Κολπικός Πτερυγισµός: ιάγνωση και Αντιµετώπιση

Κολπικός Πτερυγισµός: ιάγνωση και Αντιµετώπιση Παναγιώτης Ιωαννίδης Επιστηµονικά Υπεύθυνος Τµήµατος Αρρυθµιών & Επεµβατικής Ηλεκτροφυσιολογίας Βιοκλινικής Αθηνών 6ο Σεµινάριο Ειδικευοµένων Ελληνική Καρδιολογική Εταιρία Αθήνα 1-12-2012

Κολπικόςπτερυγισµός Ορισµός: Ταχυκαρδία οφειλόµενη σε µηχανισµό επανεισόδου, το κύκλωµα της οποίας εντοπίζεται αποκλειστικάσεκολπικόµυοκάρδιο.

Κολπικόςπτερυγισµός Ορισµός: Ταχυκαρδία οφειλόµενη σε µηχανισµό επανεισόδου, το κύκλωµα της οποίας εντοπίζεται αποκλειστικάσεκολπικόµυοκάρδιο. Εστιακή Κολπική Ταχυκαρδία

Atrial flutter: Etiology Most patients with AFL have some form of heart disease (hypertension, CAD, Valvular heart disease, cardiomyopathy) Chronic lung disease Atrial septal defects and other congenital heart diseases (pre- and postoperatively) Nearly 10% of patients in whom sodium channel blocking agents have been administered for AF Toxic and metabolic conditions (thyrotoxicosis, alcoholism) Rarely in pts without structural heart disease

ΤύποςΙ: ΤύποιΚολπικούπτερυγισµού Συχνότητα 240 µέχρι 340 σφ/λεπ Μπορεί να εφαρµοστεί παράσυρση ή να διακοπή µε ταχεία κολπική βηµατοδότηση ΤύποςΙΙ : Συχνότητα > 340 σφ/λεπ (αναφέρεται µέχρι και 433 σφ/λεπ) εν µπορεί να εφαρµοστεί παράσυρση και µε ταχεία κολπική βηµατοδότηση εκφυλίζεται σε AF

Νεότερηκατάταξη -ονοµατολογία * ίδεται βάση στην ανατοµική εντόπιση του κυκλώµατος Ισθµοεξαρτόµενος ΚΠ Αντιωρολογιακός ή τυπικός Ωρολογιακός Αγκύλη κατωτέρου βρόγχου Επανείσοδος διπλής αγκύλης Μη ισθµοεξαρτόµενος ΚΠ ή άτυπος Αγκύλη ανωτέρου βρογχου Mε συµµετοχή εγχειρητικής ουλής (εγχειρήσεις συγγενών καρδιοπαθειών (Mustard, Senning, Fontan), βαλβιδοπαθειών, CABG) Αριστερός ΚΠ Γύρω από ΠΦ στο οπίσθιο τοίχωµα του αριστερού κόλπου Μεσοκολπικό διάφραγµα Μιτροειδικός δακτύλιος Επανείσοδος διπλής αγκύλης

Pathophysiologic Mechanisms of typical Atrial Flutter Typical - Counterclockwise Atrial Flutter Reverse Typical - Clockwise Atrial Flutter

Pathophysiologic Mechanisms Lower Loop Re-entry Upper Loop Re-entry

Pathophysiologic Mechanisms Incisional Atrial Tachycardia

Pathophysiologic Mechanisms Types of Left Atrial Flutter

Typical AFL (counterclockwise) - Typical ECG

Atrial Flutter: ECG

Typical AFL (counterclockwise) - Typical ECG

Typical AFL ECG: Terminal positivity

Lower Loop Reentry ECG: Lack of terminal positivity in inferior leads

60 ετών άνδρας DCM, EF:20% Αµιωδαρόνη po AFL CL:340ms (176/min)

2:1 AV Conduction

Constancy of F waves

Atrial flutter: Treatment Goals Control of Ventricular Rate Reversion to Normal Sinus Rhythm Maintenance of Normal Sinus Rhythm Prevention of Systemic Embolization

Atrial Flutter: Risk of Stroke Biblo et al Am J Cardiol 2001;87:346-9.

LA thrombus and Spontaneous Echo Contrast (SEC) in relation to CHADS 2 and CHA 2 DS 2 -VASc score Atrial Flutter Atrial Fibrillation Parikh et al Am J Cardiol 2012;109:550-5 Providencia et al Europace 2012;14:36-45

Recommendations for anticoagulation Guidelines for the management of AF Europace (2010) 12, 1360-1420

Control of Ventricular Rate Verapamil, Diltiazem B-blockers Digitalis His ablation and permanent PM

Control of Ventricular Rate Verapamil, Diltiazem B-blockers Digitalis (His ablation and permanent PM)

Control of Ventricular Rate 2:1 4:1 6:1

Pharmacological maintenance of SR Class IA Class IC Class III Class I and III AADs should be administered along with AV conduction slowing agents Conversion of 2:1 in 1:1 Atrio-Ventricular conduction

Atrial flutter: Acute restoration of SR Pharmacological cardioversion Ibutilide iv 60-90% successful cardioversion (QT prolongation monitoring for >4h) Vernakalant: No cardioversion AFL cycle length by an average of 55 ms Camm et al. Europace 2012;14:804 809 Propafenone pill in the pocket??? Electrically cardioversion Synchronized DC shock (50J) Overdrive Atrial Pacing (permanent pacemaker, endocardial electrode, transesophageal pacing) Recurrence rates are extremely high (70% to 90%) despite maintenance on antiarrhythmic drugs Although the risk of thromboembolism after CV is lower than in AF, pts with AFL have also a substantial risk

Comparison of Medical Therapy vs first-line Catheter Ablation Patients who received ablation as a first-line strategy compared with patients who received antiarrhythmic drug therapy have: significantly better maintenance of SR fewer hospitalizations better quality of life fewer overall complications Natale et al. J Am Coll Cardiol 2000;35(7):1898 904 Da Costa et al. Circulation 2006;114(16):1676 81

Catheter Ablation Despite the excellent acute results and longterm outcome, 30% of these patients may develop AF over a 5-year period, especially if there is a history of AF or underlying heart disease Ablation of the CTI may reduce or rarely eliminate recurrences of AF CTI ablation is also effective in patients undergoing pharmacologic treatment for AF with antiarrhythmic drug induced type 1 atrial flutter (the so-called hybrid approach

Hypothetical mechanism of ΑF organizing into typical atrial flutter Roithinger et al. Circulation 1997;96:3484-91

Typical Atrial Flutter Ablation: Efficacy & Safety Meta-analysis 18 primary studies /1,323 patients Single-procedure success for AFL was 91.7% (95% confidence interval [CI] 88.4% to 94.9%) Multiple-procedure success was 97.0% (95% CI 94.7% to 99.4%). Repeat ablation was reported in 8% (95% CI 4.5% to 11.4%). Spector et al. Am J Cardiol 2009;104:671 677

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 0 0

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 0 1 1 0

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 2 0 1 2 1 0

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 2 3 0 1 2 1 3 0

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 1 2 0 3 4 0 1 2 3 4

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 0 2 3 1 2 4 3 1 0 5 4 5

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 0 2 3 1 2 4 3 1 0 6 5 4 5 6

Activation Mapping - Electro-anatomical Mapping - Local Activation Time (LAT) Map 0 0 0 6 late 2 3 1 2 1 0 6 5 4 3 4 5 0 early 6

Upper Loop Reentry: LAT map

Macro-reentrant Circuit

Entrainment Pacing Site Fusion

Entrainment Post Pacing Interval > Cycle Length

Entrainment Fusion

Entrainment Post Pacing Interval = Cycle Length

Entrainment Concealed Fusion

Entrainment Post Pacing Interval = Cycle Length Concealed Fusion Concealed Entrainment

330ms 320ms

12-Lead 12-lead ECG A 68-year-old man with previous Circumferential Pulmonary Vein Ablation presented with symptomatic and drug resistant atrial tachycardia, which was successfully mapped and ablated

Left Atrial Flutter

Initial Recording: AT with CL: 248ms

LAT Map: early meets late in roof line

Positive entrainment from the roof

Propagation Map: peri-roof re-entrant circuit in a double loop manner around ipsilateral PVs

Tachycardia termination during roof line ablation. The CL prolongation to 402ms probably represents the elimination of the faster loop

Conduction Block Validation by Pacing from the Anterior LA

Organized AT After AF Ablation

Organization to a stabile tachycardia after PV isolation. It s quite stable for LAT map

LAT- Propagation Map

LA Roof entrainment: roughly compatible

Gradual transition to a proximal to distal tachycardia

Organization to stable tachycardia with proximal to distal CS activation probably compatible with isthmus-dependent right atrial flutter

AT termination after right isthmus entrainment

Continuous CS Pacing. Right isthmus block

Therapeutic strategy Rate or Rhythm control Medical Therapy or Catheter Ablation Cardioversion or Catheter Ablation

Back up Slides

Αυτοµατισµόςήµικρο/επανείσοδος;

Atrial flutter: Definition Supraventricular rhythm with a regular rate usually 240-300 bpm Definition related to ECG presentation (undulating pattern on the surface ECG usually without an isoelectric baseline)

Κολπικός Πτερυγισµός: ΗΚΓ Επαναλαµβανόµενα ρυθµικά* «πριονοειδή» πτερυγικά κύµατα- συνεχής ηλεκτρική δραστηριότητα (έλλειψη ισοηλεκτρικής γραµµής µεταξύ των πτερυγικών κυµάτων)** συχνότητας συνήθως*** >240/λεπ Κολποκοιλιακή αγωγή σταθερή (1:1, 2:1, 4:1κλπ) κοιλιακός ρυθµός ρυθµικός Κολποκοιλιακή αγωγή µη σταθερή (Wenckebach) κοιλιακός ρυθµός άρρυθµος *µη σταθερά πτερυγικά κύµατα : κολπική µαρµαρυγή (πτερυγοµαρµαρυγή?) **κολπική ταχυκαρδία ***αντιαρρυθµικά

Success Rates for RF Catheter Ablation of AFL Author, Year, Reference No. N Electrode Length % Acute Success Follow-up, Mo % Chronic Success Feld 1992 5 16 4 100 4 ± 2 83 Cosio1993 6 9 4 100 2 18 56 Kirkorian 1994 35 22 4 86 8 ± 13 84 Fischer 1995 34 80 4 73 20 ± 8 81 Poty 1995 44 12 6/8 100 9 ± 3 92 Schwartzman 1996 45 35 8 100 1 21 92 Chauchemez 1996 48 20 4 100 8 ± 2 80 Tsai 1999 41 50 8 92 10 ± 5 100 Atiga2002 40 59 4 vs cooled 88 13 ± 4 93 Scavee 2004 38 80 8 vs cooled 80 15 98 Feld 2004 29 169 8 or 10 93 6 97 Calkins 2004 49 150 8 88 6 87 Ventura 2004 42 130 8 vs cooled 100 14 ± 2 98 Feld 2008 53 160 Cryoablation 87.5 6 80.3