ABLATION IN

ATRIAL FIBRILLATION

Budi Baktijasa
Rizka Amalia

DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE

DR SOETOMO HOSPITAL - AIRLANGGA UNIVERSITY SURABAYA
INTRODUCTION

AF  the most common arrhythmia in

1 clinical practice

Prevalence: 1-2%
2 (increase in the next 50 years)

Framingham Heart Study

3 Inciden : Men 2.1% ; Women 1.7%

PERKI, 2014
INTRODUCTION
Atrial Fibrillation

Rapid An-organized Atrial

Ventricular rate Contraction

CO compromise Blood Stasis in

Atrium

o Hypotension Risk thrombus

o Pulmonary formation in LAA
Congestion
Lilly LS, 2016
Emboly
(cerebral systemic)
Treatment is directed at 3 aspects :

1. Ventricular Rate
control

2. Methods Restore
Sinus Rhytm

3. Assessment of the need

or anticoagulation to
prevent thromboembolism
Lilly LS, 2016
INTRODUCTION

A A DRUGS
Methods Restore
Sinus Rhythm
ABLATION

SURGERY CATHETER
 Atrial Fibrillation …
Supraventricular arrhythmia
ECG :
o LOW-AMPLITUDE BASELINE OSCILLATIONS (fibrillatory or f waves)
o IRREGULARLY IRREGULAR VENTRICULAR RHYTHM.

 The f waves :
 rate of 300 to 600 beats/min
 VARIABLE IN AMPLITUDE, SHAPE, AND TIMING.

PERKI,2014
ESC, 2016
Key Mechanisms In Atrial Fibrillation
Dobrev D and Nattel S, 2010
History…

First Catheter Ablation in Human

History
• 1st study  Morillo et al (1995)
• 1996, three groups published 1-year results of percutaneous, transcatheter atrial fibrillation
ablation.
1. Swartz et al
Radiofrequency ablation (29 patients) with chronic AF
After a 12-month follow-up: 79% of the patients free from the arrhythmia.
2. Haissaguerre et al
45 patients with paroxysmal atrial fibrillation undergoing progressively complex linear lesions
created by sequential applications of radiofrequency in the right atrium
Over a 1-year follow-up : 33% free from AF.
3. A smaller contemporary experience  In this study at least 3 lesions were
performedThis strategy proved well tolerated and provided, without complications, a 56%
chance of maintaining sinus rhythm at 1 year.

Anselmino M et al, 2011

Diagram of the ablation schema used in the right atrium
(1,2,3: anterior view) and left atrium (4: posterior view).
HAISSAGUERRE M, Cardiovasc Electrophysiol, 1996
 Become the
cornerstone of
catheter ablation
of AF

Haegeli LM and Calkins H, 2014

Indications

Effective in restoring and maintaining sinus rhythm in patients : symptomatic

paroxysmal, persistent, and long-standing persistent AF (as 2nd line treatment
after failure of / intolerance to AAD therapy.

• In such patients, catheter ablation is more effective than AAD

• Complication rates were similar, when ablation was performed in
expert centres.

symptomatic recurrences of AF despite AAD drug therapy, all

RCTs showed better sinus rhythm maintenance with
catheter ablation than on AAD
ESC, 2016
Techniques
Transvenous Catheter Insertion

Right Atrium
Transeptal puncture

Left Atrium

Cauterize areas surrounding orifices of the .

pulmonary vein

Catheter positioning, as well as the anatomy of the pulmonary veins and left atrium confirmed by
fluoroscopy, pulmonary venography, 3D electroanatomical mapping, intracardiac echocardiography,
CT, MRI remote guidance or combinations.
Steven A Lubitz, Avi Fischer, Valentin Fuster, 2008
Techniques
>15 years ago, the basis for the development of
catheter ablation of AF foci of ectopic beats
originating from the pulmonary veins.

The ablation consists of a series of point-by-

point radiofrequency lesions encircling each or
both ipsilateral ostia of the pulmonary veins.

3-dimensional electroanatomical map of LA and PV endpoint : electrical deconnection of the pulmonary

ostia (red points) around ipsilateral PV.
vein from the left atrium

Performed with deep conscious sedation or with

general anaesthesia depending on patient’s
condition and centre’s preference.

Haegeli LM and Calkins H, 2014

Techniques
Cryoenergy / laser light  alternatives to conventional
radiofrequency energy applied through balloon-tipped
catheters.

High-intensity focused ultrasound energy was removed from

the market because of high incidence of a left atrio-
oesophageal fistula.

PVI is confirmed by a circular multipolar mapping catheter

placed into the PV showing entrance block.

In addition, PVI can be proved by pacing inside the PV and

documentation of an exit block out of the PV.

Haegeli LM and Calkins H, 2014

Catheter Ablation Methods
• Panel A shows the cryoballoon system.
• Panel B shows the radiofrequency catheter ablation system.
Outcome

Better rhythm outcome & lower procedure-related complications

can be expected in younger patients with a short history of AF &
frequent short AF episodes in the absence of significant structural
heart disease.

Catheter ablation is more effective than AAD therapy in

maintaining sinus rhythm.

Sinus rhythm without severely symptomatic recurrences of AF is

found in up to 70% of paroxysmal AF & around 50% in persistent
AF.
ESC Guidelines for the management of AF, 2016
Complications

ESC Guidelines for the management of AF, 2016

Anticoagulation

• Patients anticoagulated with VKAs should continue therapy during

ablation (with an INR of 2–3).
• NOACs  alternative to warfarin.
• During ablation  heparin should be given to maintain an activated
clotting time 300 s.
• Anticoagulation should be maintained for at least 8 weeks after
ablation for all patients.
• OAC after catheter ablation should follow general anticoagulation
recommendations.

ESC Guidelines for the management of AF, 2016

Guidelines

• Catheter ablation of symptomatic paroxysmal AF after failure of at least one

class 1 or 3 antiarrhythmic agent  class IA. The Consensus Statement on catheter and surgical
ablation of atrial fibrillation of the HRS/ EHRA/ECAS and the Guidelines for the management of patients with atrial fibrillation of the
ESC (European Society of Cardiology), the AHA (American Heart Association), the ACC (American College of Cardiology), and the
HRS

• Catheter ablation as a 1st line therapy is considered as reasonable (class IIa,

level B indication) in selected patients with paroxysmal AF without structural
heart disease.

• The same level of indication accounts for patients with persistent AF after
failed antiarrhythmic drug therapy.

• Primary goal of catheter ablation  control of symptoms & improvement of

quality of life.

Haegeli LM and Calkins H, 2014

Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF
Initiation of long-term rhythm control therapy
in symptomatic patients with atrial fibrillation.

ESC Guidelines for the management of AF, 2016

 CONCLUSION
Catheter ablation of AF is now an important therapeutic modality for
patients with AF.

Evidence available  catheter ablation of AF is superior to

antiarrhythmic drug therapy in controlling AF and AF ablation improves
quality of life, especially true for patients with paroxysmal AF.

Indicated for treatment of patients with symptomatic AF in whom one

or more attempts at class 1 or 3 antiarrhythmic drug therapy have
failed.

Catheter ablation of AF is a challenging and complex procedure 

potentially life threatening complications