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Minglong Chen, MD Division of Cardiology Nanjing Medical University Hospital, Mainland China

CPVI Plus Electr ophysiological S ubs t rate Ab lation of the Le ft Atrium during S inus R hythm ( STABLE-SR ) for the Treatment of Persistent AF. Minglong Chen, MD Division of Cardiology Nanjing Medical University Hospital, Mainland China. Background.

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Minglong Chen, MD Division of Cardiology Nanjing Medical University Hospital, Mainland China

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  1. CPVI Plus Electrophysiological Substrate Ablation of the Left Atrium during Sinus Rhythm (STABLE-SR) for the Treatment of Persistent AF Minglong Chen, MD Division of Cardiology Nanjing Medical University Hospital, Mainland China

  2. Background • Circumferential PV Isolation (CPVI) • Effective in curing PAF (The success rate in single procedure was 75.6%,6M Follow up) Ouyang, et al . Circulation 2004; 110: 2090-2096.

  3. Efficacy of PVI for persistent AF • Single Procedure • Limited success rate in persistent AF • Per-AF requiring aggressive ablation strategies Anthony G, et al. Heart Rhythm 2010;7:835-846.

  4. Aggressive ablation strategy • Linear ablation • CTI • LA Roof • Posterior Mitral/MI • Coronary Sinus • CFE ablation

  5. Efficacy of aggressive ablation for per-AF • “CPVI + Lines + CFE” Anthony G, et al. Heart Rhythm 2010;7:835-846.

  6. RASTA Study • Randomized Controlled Trial • 1 year Follow-up • Evaluate the single procedure efficacy of Per-AF Per-AF (n=156) Group1 (n=55) Group2 (n=50) Group3 (n=51) PVI PVI+Lines PVI+CFE

  7. RASTA Study • Primary Study End Point: Freedom from AF/AT off AADs *P=0.04 *P=0.004 29%??? PVI PVI+Lines PVI+CFE

  8. Oral H, et al. J Am Coll Cardiol 2009; 53: 782-9

  9. Does linear ablation and defragmentation really improve the success rate of persistent AF? ----Follow-up results and EP findings in the redo procedures from 169 consecutive patients

  10. Roof-line-1 Posterior mitral line-2 Roof-line-2 Posterior mitral line-3 Posterior mitral line-1 Posterior mitral line-4

  11. The Study Results • 169 consecutive Per-AF patients • 2007.5~2010.7 • Mean age: 56y • Mean LAD: 42mm • Mean AF duration: 24m • 15±8 months Follow up SR: 84 pts (50%) 169 pts AF: 34 pts (20%) AT: 51 pts (30%) AT ablation: 46pts 81 ATs Macro-AT: 36 Focal-AT: 45

  12. Proarrhythmic effects of linear lesions • Mechanism of AT after AF ablation • Macro-reentrant

  13. Proarrhythmic effects of linear lesions • Mechanism of AT after AF ablation • Macro-reentrant

  14. Proarrhythmic effects of linear lesions • Mechanism of AT after AF ablation • Focal Ju W, Chen ML, et al. PACE 2011;34(8):919-26.

  15. Proarrhythmic effects of empiric CFE ablation • CFE ablation

  16. Localized reentry as a novel type of the proarrhythmic effects of linear lesion in the left atrium----Ju et al. PACE. 2011;34:919-926

  17. The ideal ablation strategy of persistent AF still remains a matter of debate… Veenhuyzen GD, et al. PACE 2009 Mar;32(3):393-8.

  18. Comparison of Left Atrial Electrophysiologic Abnormalities during Sinus Rhythm in Patients with Paroxysmal, Persistent and Long-Standing Atrial Fibrillation • Par-AF: 30 pts • Per-AF: 22 pts • LS-AF: 28 pts • Control: 20 pts with LAP

  19. Mapping Methods • A-Focus high density mapping during sinus rhythm • Mapping was done after CPVI, Per-AF and LS-AF need cardioversion • NavX: interior and exterior projection, interpolaration were set at 5 mm • LA voltage, activation time and complex electrograms were analyzed

  20. Comparison of the LA activation time among different populations

  21. The correlation of LA activation time with overall mean bipolar voltage, left atrium diameter，low voltage index and percentage of complex electrograms

  22. Definition of Complex Electrocardiogram Distinct deflections≥ 3 Electrocardiogram duration≥ 50 ms > 50ms

  23. A: Comparison of the percentage of complex electrograms in LA. B: Comparison of the mean bipolar voltage of complex electrograms. C: Comparison of the duration of complex electrograms.

  24. Study Findings • With AF progression there was a lower mean bipolar voltage, higher low voltage index and more prevalent and larger LVZ area in LA • With AF progression there was also conduction abnormalities characterized by prolonged LA activation time and more proportion of complex electrogram • The cutoff value to define low voltage zone (0.1~0.4mV) and the transitional zone (0.4~1.3mV) was defined

  25. New ablation strategy • Novel ablation strategy for Per-AF CPVI Cavotricuspid isthmus ablation Cardioversion LA high density electroanatomic mapping Substrate modification Check linear lesions to achieve bidirectional block To double check PV being isolated

  26. Pilot Study of Circumferential Pulmonary Vein Isolation Plus ElectrophysiologicalSubstrateAblation in the LeftAtrium During SinusRhythm(STABLE-SR) in the Treatment of Chronic Atrial FibrillationClinicalTrials.gov Identifier: NCT 01716143 AF = atrial fibrillation; CPVI = circumferential pulmonary vein isolation; CTI = cavotricuspid isthmus; DC = direct current; SR = sinus rhythm; LA = left atrium; HDM = high density mapping; LVZ = low voltage zone; TZ = transitional zone

  27. Representation of substrate-based ablation during SR in the LA besides CPVI

  28. Example of relatively “healthy” LA and does not need additional ablation No LVZ was found in the LA body No CFE was found in TZ

  29. Example of diffused LVZ and SR-CFEs within TZ Color bar setting: 0.1~0.4 mV Color bar setting: 0.4~1.3 mV

  30. Lesion deployed based on HDM mapping results

  31. Continuous ablation of the site with CFE till the voltage was < 0.1 mV The circular catheter was dislodged from the PVs

  32. Example of HDM after CPVI Notice the distribution of LVZ and TZ with CFEs

  33. Lesion deployment according to HDM results Pacing from the LAA to check the conduction block Homogenization of LVZ, modification of the TZ sites with CFEs and joining these areas to the right lesion ring and the anterior mitral annulus actually create a narrow band of conduction block in the left anterior septal wall.

  34. Results Baseline Patient Characteristics (N=68)

  35. Results 75 enrolled pts CPVI + CTI ablation cv 68 7 SR ( 90.7% ) Failed ( 9.3% ) Aggressive ablation STABLE - SR Percentage of patients with LA substrates at different regions

  36. Distribution of LVZ and TZ of 57 Regions and the Corresponding Ablation Strategies

  37. Freedom of ATa off AADs after a single-ablation procedure: 53 of 68 (77.9%) Types of recurrent arrhythmia PAF in 12 of 68 (17.6%) persistent AF in 2 of 68 (2.9%) AT in 1 of 68 (1.5%) Arrhythmia recurred within the first year after ablation in 6 of 68 (8.8%) patients. Nine (13.2%) patients had recurrences after 12 months after ablation. Results Follow-up (21.5 ± 7.8 months) 68 pts Ata occurrence (15) Ata Free (53) PeAF (2) AT (1) PAF (12)

  38. Total procedure: 212 ± 34 minutes Total fluoroscopy time: 31 ± 7 minutes Adverse Events 2 (2.9%) femoral hematomas Results

  39. Comparative Study of STABLE-SR vs. STEPWISE in the Treatment of Chronic Atrial FibrillationClinicalTrials.gov Identifier: NCT 01761188 • Randomized • Comparative • Multicenter • Single blind • Prospective • Launched in June 6, 2013

  40. Conclusion • Aggressive ablation strategy is “a knife with two blades” • linear ablation and CFE ablation should be highly selective, but not empirical and extensive • CPVI plus substrate based ablation (LVZ ablation and complex electrgram modification) might be a more electrophysiological individualized ablation strategy for chronic AF patients “Nanjing Approach”

  41. 南京欢迎您！ Thank you for your attention!

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