This document summarizes the past, present, and future of pulmonary vein ablation. In the past, surgical maze procedures were developed to treat atrial fibrillation but were complex. Early catheter ablation procedures mimicked the surgical maze with linear lesions but were also complex. Segmental pulmonary vein isolation was developed and improved success rates. Advances like intracardiac echocardiography and contact force sensing aim to improve safety. Future areas of interest include ablation of complex sources like the left atrial appendage and improving outcomes for long-standing persistent atrial fibrillation.

1. Ablacion de Venas Pulmonares:
Pasado, Presente, y Futuro
9 de Octubre, 2010
Javier E. Sanchez MD
Texas Cardiac Arrhythmia Institute
St. Davids Medical Center
Austin, Texas

2. Texas Cardiac Arrhythmia Institute
at St. Davids Medical Center
Austin, Texas
Electrophysiologists Research Fellows/Nurses
• David Burkhardt MD • Luigi DiBiasi MD
• Prasant Mohanty MD
• Shane M. Bailey MD • Yan Wang MD
• Robert C. Canby MD • Deb Cardinal RN
• Rodney P. Horton MD • Chantel Scallon RN
• Barbara Thomas RN
• G. Joseph Gallinghouse MD • Elva Brown RN
• Andrea Natale MD • Jackie Kin RN
• Larry Price DO • Karla Wolter RN
• Wendy Brandhorst RN
• Javier E. Sanchez MD • Maegen Lane RN
• Jason D. Zagrodzky MD • Cindy Williams RN

3. G. Neal Kay

4. Meta
• Proveer una perspectiva personal de como
nuestro campo surgio, como ha
evolucionado, y como progresara en el
futuro cercano

5. PASADO

6. Surgical Cox Maze Procedure
Cox JL. Cox J Thoracic Card Surg 1991;101:406
and J Cardiovasc Electropysiol 2004;2:250

7. Surgical Cox Maze Series
• 276 patients (Sept 1987-June 2003)
• Lone surgery on 160
• Concomitant surgery on 113
– MV only 33
– CABG 40
– Ao V + CABG 2
– Others concomitant procedures on 38
J Thoracic and Cardiovasc Surg 2005;129:104

8. Success rate with Maze Procedure
J Thoracic and Cardiovasc Surg 2005;129:104

9. Success according to duration of AF
before surgery
J Thoracic and Cardiovasc Surg 2005;129:104

10. Maze may not “cure” all Afib, but it
dramatically decreases the incidence
of strokes
Prior stroke,
No AC
Risk factors,
no AC
Prior stroke,
with AC
Risk factors,
with AC
Lone AF, AC
Maze, no
AC
J Thoracic and Cardiovasc Surg 1999;118:883

11. Catheter “Maze Procedure”
The First Catheter Ablation Procedure for AF
• J Swartz .Circulation 1994;90:I-335
– Patient with chronic AF, CHF, and a LA of 5.8
x 7.5 cm was treated with linear ablations in a
pattern similar to the maze surgery. During
procedure, arrhythmia progressively organized
and eventually converted to sinus rhythm.
– Later extended the series to 10 patients
Never published as a full manuscript

12. Catheter Maze Procedure
• Swartz, Kay, Packer 1995-1996
– 23/29 in sinus rhythm off antiarrhythmic
therapy after 2 years of follow up (79%
success)
– Another 2 that previously had chronic AF,
converted to PAF
• Limitations
– Procedure duration ~12 hrs
– Many complications: VF, tamponades, 2
strokes, PV stenosis
Never published as a full manuscript

13. Catheter Maze Procedure:
First Published Series
• Haissaguerre JCE1996;7:1132
• 45 patients
– 3 groups in base of RA ablation pattern
– If AF after RA ablation, LA ablation offered
• Linear ablation done first. If Atrial tachycardias
noted they were mapped and ablated.

14. Catheter Maze Procedure:
First Published Series: Haissaguerre , JCE1996;7:1132

15. Catheter Maze Procedure:
First Published Series: Haissaguerre , JCE1996;7:1132
Focal ablation of atrial
tachycardias done in the
superior PV’s, the high
crista and the CS os

16. Left Superior PV
Right Anterior Oblique Left Anterior Oblique
3

17. Initial Linear Ablation System Designed
for Catheter Maze Procedure
Kay, Ellenbogen, Calkins

18. Initial Linear Ablation System Designed
for Catheter Maze Procedure
Kay, Ellenbogen, Calkins
Am Heart J 1999; 83:227D

19. Initial Linear Ablation System Designed
for Catheter Maze Procedure
Kay, Ellenbogen, Calkins

20. Strategy
• Patients with structural heart disease;
with permanent or persistent atrial
fibrillation
– RA ablation
– LA ablation
– “Focal ablation” (which really meant PV
ablation, although it wasn’t called that in initial
protocol)
Calkins et al. Am Heart Journal 1999;83:227D

21. Results
• 49 Patients underwent RA linear
ablation; in 7, SR obtained
• 28 Patients underwent LA linear ablation
– In 13, sinus rhythm was obtained; in 5, AF
converted to paroxysmal
– PV isolation performed in 19:
• in 15, SR obtained; in 2, AF converted to
paroxysmal; in 2, AF persisted
• (overall 71% success rate)
Calkins et al. Am Heart Journal 1999;83:227D

23. 62% Success Rate at 8 + 6 Months
25% 45%
9% 16%
94%
(Haïssaguerre M et al. NEJM 1998; 339: 659-66)

24. Aislamiento de las Venas Pulmonares
(Ablación en segmentos)
• Resultados clínicos mas sostenidos
• Menos estenosis de las VPs
• Resultatado en FA crónica menos de 35%

25. Circulation 2000;101:1409-1417
3

26. Segmental Ostial Ablation
RAO LAO

27. Ablation at 2 segments
around this vein achieves
electrical isolation of the PV
Circulation
2000;101:1409
Recordings from inside the PV

28. Basket in Right Superior PV
Right Anterior Oblique Left Anterior Oblique

29. Before Segmental Ostial Ablations
Circulation 2003;108:590

30. After Segmental Ostial Ablations
Circulation 2003;108:590

31. An uncommon case

32. Basket in Left Superior PV
Right Anterior Oblique
3 Left Anterior Oblique

33. Basket in Left Inferior PV
Right Anterior Oblique
3 Left Anterior Oblique

34. Basket in Right Superior PV
Right Anterior Oblique
3 Left Anterior Oblique

35. Basket in Right Inferior PV
Right Anterior Oblique 3 Left Anterior Oblique

36. Basket in SVC
Right Anterior Oblique Left Anterior Oblique
3

37. Ablación Circular del Atrio Izquierdo
(sin aislar las venas)
Pappone et al., Circulation. 2001;104:2539

38. Registro (vs casos controles)
Freedom from Atrial Fibrillation
JACC 2003:42;185

39. Probabilidad de Eventos Adversos
Decreased incidence of strokes,
CHF admissions, and death
Pappone et al. JACC 2003:42;185

40. Circular Ablation Vs Segmental
Ostial Isolation
Oral et al. Circulation 2003;108:2355

41. AF Catheter Ablation Strategies
Exit (Os) Focal
Antrum
More Proximal ablation: The PV Antrum

42. Atrial Esophageal Fistula
Pappone et al. Circulation 2004;109:2724

43. Left atrial circular ablation achieving vein isolation
with the use of Intracardiac echo (ICE)
Intracardiac
echocardiography (ICE)
facilitated ablation in the
atrium without ablation
inside of the veins
Circulation. 2003;107:2710

44. ICE guided ablation
-The presence of microbubbles indicates excessive heating
-Decreasing ablation power when microbubbles are seen
increases safety Circulation. 2003;107:2710
Circulation. 2003;107:2710

45. Improved safety and success with
use of ICE
Circulation. 2003;107:2710

46. Ablation of Fractionated Electrograms
(Dr Nademanee)
JACC 2004;43:2044 HRJ 2006;8:981

47. Lessons Learned

48. Right Atrium

49. Right Atrium

50. Considerations for AF
Transseptals
• For the lasso: anterior is better

51. Considerations for AF
Transseptals
• For the ablation a more inferior and
posterior approach is better

52. PFO is Superior and Anterior to AF
Transseptal Ideal Site
To use the transseptal for the ablation prolongs total RF energy delivery and
procedure duration but does nor affect clinical result (JCE 2008;19:1236)
For AF ablation I prefer to do 2 transseptals and not use the PFO
Another option is to use the PFO for the sheath that will have the circular
mapping catheter

53. Transseptal Sheath not in PFO

54. Transseptals During Redo
Procedures
• Tend to be a little higher
• Septum tends to be a little tougher
– May costumize needle to resemble a BRK 1
– May use electrocautery or RF energy
Europace 2008;10:276

55. Bending Needle to Resemble a
BRK 1 Useful
PACE 2007:30:1506

56. Transseptal Needles – BRK™
Series
Direction
Arrow
~70%
Pediatric Use
Stopcock Valve
~30%
May use stylet to avoid scratching the sheath

57. RF Energy or Electrocautery For
Transseptal Cathetherization
Circ AE 2008;1:169

58. Evaluating PV Anatomy

59. Area of Interest

60. Area of Interest

61. Area of Interest

62. Ablation Strategy: Avoid the PV’s

63. Ablation Strategy: Avoid the PV’s

64. Techniques Are Complementary
Limitations of Esophageal Temperature Probe

65. Direct Visualization with ICE
Ablation Catheter on top of Esophagus

66. Mapping Facilitated by Circular Catheter
Left Pulmonary veins: Right Pulmonary veins: SVC:
Low #’s are anterior Low #’s are posterior Low #’s are posterior

67. Mapping Facilitated by Circular Catheter
Left Pulmonary veins: Right Pulmonary veins: SVC:
Low #’s are anterior Low #’s are posterior Low #’s are posterior
Recognize where far-field signals are

68. PRESENTE

69. Randomized Trial Of PAF
Refractory to 1 Antiarrhythmic
(multicenter)
No redo”s
Navistar Thermocool Study March 2009

70. Randomized Trial Of PAF
Refractory to 1 Antiarrhythmic
(single center)
Redo 23 patients
Jais et al. Circ 2008;118:2498

71. Ablation in Persistent AF
• Success rates are less
• Redo’s are more common
• (Complications are the same)

72. Long Standing Persistent AF
PVAI + Defragmentation + Pharmacologic
Challenge
Success after 1 procedure: 11% 40% 61%
Review: Cardiol Clin 2009; 27:163 Elayi et al. HRJ 2008; 5:1658

73. Long Standing Persistent AF
PVAI + Defragmentation + Pharmacologic
Challenge
Success after 1 procedure: 11% 40% 61%
94% of patients in sinus after redo in 20% and 14% on AAD
Review: Cardiol Clin 2009; 27:163 Elayi et al. HRJ 2008; 5:1658

74. Ablation of Fractionated Electrograms
(Consensus opinion: limited utility as stand-alone strategy, useful as
an add-on to PV isolation)
PA AP
Nademanee HRS Afib Summit 2007
Common sites where fractionated electrograms are present

75. Ablation of Long Standing
Persistent AF
Linz et al. J CE 2010; published ahaed of print Sept 2010

76. Linz et al. J CE 2010; published ahaed of print Sept 2010

77. Ablation of Long Standing
Persistent AF
Linz et al. J CE 2010; published ahaed of print Sept 2010

78. FUTURO

79. Left Atrial Appendage: An under-
recognized source of AF triggers

80. Left Atrial Appendage: An under-
recognized source of AF triggers
(isuprel induced)

81. LAA: segmental isolation similar to a PV

82. A B
C

83. LAA dissociated firing
A B

84. Left Atrial Appendage: An under-
recognized source of AF triggers

85. Lateral Left Atrium
EHJ 2008;29, 356

86. Lateral Left Atrium
EHJ 2008;29, 356

87. Increasing Complexity of AF Ablation Sinus Rhythm
Organized NonPV
Atrial Arrhythmias Sources
86
Left Atrial Lines
Atrial Fibrillation Isthmus/Roof/Antrum
82
4 PVs
70
3 PVs
50
2 PVs
1 PV
RA Lines 11
1994 2002
Time

88. Challenge: Need for Redo Procedures
• 20-40% redo rates are needed
• Redo procedure are done mostly to
re-ablate previously ablated sites.
1 Hindricks G et al, Late recurrent arrhythmias after ablation of atrial
fibrillation: incidence, mechanisms, and treatment. Heart Rhythm
2004;1:676–683.
2 Callans DJ et al, Efficacy of repeat pulmonary vein isolation procedures in
patients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol
2004;15:1050–1055.

89. Challenge: Life-threatening
Complications Remain Present
JACC 2009;53:1798

90. Challenge: Life-threatening
Complications Remain Present
Could some complications be avoided with contact force
feedback?
JACC 2009;53:1798

91. Safety: steam pops
Incidence of Steam Pops in % at 40W*
P<0.01
% P=0.08
4/9 6/9
0/9
Low Force Moderate Force High force
10 g 25 g 70 g
Steam pop occurred only with high contact force at 30 W in RV
and moderate and high contact force at 40W and 50 W in LV.
Nakagawa et al, 2008 HRS abstract (beating heart dog model in ventricles)
* One ablation out of nine done at 50W

92. Safety: Esophageal injury
This canine model demonstrates the striking role of contact
force in Eso injury during RF ablation in the LA close to Eso.
Source: A. Ikeda, HRS 2008

93. Safety: Perforation
Perforation Force [g] 350
300
250
200 RA lesion
150 RA tissue
100
50
0
5
1
2
7
4
6
3
e
e
e
e
e
e
e
pl
pl
pl
pl
pl
pl
pl
m
m
m
m
m
m
m
Sa
Sa
Sa
Sa
Sa
Sa
Sa
Perforation with a typical ablation catheter through the
healthy free walls of a pig heart required > 100 g of
force. (less through recently ablated tissue)
Shah et al, HRS 2008 abstract (ex vivo pig heart)

94. Extreme Variability of Forces
(when blinded to contact force data)
Source: D. Shah, HRS 2009

95. Summary
• Surgical Maze remains the “best” single
procedure (and it is very far from perfect)
• Present techniques are effective and safe for
the treatment of paroxysmal and recently
persistent atrial fibrillation
• Long-standing persistent atrial fibrillation
remains a challenge

96. Summary
• 2 major obstacles remain)
– Need for redo procedure to accomplish
permanent results (which hopefully will
improve with contact force information in near
future )
– Identification of sites other than the PV antral
region

97. Gracias!

99. Termination during persistent AF
HRJ 2010 ahead o
print

101. Mechanism of AF
(from the perspective of an
ablationist)
• AF is initiated by sites/regions of abnormal
automaticity
• AF is maintained by sites/regions with
either abnormal automaticity or short
refractory periods where local reentry
occurs (the cardiac autonomic system may
facilitate or cause some of these areas)

102. AHA/ACC Proposed Clinical Algorithm
(How to maintain sinus, sub-divided by underlying cardiac disease)
Circ 2006;114:700

103. AHA/ACC Proposed Clinical Algorithm
(How to maintain sinus, sub-divided by underlying cardiac disease)
Ablation is an alternative to initiation of amiodarone in all patients
except those with CHF Circ 2006;114:700

104. What should we call the procedure?
• Initial concept: “Focal” ablation
• Anatomic circumferential left atrial (PV) ablation
– (Pappone et al)
• Pulmonary vein antrum isolation
– (Cleveland Clinic)
• Ablation of fractionated electrograms
– (Nadamanee)
• Tailored approach
– (Morady et al)
• Stepwise ablation: “PVI” plus “linear” plus
“defragmentation” plus “linear…
– (Haissaguerre et al)
Probably: “A Fib Ablation”

105. Surgical Ablation: “Maze”
Cox JL. Cox J Thoracic Card Surg 1991;101:406
and J Cardiovasc Electropysiol 2004;2:250

106. Relation Between LA
Appendage and Left PVs
Ho SY, et al
Heart 2001;86:265
3

108. PV-Antrum and SVC Disconnection
SVC
RA LA
MA

109. Pulmonary Vein Antrum

110. Titration of power
Microbubble formation

111. All relevant structures visualized

112. Identifying complications
Thrombus in transseptal sheath
Marchlinski et al

113. Current Approach
PVAI + Defragmentation + Pharmacologic Challenge
PVAI+CFAE: 94% of patients in sinus after redo in 20% and 14% on AAD
Elayi et al. HRJ 2008; 5:1658

114. Isoproterenol Induced CS Tachycardia
1007-1,02

115. Adenosine Induced Atrial fibrillation
1007-1,03

116. Recovery of PV Conduction With Isoproterenol

117. Recovery of PV Conduction With Isoproterenol

118. Pulmonary Vein Antrum Isolation
2007

119. Pulmonary Vein Antrum Isolation
2008

120. Advantages of extensive PVAI
• Objective endpoint
– Practical: no arguments about how far from the
ostium, or about “far-field” versus local, or
about entrance or exit block
– Reproducible results among various operators
Verma et al. HRJ 2007;4:1177

121. Advantages of extensive PVAI
• Objective endpoint
– Practical
– No arguments about:
• how far from the ostium
• “far-field” versus local electrograms
• entrance or exit block
– Reproducible results among various operators

122. Advantages of extensive PVAI
• Targets all triggers
• Acknowledges the reality that there will be
some ablated sites that will regain
conduction
– If a trigger regains, it will probably remain
isolated
– If an ablation site that is part of a “line of block
regains, neighboring sites are probably still
enough to accomplish block

123. Advantages of extensive PVAI
• Achieves complete autonomic denervation
– 20 patients underwent identification of vagal
sites, followed by PVAI by another operator
• Post ablation vagal sites no longer present
– 22 redo patients (another unrelated group)
• Before ablations (in second procedure) 19/22 with
no identifiable vagal sites
Verma et al. HRJ 2007;4:1177

124. The importance of AF termination
(after redo’s in 52%)
O’Neill et al. Eur Heart J 2009 (in print)

125. Haissaguerre: Stepwise approach in Persistents
(Predictors of termination)
Duration in AF Cycle Length in LAA
O’Neill et al. Eur Heart J 2009 (in print)

126. Basic Rules
• Minimize catheter manipulations
– If the catheter is in a place you will ablate, ablate
– If ablation is not having the desired effect, ablate somewhere else
• Recognize impossible manipulations
– Going from left atrial appendage to the pulmonary veins
– Going from one vein to another vein
• Avoid dangerous manipulations
– Never counterclock the circular catheter (always clock it)
– Transseptal sheaths only go from 3 o’clock to 9 o’clock
• (3-4-5-6-7-8-9; 9-8-7-6-5-4-3)