PRIMARY RESULTS OF RF CATHETER ABLATION FOR AF IN VIETNAM HEART INSTITUTE
PHAM QUOC KHANH, MD, PhD. et al Vietnam Heart Institute
Background - Forms of Atrial Fibrillation
- Clinical type of AF:
+ paroxysmal <7days: self-terminating.
+ persistent > 7 days: require intervention
termination.
+ permanent: refractory to cardioversion or
accepted as final rhythm.
-
Background - Prevalence of AFib
General population-based prevalence
ATRIA study
0.95%
2.5% Olmsted County study
Go AS, et al. JAMA (2001) 285: 2370
Miyasaka Y, et al. Circulation (2006) 114: 119
Prevalence of AFib
Olmsted County study
15.9
15.2
16
14.3
F A h t i
14
13.1
11.7
12
10.2
12.1
11.7
10
8.9
11.1
) s n o
w s n o s r e p f o
7.7
10.3
i l l i
8
9.4
6.7
m
(
5.9
8.4
5.1
6
7.5
6.8
6.1
5.6
4 5.1
2
r e b m u n d e t c e j o r P
0
2000
2005
2010
2025
2030
2035
2040
2045
2050
2015 2020
Year
Miyasaka Y, et al. Circulation (2006) 114: 119
Increased Risk of Cardiovascular Events
Death or hospitalization in individuals with CV event(s) after 20 years
100
Men Women
89
)
%
80
66
60
45
40
27
20
( t n e v e V C e n o t s a e l t A
0
AFib No AFib AFib No AFib
Stewart S, et al. Am J Med (2002) 113: 359
Mortality Associated with AFib
Framingham Heart Study, n=5209
80
)
%
60
( p u - w o
Men AFib+ Women AFib+
l l
40
Men AFib- Women AFib-
20
o f g n i r u d y t i l a t r o M
0
0 1 2 3 4 5 6 7 8 9 10
Follow-up (y)
Benjamin EJ, et al. Circulation (1998) 98: 946
Objectives
1. To evaluate the effect of RF catheter ablation
for the treatment of AF
2. To study the applicability of this method
for the clinical practice in Vietnam
METHODS
• 13 consecutive patients (12 male, 1 female) with AF:
( paroxysmal, persistent)
• Mean age:55,9 8,9 ( 46 – 71 )
• Multi-drug-resistant AF
• Serial MSCT before and 3 months after ablation
• 24-hour Holter and patients questionnaire at 3 months
after procedure
Digitex 2400 Angiograph
EP system
angiograph
Carto system
catheter positions
Ablation LIPV
CartoXPTM vs. CartoMergeTM
CARTO XP:
79 pts.
CARTO Merge:
82 pts.
AF ABLATION APPROACH
• Circumferential
approach (WACA)
(Pappone C et al., Circulation 2000; 102(21):2562-4)
• PV-Isolation
(Haissaguerre M et al., N Engl J Med 1998; 339:659–65)
• Additional lines as
needed.
Follow up
• Fu after 1 month (clinical examination, 24h-Holter-
EKG, QOL)
• In hospital Fu at 3, 6 (clinical examination,
Holter/Monitor, Echo, TEE, QOL; Lung scan and MRI as needed)
results and discussions
13 patients: + Age : 46 - 71; Average : 55,9 8,9
+ Sex : M: 12 ; F: 1
+ Biochemical test: normal
+ TEE: no thrombus in cardiac chambers.
+ Blood test: Normal.
+ Coronary angiography:
- 3 : CHD
- 10: Normal
ECHOCARDIOGRAPHY
LA (mm)
36,3 4,3
Aotic (mm)
31 2,8
Dd (mm)
48,3 4,4
Ds (mm)
30,5 3,2
EF (%)
66,4 6,9
MSCT of LA
RSPV (mm)
16,5 3,5
RIPV (mm)
25,1 4,2
LSPV (mm)
16,5 3,4
LIPV (mm)
15,1 3,2
Left atrial volume(cm3)
48,5 11
Arrhythmia
• Paroxysmal: n = 12 (92,3 %)
• Persistent: n = 1 ( 7,7%)
Classification of success
• Complete : 0 recurrences, 0 drug:
• Partial:
0 recurrences, + drug
• failure:
+ recurrences, + drug
• Clinical response: complete + partial success
+ Complete: 12/13 ( 92,3%).
+ Failure: 1/13: ( 7,7% )
Meta-analysis of Catheter Ablation Studies (I)
Paroxysma l AF
SHD
Patients
6-month cure 6-months OK
Ablation method
Linear
443
75%
26%
33%
55%
Focal
508
81%
35%
54%
71%
Isolation
2,187
83%
36%
62%
75%
Circumferential (all)
15,455
68%
37%
64%
74%
2,449
65%
37%
59%
72%
Circumferential (LACA, WACA)
11,132
68%
42%
67%
76%
Circumferential (PVAI)
559
51%
49%
75%
87%
Substrate ablation (CFAE)
TOTAL
23,626
61%
55%
63%
75%
Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the absence of AAD. OK means improvement (fewer episodes, no episodes with previously ineffective AAD). SHD indicates structural heart disease.
Fisher JD, et al. PACE (2006) 29: 523
Meta-analysis of Catheter Ablation Studies (II)
Patients
Paroxysma l AFib
SHD
6-month cure 6-months OK
Condition / Type of AFib
No structural HD
1,026
86%
3%
81%
72%
Structural HD
350
29%
100%
74%
79%
Paroxysmal AFib
3,880
100%
23%
64%
73%
3,741
0%
82%
66%
74%
Persistent – Permanent AFib
Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the absence of AAD. OK means improvement (fewer episodes, no episodes with previously ineffective AAD). SHD indicates structural heart disease.
Fisher JD, et al. PACE (2006) 29: 523
Worldwide Survey on Efficacy and Safety of Catheter Ablation for AFib
• Total success rate: 76%
• Of 8745 patients:
–27.3% required 1 procedure
–52.0% asymptomatic without drugs
–23.9% asymptomatic with an AAD within <1 yr
• Highly variable outcome between centres
Cappato R, et al. Circulation (2005) 111: 1100
Results from Pioneering Centres
• Total success rate: 75-88%
Study
Year
Follow-up
Age, y
Tool(s)
End point
Parox, %
SHD, %
AF Free (Off drugs), %
Follow-up, d
2004 41 63 ± 9 100 NA 76 178 Ouyang et al CART O PV Isolation
2004 70 53 ± 8 NA 43 Fluoro 79 210 Haïssaguerre et al PV Isolation
2004 40 55 ± 10 80 13 75 330 Mansour et al CART O PV Isolation
2003 259 54 ± 11 51 21 ICE 87 347 Marrouche et al PV Isolation
2003 40 54 ± 11 100 3 88 365 Oral et al CART O EGM Reduction
2003 589 65 ± 9 69 6 79 861 Pappone et al CART O EGM Reduction
Verma A & Natale A Circulation (2005) 112: 1214
Total 1039 81.0
COMPLICATION RATE (n= 13)
Complications
Rate
Transient ischemic attack
0%
Stroke permanent
0%
Tamonade/ perforation
1 /13 (7,7%)
Severe vascular access complication 0%
Complication rates
Consuming time and fluoroscopy time in procedures
Fluoroscopy
Cosuming time(minutes)
time (minutes)
Patients (n=13) 56,5 18,4
266,6 62,8
Case report
• 61-year-old gentleman
• Smoker but quit several years
ago.
• No hypertension, no diabetes
• Symptomatic paroxysmal AF not responded to Amiodarone (300 mg/day)
• Blood test: Normal (Creatinin: 110 mcmol/L)
• Chest X-ray: Normal cardiac silhouette,
clear lungs
• TTE and TEE: Dd 51 mm; EF 71%, very mild
MR, no thrombus in LA
• Coronary MSCT (12/2006): < 50% narrowing
of proximal RCA
MSCT of LA and PVs LA dimensions are 54 mm x 26 mm x 55 mm (LR x AP x SI, respectively). Estimated LA volume: 41 ml
LSPV: 18,3 mm; LIPV: 17 mm; RSPV: 18,7 mm; RIPV: 18,1 mm
A
PV
PV Antrum Isolation
RAO
LAO
conclusion
1. RF catheter ablation can cure paroxysmal and
persistent AF with high successfull rate
2. Further
training and development of the to needed program are this modality of
electrophysiology improve the availability of treatment for AF in Vietnam.
THANK YOU FOR YOUR ATTENTION
