimal approach in pts with Pers AF presenting with AF and atrial
myopathy
Atrial myopathy is a progressive disease? So AF elimination with AF
ablation probably is not a long term cure?