docFire or Ice Radiofrequency or cryo ablation
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Fire or Ice Radiofrequency or cryo ablation
IDSS Tel Aviv 2015 Fire or Ice Radiofrequency or cryo ablation Gerhard Hindricks University of Leipzig - Heart Center Dept. of Electrophysiology Presenter Disclosure Information Gerhard Hindricks/Department of Electrophysiology has received scientific grants and research grants through the University Leipzig / Heart Center from German Heart Foundation, ProCordis Foundation, St. Jude Medical, Biotronik, Boston Scientific, and Volkswagen Foundation. No personal financial relation to disclose. Fire or Ice for AF ablation Current role of point-by-point RF ablation • point-by-point RF ablation is standard of care for AV-nodal reentrant tachycardia tachycardia due to accessory pathway ectopic atrial tachycardia typical and atypical atrial flutter ventricular arrhythmia • RF ablation is the most frequent technology for catheter ablation of atrial fibrillation Fire or Ice for AF ablation PV-devices and alternative energy sources Cryo-Balloon Cardiofocus Mesh-Ablator Ablation Frontiers ? highly complex, no benefits 10% PVI rate 40% silent stroke HIFU complications incl. death Fire or Ice for AF ablation PV ablation devices and energy: What counts ? • Conceptual aspects and ablation strategies • Procedural aspects (duration, fluoro time ...) • Safety and Efficacy • Development of future technologies Fire or Ice for AF ablation PV ablation devices and energy: What counts ? • Conceptual aspects and ablation strategies • Procedural aspects (duration, fluoro time ...) • Safety and Efficacy • Development of future technologies Fire or Ice for AF ablation PV devices: One size fits all ? Fire or Ice for AF ablation PV devices: Level of PV isolation • 14 pat. with AF ablation devices (cryo, laser, HIFU) • 3D voltage map before and after ablation Reddy et al.; Heart Rhythm 2008 • level of PV isolation was – distal within the PV antrum (segmental position) – AF substrate within the PV antrum untreated Fire or Ice for AF ablation PV ablation devices and energy: What counts ? • Conceptual aspects and ablation strategies • Procedural aspects (duration, fluoro time ...) • Safety and Efficacy • Development of future technologies Fire or Ice for AF ablation Ablation strategies to approach AF: Changing paradigms • • • • • • • PV-isolation activation maps entrainment maps substrate maps CFAE maps rotor maps HD maps • • • • • • • distal PVI - no - no - no - no - no - no Fire or Ice for AF ablation New technologies will furhter improve RF ablation Fire or Ice for AF ablation Carto 1 Fire or Ice for AF ablation Substrate-based AF ablation strategies Rolf S et al.; Circulation AE 2014, in press Fire or Ice for AF ablation Substrate-based AF ablation strategies Rolf S et al.; Circulation AE 2014, in press Fire or Ice for AF ablation Substrate-based AF ablation strategies Rolf S et al.; Circulation AE 2014, in press Fire or Ice for AF ablation MRT around fossa ovalis Fire or Ice for AF ablation MRT around fossa ovalis Fire or Ice for AF ablation MRT around fossa ovalis Fire or Ice for AF ablation Assumption one: • Cryo balloon ablation ablation is as effective as radiofrequency ablation...... • This has never been shown by means of a prospective randomized study performed in centers that are experienced in the use of point-by-point RF ablation......even not for paroxysmal atrial fibrillation. For substrate driven AF, cryo ablation is absolutely ineffective. Fire or Ice for AF ablation Non-randomized comparison of Cryo vs RF-ablation Mubnai G et al., Am J Cardiol 2014 Fire or Ice for AF ablation Randomized comparison of Cryo vs RF re-ablations Pokushalov I et al., JCE 2013 Fire or Ice for AF ablation Randomized comparison of Cryo vs RF re-ablations Pokushalov I et al., JCE 2013 Fire or Ice for AF ablation Assumption two: • Cryo balloon ablation ablation is as safe or even safer as compared radiofrequency ablation...... • No data support this assumption. Reported data indicate that complication rates may be higher as compared RF ablation. Let´s look to the data..... Fire or Ice for AF ablation Cryo ablation and complicatons: the reality Packer et al., JACC 2013 Fire or Ice for AF ablation Cryo ablation and complicatons: the reality Schmidt B et al., JCE 2014 Fire or Ice for AF ablation Assumption three: • Atrio-esophageal fistula does not occur after cryo ablation. • Unfortunately this is not true. Severe esophageal injury as well as perforation with atrio-esophagal fistula has been reported. Fire or Ice for AF ablation Assumption four: • Cryo balloon ablation ablation is faster than radiofrequency ablation...... n= 2850 905 Schmidt B et al., JCE 2014 Fire or Ice for AF ablation Cryo-energy versus RF energy • Prospective randomized studies have compared the efficacy and safety of cryo-energy and radiofrequency energy in the setting of - typical atrial flutter (3 studies) - AV-nodal reentrant tachycardia (2 studies) • all studies confirmed superiority of radiofrequency energy as compared to cryo energy. • Key finding: higher recurrence rate with cryo, same complication rate! Fire or Ice for AF ablation Cryoenergy versus RF energy Fire or Ice for AF ablation Catheter ablation at Heart Center Leipzig Fire or Ice for AF ablation Cryoballoon versus RF energy • Cryo RF all types of AF no yes individualized ablation no yes antral ablation no yes mapping capabilities no yes concomitant flutter ablation right atrium left atrium no no yes yes non fluoroscopic navigation no yes Fire or Ice for AF ablation Workflow for FIRM ablation Sommer et al.; JCE 2015 LA map – geometry and voltage MRI-guided AF ablation Fire or Ice for AF ablation Should cryo ablation be first line treatment for PAF? • Why did cryo ablation not evolve as a key ablation strategy in true high volume ablation centers? • Because it is less effective, takes longer, and is more expensive as compared to RF ablation. • Point-by-point RF ablation does • enable individualized treatment of anatomy and substrate • enable safer and more efficacious lesion deployment • enable innovative 3D/4D catheter navigation • lead to procedures with • with procedure duration < 120 min • with fluoroscopy time < 10 min • with clinical efficacy > 80% in PAF
