Cryoablation vid förmaksflimmer abl? Carina Blomström-Lundqvist Dept of Cardiology, University Hospital Uppsala, Sweden

Transkript

1 Cryoablation vid förmaksflimmer abl? JA Carina Blomström-Lundqvist Dept of Cardiology, University Hospital Uppsala, Sweden

2 Cryoablation: Dagsläget? Vilken metod för flimmerablation? Vilken teknik är mest effektiv för PVI? One shot tool vs punktvis ablation för flimmerfrihet? Vad är säkerheten med over the wire teknik jmf att bränna fritt? Inlärningskurva

3 Multifactorial AF mechanism Multiple lesion sets see what happens stategy PV isolation WACA / Antrum Isolation: Rotor modulation CAFE Linear lesions Calkin, Europace 2012

4 Multifactorial AF mechanism Multiple lesion sets see what happens stategy PV isolation WACA / Antrum Isolation: Rotor modulation Bäst? CAFE Linear lesions Calkin, Europace 2012

5 Men Calkin, Europace 2012

6 STAR AF 2 : PVI + linear or CAFE lesions in persistent AF pats? 3 arms: PVI / PVI+linear lesions / PVI+CAFE AF > 30 s after 1 procedure (+AAD) No difference in Outcome Verma NEJM 2015 Ingen annan ablations strategi än PVI har visats förbättra FF frihet

7 Cryoablation: Dagsläget? Vilken metod för flimmerablation? Vilken teknik är mest effektiv för PVI? One shot tool vs punktvis ablation för flimmerfrihet? Vad är säkerheten med over the wire teknik jmf att bränna fritt? Inlärningskurva

8 PVI = standard teknik för FF ablatio - men hur?

9 Cryoballong - PVI LIPV, LAO Over the wire teknik Säker One shot teknik Inga gaps RSPV, RAO RSPV, RAO Ingen rtg under applik Inget mapping system behövs LIPV, RAO Hook technique

10 Cryoablation: Dagsläget? Vilken metod för flimmerablation? Vilken teknik är mest effektiv för PVI? One shot tool cryo vs punktvis RF ablation för flimmerfrihet? Vad är säkerheten med over the wire teknik jmf att bränna fritt? Inlärningskurva

11

12 Single Procedure Freedom from AF at 12 mo - Arctic Front Advance Single Center Studies 1-Year Single Procedure Freedom From AF Off AADs Di Giovanni, et al.j Cardiovasc Electrophysiol ; In Press, Fürnkranz, et al. Journal of Cardiovascular Electrophysiology 2014 ; In Press, Metzner, et al., Circ Arrhythm Electrophysiol. 2014; In Press, Chierchia, et al. Europace 2014; In Press, Kumar et al. J Interv Card Electrophysiol 2014; In Press

13 82 % 84 % PAF

14 82 % N=143 pat; PAF 79% 73 % Ciconte Heart Rhyhtm 2015

15 N= 393 pats; single procedure

16 RF Catheter Ablation Efficacy Summary - Systematic Literature Review and Meta-Analysis 63 RF ablation studies in review pats with AF Success varies depending on no of procedures and AADs Mean follow-up: 14 mos. (2-30 mos.) Blanking period ranged 2-12 weeks. Calkins H, et al. Circ Arrhythmia Electrophysiol. 2009; 2(4):349-61

17 Freedom from AF in Drug Refractory PAF Large RF Multicenter Clinical Trials or Surveys Published Since 2010 Freedom from PAF in large RF multi-center studies and surveys, incl clinical study results from recent RF advancements, is 61-74% RF Contact Sensing nmarq (n=103) (n=9590) (n=871) (n=172) (n=300) (n=168) *RF used in 98% of procedures, Cryo 2% **RF used in 85% of procedures, 10% cryo 1 Wilber et al. JAMA 2010;303(4):333-40, 2 Cappato, et al. Circ Arrythm Electrophysiol 2010;3(1):32-8, 3 Arbelo, et al. Eur Heart J 2014 ;35(22): , 4 Natale, J Am Coll Cardiol 2014;19;64(7):647-56, 5 Mansour, HRS 2014 Presentation, 6 Jais, et al. Cardiostim 2014 Abstract #PO03-34

18 376 PAF pats; 198 RF; 178 CryoB. 4 centres: RF Cryo Procedure shorter for CryoB than RF group vs min, P = 0.003)

19 Cryoballoon vs RF for persist AF non RCT comparison (n=100 pat) No blanking 3 mo blanking

20 Cryo RF Cryo RF N=1196 pats, PAF 76%, 5 centra. Cryo RF Cryo RF Non RCT. CryoB-2 n = 773 Irrigat RF n = 423 Aryana, J Cardiovasc Electrophysiol, 2015

21 Aryana, J Cardiovasc Electrophysiol, 2015

22 PV LA rekonduktion ses oftare efter RF ablatio (contact force) jmf efter Cryoballong. RF grupp (119 PVs): 36.1% re-konduktion (1.8/pat), Cryoballoon (103 PVs): 20.4% re-konduktion (1.2 /pat) (P = 0.01). Cryo Distribution av gaps RF Ciconte Europace 2015

23 Cryoablation: Dagsläget? Vilken metod för flimmerablation? Vilken teknik är mest effektiv för PVI? One shot tool vs punktvis ablation för flimmerfrihet? Vad är säkerheten med over the wire teknik jmf att bränna fritt? Inlärningskurva

24 Cryoballong gamla vs nya Procedur / Fluoro tid, min Furnkranz, Europace % / -29%

25 Meta-Analysis Cryoballoon vs RF ablation for PVI? MEDLINE and EMBASE databases (Sept 2013) 469 cryoballoon and 635 RF AF ablations pats, 14 trials. Fluoro time Cryo : min, p = Procedure time Cryo : min, P = Xu, PLOS ONE 2014

26 Meta-Analysis Cryoballoon vs RF ablation for PVI? MEDLINE and EMBASE databases before Sept cryoballoon and 635 RF AF ablations pats 14 clinical trials. Xu, PLOS ONE 2014 Major complications did not differ

27 Single procedure

28 RF Catheter Ablation Safety Summary - Systematic Literature Review and Meta-Analysis 63 RF ablation studies 8789 pats with AF Major complications in 4.9% pats Most common complications; PV stenosis (1.6%), Cardiac tamponade (0.7%), Pericardial effusion (0.6%), Periprocedural stroke (0.3%) Periprocedural TIA (0.2%) Calkins H, et al. Circ Arrhythmia Electrophysiol. 2009; 2(4):349-61

29 Frenikus pares at discharge N Pares % Publik Metzner 115 3,5 JCE 2014 Furnkranz 254 2,8 Europace 2015 Saitoh 199 4,5 PACE 2015 Straube 120 1,7 CircArrh El 2014 Luik 156 5,8 Circulation 2015 Furnkranz 360 4,8 0 Europace 2015 Reduced with time

30 Meta-Analysis of Phrenic Nerve Palsy - Review of Published Studies with Arctic Front 539 Arctic Front articles screened, 23 were retained for final analysis (1309 patients): 1 2 PNP overall incidence of 6.38% 4.73% of PNP persisted after the ablation procedure 0.37% of patients experiencing PNP that persisted beyond 1 year. 1 Andrade, et al. Heart Rhythm 2011;8(9): , 2 Cappato et al. Circ Arrhythm Electrophysiol 2010;3:32 38

31 Atrial Esophageal fistula RF ablation risk = 0, % Higher risk if anesthesia is used. Cryoballoon 7 fistula cases: Risk (gen.1): 3 / 35,000 cases = 0.009%. Risk (gen 2): 4 /29,000 cases = 0.014%) Actions: Avoid general anesthesia Use ProtonPumpInhib PPI Avoid extreme low temp Future: 1 application

32 Konklusion Cryoballong enkelt o säkert Over the wire teknik Kortare fluoro tider Kortare procedur tider Lika eller mer effektivt än RF One shot teknik Inga gaps

33