Νέεο πξνζεγγίζεηο γηα ηελ θαηάιπζε ηεο θνιπηθήο καξκαξπγήο

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1 Νέεο πξνζεγγίζεηο γηα ηελ θαηάιπζε ηεο θνιπηθήο καξκαξπγήο ηπιηαλόο Σδέεο, MD, PhD, FESC Δπηκειεηήο Α - Καξδηνινγηθή Κιηληθή Ννζνθνκείν Δξξίθνο Νηπλάλ

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4 Pulmonary vein reconnection

5 Έιεγρνο δύλακεο επαθήο Ιζνξξνπία κεηαμύ αζθάιεηαο θαη απνηειεζκαηηθόηεηαο έλαληη ΑΝΔΠΑΡΚΗ ΓΤΝΑΜΗ ΔΠΑΦΗ Αλεπαξθείο βιάβεο Αύμεζε επαλαζύλδεζεο PV-LA Αύμεζε ππνηξνπώλ ΤΠΔΡΒΟΛΙΚΗ ΓΤΝΑΜΗ ΔΠΑΦΗ Κίλδπλνο επηπσκαηηζκνύ Κίλδπλνο νηζνθαγηθήο βιάβεο Κίλδπλνο steam pops

6 Βιάβε κε κηθξόηεξε δύλακε επαθήο Αδύλακνο θξίθνο αιπζίδαο EFFICAS I - Neuzil et al.. Circ Arrhythm Electrophysiol. 2013;6: gap isolated CLINICAL PERSPECTIVE Ablations with lowest FTI (<400 gs) are responsible for quality of the entire circumferential lesion line around each PV, and thus also contributors toward unsuccessful outcome. Target CF: 20g (not less than 10g) Stability Minimum FTI 400 g. sec

7 A CF threshold of > 12 g predicts a complete lesion with high specificity (94%) and positive predictive value (91%). Heart Rhythm Aug 10. pii: S (15) doi: /j.hrthm [Epub ahead of print

8 Redo ablation παξνμπζκηθήο ΚΜ - Contact force indicator - NavX

9 CARTO 3 SMART TOUCH Catheter

10 Eleven studies involving 1428 patients - CF was deployed in 552 patients. Lower recurrence rate Major complications Fluoroscopy time

11 Pace capture guided ablation

12 Αδελνζίλε Τπεξπόιωζε κέζω ελεξγνπνίεζεο IKAdo

13 Adenosine administration No dormant PV conduction

14 Adenosine infusion Awakening of dormant PV conduction

15 Additional ablation at the gap (dormant PV conduction)

16 Lancet 2015; 386: Methods: Following PVI, 284 paroxysmal AF patients with dormant PV conduction were randomized to no further ablation or additional ablation until dormant conduction was abolished. Freedom from symptomatic AT after single ablation 69,4% 55,7% 42,3% Highly prevalent [284 of 534 pts, (53%)] Its elimination markedly improves arrhythmia-free survival without increased procedural risk. 27% absolute risk reduction number-needed- to-treat: 3.7 patients

17 2113 patients undergoing AF ablation were randomized to ATP-guided PVI or conventional PVI. 27.6% of patients had dormant PV conduction No significant reduction in the incidence of recurrent atrial tachyarrhythmias after catheter ablation for AF with ATP-guided PVI when compared with conventional PVI.

18 Second generation cryoballoon

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20 Σεθκεξίωζε ειεθηξηθήο απνκόλωζεο κε ηε βνήζεηα θπθιηθνύ θαζεηήξα Πξννδεπηηθή θαζπζηέξεζε PVP 2 πξνο 1 απνθιεηζκόο εηζόδνπ Απνθιεηζκόο εηζόδνπ Ηιεθηξηθή απνκόλωζε

21 RF ablation vs Cryoablation

22 Non-inferiority of cryobaloon versus RF catheter ablation

23 ** All cases of phrenic nerve palisies had been resolved at 12 months **

24 Heart Rhythm 2014;11:

25 Configuration of surface electrodes for recording diaphragmatic compound motor action potential on modified lead I Recordings of the diaphragmatic compound motor action potential (CMAP) during pacing from the multipolar catheter at a cycle length of 1000 ms located in the SVC

26 A decrease in CMAP amplitude by 35% from baseline predicts and prevents phrenic nerve injury

27 Third-generation cryoballoon designed to allow enhanced positioning and help improve capture of real time data with Achieve Mapping Catheter 40% shorter tip

28 πλέρηζε ΚΜ κεηά από απνκόλωζε πλεπκνληθώλ θιεβώλ Πνην είλαη ην ελδεδεηγκέλν επόκελν βήκα??? Ηιεθηξηθή αλάηαμε θαη νινθιήξωζε επέκβαζεο Καηάιπζε θαηαθεξκαηηζκέλωλ ειεθηξνγξακκάηωλ Γεκηνπξγία γξακκνεηδώλ βιαβώλ Καηάιπζε γαγγιίωλ απηνλόκνπ 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Whereas a consensus has been reached on the approach to ablation of patients with paroxysmal AF, no consensus exists for patients with non-paroxysmal AF. This currently is an area of debate at most AF meeting and conferences.

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30 Population : 589 patients with symptomatic persistent AF (> 7 days and < 3 years) *** SOS *** 75% of patients constantly in AF > 6 months 1:4:4 : PVI, PVI+CFE, PVI+Lines Repeat ablation procedures allowed with the use of the identical randomized strategy as the first ablation Follow-up: Patients were followed for 18 mo Visit, ECG and 24 hour Holter at 3, 6, 9, 12 and 18 months Weekly TTM transmissions for 18 months

31 Primary outcome: AF > 30 sec after one procedure with or without AAD Freedom from AF after 1 procedure Freedom from AF after 2 procedures PVI PVI+CFE PVI+LINES p value 59 % 48 % 44 % % 60 % 58 % 0.18

32 STAR AF II - Conclusions Largest randomized trial to examine outcomes of catheter ablation in persistent AF Additional CFE or Lines ablation increased procedural time No benefit in AF reduction when additional substrate ablation (CFE or Lines) was performed on top of PVI STAR AF II Discussant - P. Kirchoff

33 Focal impulse and rotor modulation (FIRM) mapping Electrical rotors: rotational activation around a core Focal impulses: centrifugal activation from an origin Methodist Debakey Cardiovasc J Apr-Jun;11(2):76-81

34 FIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence J Am Coll Cardiol 2014;63:1761 8

35 The noninvasive system can map AF preprocedurally and help shorten invasive procedural time by performing identification of AF drivers Circulation. 2014;130:

36 πκπεξάζκαηα Πεξηζζόηεξα εξγαιεία γηα απνηειεζκαηηθέο βιάβεο Βειηίσζε θαζεκεξηλήο πξαθηηθήο γηα ειαρηζηνπνίεζε όςηκεο επαλαζύλδεζεο ζηηο πλεπκνληθέο θιέβεο Γθξίδα δώλε ζηε βέιηηζηε ζηξαηεγηθή θαηάιπζεο ζε εκκέλνπζα θνιπηθή καξκαξπγή