Innehållet i denna fil får endast användas för privat bruk. Kopiering eller annan användning kräver tillstånd från Dr Mats Jensen-Urstad, Karolinska

Transkript

1 Innehållet i denna fil får endast användas för privat bruk. Kopiering eller annan användning kräver tillstånd från Dr Mats Jensen-Urstad, Karolinska Universitetssjukhuset

2 Behandling av förmaksflimmer med cryoablation Mats Jensen-Urstad Hjärtkliniken Karolinska Universitetssjukhuset

3 Catheter ablation in A-Fib Ingen (minimal) hjärtsjukdom Hypertoni Ischemisk hjärtsjukdom Hjärtsvikt Uttalad VKH Flekainid Propafenon Sotalol Nej Ja Sotalol Amiodaron Amiodaron Kateterablation Flekainid Propafenon Sotalol Amiodaron Amiodaron Kateterablation Kateterablation Amiodaron Kateterablation Kateterablation

4 Vidgade indikationer ökat behov Behov > 4000 ingrepp/år 2008 gjordes 608 ingrepp i Sverige Hur klara framtida behov?

5 RF in Atrial Fibrillation - Isolation of PVs - Complete isolation - Complex procedure (long learning curve ) - Time-consuming procedure Point by point - Need of CT/MR and 3D mapping - Effective in trained hands

6 RF in Atrial Fibrillation RF Complications PV stenosis Atrio-oesophageal fistula Thrombus formation Tamponade Painful Pro-arrhythmic

7

8 Vad önskar vi av en ny teknik? Enklare Snabbare Kortare inlärningskurva Säkrare

9 Cryo bakgrund Pressurized liquid N 2 0 is delivered from the CryoConsole through an ultrafine, robust injection tube, to the tip of the catheter The vapor is returned to the console through a lumen maintained under vacuum Inside the tip, the liquid N 2 0 vaporizes as it encounters heat from the surrounding tissue

10 Cryo - bakgrund

11 Cryo - bakgrund Välavgränsade lesioner Möjlighet till cryomapping Låg risk för skador på omliggande vävnader Mindre trombogent Mindre smärta

12 RF vs Cryo RF Cryo

13 Cryo bakgrund Karolinska Startade cryo cryoprocedurer sedan dess Ca 1/3 av våra ablationer görs med cryo, cryoingrepp Erfarenhet av osteala PV isoleringar med cryo, 120 ingrepp

14

15 Cryoballoon in Atrial Fibrillation

16 Möjliga fördelar med cryoballong Enklare teknik kortare inlärningskurva Inget behov av 3-D map Ingen risk för lungvensstenoser Ingen risk för förmaks-esofagusfistlar Låg risk för trombbildning Låg proarytmisk risk Mindre smärtsamt

17 Teknik Transseptalkateterisering med sedvanlig teknik, enkel eller dubbla transseptaler Kontroll av konduktion i lungvener med Lassokateter Byte till 12 F introducer för cryoballong Isolering med ballong

18

19 Procedure 6 Steps 1. Wiring 2. Inflation 3. Positioning 4. Ablation 5. Thawing 6. Retracting Wire the target vein with guidewire

20 Procedure 6 Steps 1. Wiring 2. Inflation 3. Positioning 4. Ablation 5. Thawing 6. Retracting Confirm Arctic Front balloon is outside of FlexCath Do not inflate balloon inside a pulmonary vein

21 Procedure 6 Steps 1. Wiring 2. Inflation 3. Positioning 4. Ablation 5. Thawing 6. Retracting Good Poor The best predictor of success is the level of occlusion It s worth spending the extra time!

22

23 Fryser 300 sekunder 2 applikationer per ven Kontroll av frenicusfunktion fra höger sida Kontroll med Lasso Ev komplettering

24 Case - Background 60 year old man Hypercholesterolemia Px a fib 2001, becoming persistent Cardioversion x 15 Decreased physical performance during a fib

25 Background (2) Riding in the wood, jumping Worried about being on warfarin Current medication: flecainide 100 mg x 2, metoprolol 50 mg x 1, simvastatin 20 mg x 1, warfarine 182 cm, 98 kg, BMI 29.6

26 Background (3) CT thorax shows 4 pulmonary veins INR therapeutic TEE day before procedure: thrombus in LAA cannot be excluded

27 Procedure 3 introducers in right femoral vein Intracardiac ultrasound shows a free LAA with normal velocities CS catheter Double transseptal puncture 20 mm Lasso 28 mm CryoBalloon

28 LSPV preablation

29 300 s -48

30 300 s -58

31 LSPV postabl

32 LIPV preabl

33 300 s -46

34 300 s -45

35 300 s -49

36 LIPV postabl

37 RSPV preabl

38 300 s -56

39 300 s -56

40 RSPV postabl

41 RIPV preabl

42 300 s -54

43 300 s -52

44 RIPV postabl

45 Total procedure time 160 min (ICE, PV, CTI) First procedure Dec 2007 Redo March 2008 after that no recurrences, no AA, warfarin stopped after 3 months

46

47 Cryoballoon in Atrial Fibrillation (Neumann et al.) 346 consequtive pts PAF 293 (85%) Persistent AF 53 (15%) Age 59 (52-66) Isolated veins with balloon 89% Touch-up, no of veins 8% Total no of isolated veins 97% Procedure time, min 170 ( ) Fluoroscopy time, min 40 (30-57)

48 Cryoballoon in Atrial Fibrillation (Neumann et al.) Median FU 12 (7-16) months Free from PAF 74% Free from Persistent AF 42%

49 Cryoballoon Complications (Neumann et al.) 2 pericardial tamponades 5 groin hematoma 2 femoral arterial pseudoaneurysm 1 arteriovenous fistula 2 transient ST segment elevation inferiorly. Air embolus due to bubbles inside of the sheath

50 Cryoballoon Complications (Neumann et al.) Phrenic Nerve Palsy (7.5%) 26 (out of 346) pts right PNP. RSPV - 24 of mm balloon - 2 of mm balloon - Full recovery of PNP < 1 year!

51

52 Cryoballoon in Atrial Fibrillation (Van Belle et al.) 57 consequtive pts px a fib Mean age 55±9 Isolated veins with balloon 84% Touch-up, no of veins 15% Total no of isolated veins 99% Procedure time, min 211±108 Fluoroscopy time, min 52±36

53 Cryoballoon in Atrial Fibrillation (Van Belle et al.) FU with ER, daily transtel. ECG 3 mon Free from AF 60% Reversible PNP 7% (4pts) Tamponade 1 Left-sided haemothorax 1

54 Example of Learning Curve Over 50 Cases minutes proc. time rad. time Van Belle, Y et al.: Pulmonary vein isolation using an occluding cryoballoon for circumferential ablation: feasibility, complications, and short-term outcome. 54

55

56 Cryoballoon in Atrial Fibrillation (Chun et al.) 27 consequtive pts Mean age 56±9 Isolated veins with balloon 98% Median Procedure time, min 220 ( ) Median Fluoroscopy time, min 50 (42-69)

57 Cryoballoon in Atrial Fibrillation (Chun et al.) Median FU (days) 271 ( ) Daily tele-ecg Free from AF 70% (3 months blanking period) Reversible PNP 11% (3pts)

58 Hockey Stick Technique

59 Pull-down technique

60 Big loop technique

61 Cryoballoon in Atrial Fibrillation (Karolinska)

62 Cryoballoon in Atrial Fibrillation (Karolinska) 75 consequtive pts Median age 57 (31-75) Targeted veins 304 Isolated veins with balloon 273 (90%) Touch-up, no of veins 28 (9%) Total no of isolated veins 301 (99%) Procedure time, min 204±59 Fluoroscopy time, min 46±19

63 Cryoballoon in Atrial Fibrillation (FU) Median FU 13 month (4-28) Free from AF 68% Significantly improved 17% Redo cryoballoon 4 AA at the time of evaluation 40% Reversible PNP 13% (10pts)

64 Conclusions Simple and straightforward Reasonably short learning curve No need of 3D mapping Less serious complications Comparable success rate with RF for px a fib Need of randomised trials

65 Cryoballoon vs RF in Atrial Fibrillation (Karolinska) Px a fib Prospective Randomised Single blind Procedural success Procedure-related perceived pain Long-term results QoL 130 pts per group

66 Tack!