Arrhythmias and Clinical EP Atrial Fibrillation: Contemporary Management Strategies

Arrhythmias and Clinical EP Atrial Fibrillation: Contemporary Management Strategies

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Description: I receive royalties for work licensed through Mayo Clinic to a privately held company for contributions related to the use of nerve signal modulation to treat central, autonomic and peripheral nervous system disorders, including pain. Mayo Clinic receives royalties and owns equity in this company. The company does not currently license or manufacture any drug or device in the medical field.

 
Author: Samuel Asirvatham MD, Enrique Melgarejo Rojas MD  | Visits: 218 | Page Views: 470
Domain:  Medicine Category: Therapy 
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Contents:
Arrhythmias and Clinical EP
Atrial Fibrillation:
Contemporary Management Strategies
Samuel Asirvatham, MD & Enrique Melgarejo Rojas, MD

Saturday, June 24, 2017
2:40 to 3:25 p.m.

AF Ablation and
The Impact on Clinical Practice

Samuel J. Asirvatham, M.D.
Mayo Clinic – Rochester

©2012 MFMER | 3200268v1(2003)-3

Disclosures
Relevant financial relationship(s) with industry
•I receive royalties for work licensed through Mayo Clinic to a privately held company for contributions
related to the use of nerve signal modulation to treat central, autonomic and peripheral nervous
system disorders, including pain. Mayo Clinic receives royalties and owns equity in this company. The
company does not currently license or manufacture any drug or device in the medical field.

•Co-patent holder for technique to minimize coagulum formation during radiofrequency ablation
•Products or techniques related to the above disclosures are not being discussed in this presentation
•Pertains to inventions/startup companies that include Nevro, Aegis and the Phoenix Corp

Honoraria/Speakers
•Abiomed, Atricure, Biotronik, Blackwell Futura, Boston Scientific, Medtronic, Medtelligence
Sanofi-aventis, Spectranetics, St. Jude, Zoll

Consulting
•Aegis, ATP, Nevro, Sanovas, Sorin Medical, FocusStart

Impact of AFFIRM and Other
Trials on Clinical Management
Maintenance of
sinus rhythm

Rate control

• Safe
• Effective
• Preferred method

• Symptom driven

for majority

• Optimal control cannot
be determined at rest

Atrial Fibrillation: Rate Control
Atrial fibrillation

Medications






Ca++ blockers
Beta blockers
Digitalis
AVN ablation

AV junction ablation

• 99%+ success rate
• Regular and controlled HRPPM required

• Freedom from medications
For both: AF persists in the atria

• Stroke prophylaxis needed
CP1077727-8

47yrs female with paroxysmal palpitations
and fatigue

CP1048303-3

Mechanisms of AF
Persistent

• All atrial
myocardium

• Underlying
disease

• Anatomical/
electrical

• Remodeling
Substrate

Paroxysmal

• Autonomic
modulation

• Atrial
stretch
channels

• Other
tachycardia

Trigger

Mechanisms of AF
Extracardiac
factors:
Hypertension
Obesity
Sleep apnea
Hyperthyroidism
Alcohol/drugs

Atrial Structural
Abnormalities:
Fibrosis
Dilation
Ischemia
Infiltration
Hypertrophy

AF

Atrial tachycardia
remodeling

Genetic Variants:
Channelopathy
Cardiomyopathy

Inflammation
Oxidative stress

RAAS activation

Atrial Structural Abnormalities:
Heterogeneity
Conduction
Action potential
duration/refractoriness
Automaticity
Abnormal intracellular Ca++ handling

January et al: AHA/ACC/HRS, 2014

Autonomic
nervous system
activation

Asirvatham,Packer JCE ‘98

AFIB Terminates Tachycardia Continues

CP1282493-4

PV Potentials Modification and
Elimination
After Abl 1 After Abl 6

End Abl

HRA
PV 1, 2
PV 2, 3
PV 3, 4
PV 4, 5
PV 5, 6
PV 6, 7
PV 7, 8
PV 8, 9
PV 9, 10
PV 10, 1
ABL dis
CP1034394-2

Lasso in SVC: ERAF
AZYGOUS
OSTIUM

ECTOPY FROM LOM

Anatomy of Complications of Atrial Fibrillation Ablation:

Ablation, Understanding the Anatomy

• Pulmonary vein
stenosis
• Coronary arterial
damage
• Pulmonary artery
damage
• Aorta
• Esophagus

• Phrenic nerve
• Mitral valve

• Thrombus formation
• Sequela of autonomic
ganglia ablation

Anatomy of Complications of Atrial Fibrillation Ablation:

Esophagus
• Immediate posterior relation of the left
atrium/posterior wall of pulmonary vein
• Posterior relation of the mid coronary sinus
• Esophageal arterial supply, mostly on the anterior
wall
• Pericardial esophageal arteriovenous drainage
• Azygous vein and posterior mediastinial tissue
anchors esophagus limiting lateral mobility

Atrio-Esophageal fistula

Aortic
Arch

Asc
Aorta

LB

RPA

LA

Eso

Left Lateral View

Desc
Thor
Aorta

External Cardiac Anatomy
Pericardium

Heart
Removed

Oblique Sinus (Anterior View)

Esophageal-LA interface Identification

Complications

Non-invasive Assessment of Tissue
Heating During Cardiac Radiofrequency
Ablation Using MRI Thermography

Bragg Peak
X-ray beam

Bert et al. Medical Phys. 2012 Apr;39(4):1716-27

Contouring and Carbon Ion Beam Treatment
Planning Outcome
Transverse view

12C

12C

Sagittal view

Coronal view

Treatment planning: contoured volume dissected into
its voxels, optimal amount of accelerator energies,
scanning in x- and y- dimension are determined
Target volume outcomes:
AV node contour
(cm3)

Treated volume
(cm3)

Volume
Coverage

1.0 ± 0.3

25 ± 2

100%

3016338

WACA Contouring Outcome
Lesion Dimension = 6x6 mm

WACA-ring metrics (0% RR)

Transverse

Dimension

Mean ±SD (mm)



33.8 ± 5.8

LPVs ant.-post.

28.4 ± 4.3



LPVs sup.-inf.

29.1 ± 5.7

Sagittal

Coronal
RPVs
WACA ring

RPVs sup.-inf.



Esophagus

34.6 ±4.2



RPVs
WACA ring

RPVs ant.-post.

LSPV
RPVs
WACA ring

LA
wall
Esophagus

3016338

Rationale For AF Ablation
Wide
area
circum
Complex
fractionated,
Egms / DFs

Perpetuators
Rotors

Anatomy

PV
isolation

Triggers/
Drivers

Physiology

Ultra
wide area
lasso/ICE

Fibrillatory
Conduction

Ganglion
plexus

CP1203524-4

Four Stages of Left Atrial Tissue Fibrosis
Based on 3D Delayed Enhancement MRI Scans

Marrouche, et al. JAMA 2014:498

Singularlity Points Revealed
by Phase Plane Analysis

Pandit/Jalife. Circ Res 2013:849

Rotor Locations

Haissaguerre et al 2013

Distribution of Atrial Ganglionated Plexuses

Armour et al: Anat Rec 24:289, 1997

CP1182989-7

CP1282493-8

Restoration of Atrial Mechanical Function After
the Surgical Maze Procedure
Outcome

LA Function

1.5

A Wave
Velocity
P