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in the Treatment of
Atrial Fibrillation
Atrial Fibrillation
First described in 1903 by Hering Most common sustained arrhythmia
Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis
10% VT
2% VF
Atrial Fibrillation
What is Atrial Fibrillation? Chaotic circular impulses in the atria
Several reentrant circuits moving simultaneously Atrial rates
300 to 600 beats per minute
Increases to
8.8% in the 80-89 age group
During the next 7-8 years, the number of people over the age of 80 is expected to quadruple
U.S. population
20,000
10,000
<5
5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- 90- >95 9 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89 94
Age, yr
Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.
Can lead to electrophysical and structural changes in the myocardium (remodeling) that can lead to Permanent AF AF with duration of greater than 7 days rarely spontaneously converts
Mechanisms of AF
Theories of the mechanism of AF involve 2 main processes:
- Enhanced automaticity in one or several rapidly
depolarizing foci
- Reentry
Mechanisms Contributing to AF
Mechanisms of AF
Rapidly firing atrial foci, located in one or several pulmonary veins (PVs), can initiate AF in susceptible patients Foci also can occur in RA and infrequently in the superior vena cava or coronary sinus
Mechanisms contributing to AF
Loss of AV synchrony Loss of atrial kick Rate-related cardiomyopathy due to rapid and irregular ventricular response
Rate-related atrial myopathy and dilatation Chronic symptoms and reduced sense of well-being
Curative procedures
Advantages
High efficacy for some patients, at least initially (< 50% of all patients) Low initial cost Noninvasive
Disadvantages
High recurrence rate High long-term cost Non-curative Adverse effects Potential proarrhythmia
Antiarrhythmic Suppression
Drugs
Conversion of AF
Class 1A (decrease conduction velocity, increase refractory periods of cardiac tissue, suppress automaticity)
Quinidine Procainamide
Class III (decrease conduction velocity, increase refractory periods of cardiac tissue, suppress automaticity)
Amiodarone Sotalol Ibutilide (Corvert) Dofetilide
Antiarrhythmic Suppression
Drugs
Maintenance of normal rhythm
Class 1A Class III Class 1C (decrease conduction velocity)
Flecainide Propafenone
RF Ablation Techniques
A) B) Focal ablation of PV (Pulmonary vein) triggers Segmental PV isolation
C) Wide Area Circumferential Ablation D) Ablation of Fractionated Complex Electrograms E) Targeted ablation of ganglionated autonomic plexi in the epicardial fat pads
Initiation of AF by PV Discharges
PV Potentials
PV potentials
PV Potentials
PV Potential on 6-10
Loss of PV Potentials
PV Stenosis
PV Stenosis
PV Stenting
The incidence of perforation during ablation of the left atrium is relatively low
Segmental PV Isolation
Segmental PV Isolation
Limitations associated with focal ablation have prompted the development of other techniques for eliminating the PV arrhythmias. Anatomically PV isolation has significant advantages over focal ablation.
Circumferential Ablation
It is an anatomic approach in which circumferential lines of block are created using 3D maps ( Carto, NavX..) around the ostia of PVs for isolation of PVs from LA. Additional linear lesion from LIPV to mitral annulus for preventing LA incisional tachycardia ( 2%). Additional linear lesions (posterior, roof, right isthmus.) may be created deepening on operators preference.
Pappone C, et al. Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation: efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation. Circulation 2001;104:25392544.
NavX Map
Anatomical Reconstruction of LA
Circumferential Ablation
Circumferential Ablation
Carto Map
Circumferential Ablation
Circumferential Ablation
Circumferential Ablation
Electroanatomic Map
Circumferential Ablation
Effective in both paroxysmal and chronic AF (81%, 76%) Bipolar amplitude < 0.1 mv inside and around the lesion may be acceptable for showing PV isolation.
Integrated Approach
Exclusion criteria
NYHA functional class IV Age > 80 years Contraindications to anticoagulation Presence of cardiac thrombus Left atrial diameter 65 mm Life expectancy < 1 year Thyroid dysfunction Patients with mitral and/or aortic metallic prosthetic valves are not excluded Previous repair of atrial septal defects is not an absolute contraindication
Recent updates
Asymptomatic Patients
To date there is no evidence that treatment of AF by ablation improves mortality, although there are uncontrolled data suggesting that this may be the case. Therefore, asymptomatic patients should not be offered curative ablation of AF, except in the case of those patients undergoing cardiac surgery who may benefit from surgical ablation of their AF as an adjunctive procedure. There is also evidence that patients with heart failure have significant improvements in left ventricular function following successful catheter ablation of AF.
Conclusion
For many patients with a previously untreatable heart rhythm, ablation has dramatically improved their symptoms by restoring and maintaining sinus rhythm. Preliminary randomized studies of catheter ablation of AF provide evidence that ablation (with or without concurrent anti-arrhythmic drug use) effectively improves maintenance of sinus rhythm when compared with current anti-arrhythmic drugs.
Although prognostic and quality of life data from long term randomized trials of catheter ablation for AF are still in preparation, the non-randomized data comparing ablation to continued medical treatment suggests a strong benefit from ablation.