Michalis Efremidis Electrophysiological LAB Second Department of Cardiology Evangelismos Hospital Athens

Michalis Efremidis Electrophysiological LAB Second Department of Cardiology Evangelismos Hospital Athens

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

26 patients had persistent PVI out of 63 pts undergoing redo procedure (41%) [in 300 pts with initial AF ablation 41% pers AF] J Am Coll Cardiol EP 2016;2:723 31

Aa Ba Ab Bb Ab Bb A 17% LA fibrosis with AF recurrence 5 m post RF B 1.1% LA fibrosis with SR post RF

Atul Verma N Engl J Med 2015;372:1812-22

1 st 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 continuous deflection of a prolonged activation complex (2) stationary CFAEs that have temporal and spatial stability (3) short cycle length (CCL 50 120 ms) EGMs that occur repeatedly with a relatively stable frequency with or without multiplepotentials as CFAEs Oketani et al Heart Rhythm 2016 Atul Verma N Engl J Med 2015;372:1812-22

2 nd Limitation 3nd Limitation Randomized studies using operators who perform the technique regularly in their laboratories to compare this technique with other ablative approaches The common CFAE sites of STAR AF II are located in the posterior wall close to the roof and in the middle of the posterior wall; these are not the usual sites we ablate. Our common sites are typically at the antra of PVs, septal wall, posterior mitral annulus, mouth or atrial appendage, and coronary sinus. Oketani et al Heart Rhythm 2016

4 th Limitation: At the time of ablation, 79% of patients were in spontaneous atrial fibrillation 5 th Limitation: For the group assigned to isolation plus lines, all patients had the required lines performed, with 74% showing complete conduction block across both lines 6 th Limitation: Complex fractionated electrograms were successfully eliminated in 80% of patients 7 th Limitation: Rates of freedom from atrial fibrillation after two ablation procedures, with or without antiarrhythmic medication, were not significantly different among groups Atul Verma N Engl J Med 2015;372:1812-22

Simon Kochhäuser Heart Rhythm2017;14:476 483 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).

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???? 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 strongest predictor of better outcome Simon Kochhäuser Heart Rhythm2017;14:476 483

!!!!!!!! Τhe longest episode of continuous AF had been <12 months in most patients. J Am Coll Cardiol 2015;66:2743 52

Too good to be true

Circ Arrhythm Electrophysiol. 2016

Initial ablation procedure: The termination site was the PV antrum (24pts 18%), LA (35pts 26%), and RA 10 pts 7% Heart Rhythm2016;0:1 7

Daniel Scherr Circ Arrhythm Electrophysiol. 2015;8:18-24.

LAA CL ~180ms

LS 2-3 Δυναμικό > 0.25mV. Εμφανίζει όμως τη μέγιστη κυρίαρχη συχνότητα DF max = 6.1Hz. DF = 6.1 RI = 0.20

LS 12-13 Δυναμικό μεταξύ 0.04-0.25mV. Μήκος κύκλου >120msec. DF = 6.1 RI = 0.20 Εμφανίζει όμως τη μέγιστη κυρίαρχη συχνότητα DF max = 6.1Hz.

LS 19-20 Δυναμικό < 0.04mV. Το μεγαλύτερο μέρος του ηλεκτρογράμματος βρίσκεται μέσα στα όρια του θορύβου. DF = 5.8 RI = 0.22 Εμφανίζει κυρίαρχη συχνότητα ίδια με το κατάλληλο ηλεκτρόγραμμα.

LS 18-19 Δυναμικό μεταξύ 0.04-0.25mV. Μήκος κύκλου <120msec. DF = 5.8 RI = 0.21 Κυρίαρχη συχνότητα μικρότερη από αυτή των προηγούμενων ακατάλληλων ηλεκτρογραμμάτων.

AF termination in Persistent atrial fibrillation ablation Evangelismos 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?