Innehållet i denna fil får endast användas för privat bruk. Kopiering eller annan användning kräver tillstånd från Dr Mats Jensen-Urstad, Karolinska Universitetssjukhuset
Behandling av förmaksflimmer med cryoablation Mats Jensen-Urstad Hjärtkliniken Karolinska Universitetssjukhuset
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
Vidgade indikationer ökat behov Behov > 4000 ingrepp/år 2008 gjordes 608 ingrepp i Sverige Hur klara framtida behov?
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
RF in Atrial Fibrillation RF Complications PV stenosis Atrio-oesophageal fistula Thrombus formation Tamponade Painful Pro-arrhythmic
Vad önskar vi av en ny teknik? Enklare Snabbare Kortare inlärningskurva Säkrare
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
Cryo - bakgrund
Cryo - bakgrund Välavgränsade lesioner Möjlighet till cryomapping Låg risk för skador på omliggande vävnader Mindre trombogent Mindre smärta
RF vs Cryo RF Cryo
Cryo bakgrund Karolinska Startade cryo 2002 1500 cryoprocedurer sedan dess Ca 1/3 av våra ablationer görs med cryo, 2009 304 cryoingrepp Erfarenhet av osteala PV isoleringar med cryo, 120 ingrepp
Cryoballoon in Atrial Fibrillation
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
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
Procedure 6 Steps 1. Wiring 2. Inflation 3. Positioning 4. Ablation 5. Thawing 6. Retracting Wire the target vein with guidewire
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
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!
Fryser 300 sekunder 2 applikationer per ven Kontroll av frenicusfunktion fra höger sida Kontroll med Lasso Ev komplettering
Case - Background 60 year old man Hypercholesterolemia Px a fib 2001, becoming persistent Cardioversion x 15 Decreased physical performance during a fib
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
Background (3) CT thorax shows 4 pulmonary veins INR therapeutic TEE day before procedure: thrombus in LAA cannot be excluded
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
LSPV preablation
300 s -48
300 s -58
LSPV postabl
LIPV preabl
300 s -46
300 s -45
300 s -49
LIPV postabl
RSPV preabl
300 s -56
300 s -56
RSPV postabl
RIPV preabl
300 s -54
300 s -52
RIPV postabl
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
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 (140-195) Fluoroscopy time, min 40 (30-57)
Cryoballoon in Atrial Fibrillation (Neumann et al.) Median FU 12 (7-16) months Free from PAF 74% Free from Persistent AF 42%
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
Cryoballoon Complications (Neumann et al.) Phrenic Nerve Palsy (7.5%) 26 (out of 346) pts right PNP. RSPV - 24 of 26.. 23 mm balloon - 2 of 26. 28 mm balloon - Full recovery of PNP < 1 year!
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
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
Example of Learning Curve Over 50 Cases minutes 400 300 proc. time rad. time 200 100 0 1-10 11-20 21-30 31-40 41-50 Van Belle, Y et al.: Pulmonary vein isolation using an occluding cryoballoon for circumferential ablation: feasibility, complications, and short-term outcome. 54
Cryoballoon in Atrial Fibrillation (Chun et al.) 27 consequtive pts Mean age 56±9 Isolated veins with balloon 98% Median Procedure time, min 220 (190-245) Median Fluoroscopy time, min 50 (42-69)
Cryoballoon in Atrial Fibrillation (Chun et al.) Median FU (days) 271 (147-356) Daily tele-ecg Free from AF 70% (3 months blanking period) Reversible PNP 11% (3pts)
Hockey Stick Technique
Pull-down technique
Big loop technique
Cryoballoon in Atrial Fibrillation (Karolinska)
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
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)
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
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
Tack!