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CONTACT FORCE-GUIDED VERSUS CONTACT FORCE-BLINDED CATHETER ABLATION OF TYPICAL ATRIAL FLUTTER: A PROSPECTIVE STUDY
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Canadian Cardiovascular Society (CCS) Oral ATRIAL FIBRILLATION ABLATION Monday, October 26, 2015 422 PROGRESSION OF PAROXYSMAL TO PERSISTENT AF IN PATIENTS AWAITING AF ABLATION S Kochhaeuser, DG Dechering, K Trough, P Hache, T Haig-Carter, Y Khaykin, Z Wulffhart, A Pantano, B Tsang, L Eckardt, A Verma Newmarket, Ontario
Atrial fibrillation (AF) is a progressive disease for which ablation has become an important treatment option. Success rates have been shown to be significantly higher while AF has not yet progressed to persistent. In a general AF-population the HATCH-score has been proposed to predict the risk of progression to persistent AF. However, little is known about predictors of progression in patients awaiting AF ablation. METHODS/RESULTS: We performed a retrospective, single centre investigation of patients with paroxysmal AF at the time they were placed onto our AF ablation waiting list and evaluated possible risk factors for the progression of AF until the time of the actual ablation of 564 patients (median age 60.4 (15.1) years, 194 (34.4%) female) 60 (11%) progressed from paroxysmal to persistent AF during a median waiting time of 291 (244.3) days. In patients that progressed to persistent AF, ablation took significantly longer (18099 min vs. 15785min; p 0.009), had a tendency to require longer RFenergy delivery (68.940 min vs. 61.844 min; p 0.052) and was associated with a higher rate of recurrence (53.3% vs. 39.1%; p<0.001). Patients that did progress to persistent AF had tied significantly more antiarrhythmic drugs (1 (2) vs. 1(1); p 0,048) and more frequently had a history of amiodaron treatment (21.7% vs. 11.9%; p 0.03). The previously proposed HATCH-score was only a poor predictor of AF progression (AUC 0.54). Furthermore, none of the individual HATCH-score parameters was a significantly predicted the progression of AF in our population. However, a left atrial (LA) diameter of more than 45mm (OR 3.46, p< 0.001) and heart failure (OR 3.11, p 0.036) were strong and independent predictors of AF progression in multivariable analysis. CONCLUSION: Patients with an increased LA-diameter or heart failure have a significantly increased risk to progress to persistent AF. If ablation is considered in such a patient it should be conducted as soon as possible to prevent progression to persistent AF. OBJECTIVE:
Canadian Journal of Cardiology Volume 31 2015 BACKGROUND: Catheter-tissue contact is essential for effective lesion formation hence there is a growing usage of contact force (CF) technology in atrial fibrillation (AF) ablation. Data regarding the efficacy and safety of CF for catheter ablation of AF are limited. We conducted a metaanalysis to assess the impact of CF on clinical outcomes and procedural parameters in comparison to conventional catheter (CC) for AF ablation. METHODS: An electronic search was performed using Cochrane central database, PubMed, Embase, and Web of Knowledge. References were searched manually. Outcomes of interest were: recurrence rate, major complications (including major bleeding, ischemic stroke, embolism or transient ischemic attack), total procedure, and fluoroscopic times. Continuous variables were reported as standardized difference in means (SDM); odds ratios (OR) were reported for dichotomous variables. RESULTS: Eleven studies (2 randomized controlled studies and 9 cohorts) involving 1428 adult patients (855 patients (60%) with paroxysmal AF) were identified. CF was deployed in 552 patients. The range of CF used was between 2 and 60 grams-force (Mean CF 175 g). Follow up period ranged between 10- 53 weeks. In comparison between CF and CC groups, a lower recurrence rate was noted with CF (35% vs. 46%, OR 0.62 (95% confidence interval [CI] 0.45; 0.86), P¼0.004). No significant heterogeneity was noted for the comparison (I2¼23%, P¼0.23). Shorter procedure and fluoroscopic times were achieved with CF (156 vs. 173 mins, SDM -0.85 (95% CI -1.48; -0.21), P¼0.009; 28 vs. 36 mins, SDM -0.94 (95% CI.66; -0.21), P¼0.01, respectively). Major complication rate was higher numerically in the CC group but this did not reach statistical significance (1.33% vs. 1.94%, OR 0.71 (95% CI 0.29; 1.73), P¼ 0.45). CONCLUSION: The use of CF technology results in a significant reduction of AF recurrence rate after AF ablation in comparison to CC group. CF technology is able to significantly reduce procedure and fluoroscopic times without compromising complication rate.
424 CONTACT FORCE-GUIDED VERSUS CONTACT FORCE-BLINDED CATHETER ABLATION OF TYPICAL ATRIAL FLUTTER: A PROSPECTIVE STUDY S Venier, J Andrade, M Dubuc, K Dyrda, P Guerra, P Khairy, B Mondésert, L Rivard, D Roy, M Talajic, B Thibault, N Malliet, S Gomes, R Tadros, L Macle Montréal, Québec
423 IMPACT OF CONTACT FORCE TECHNOLOGY ON ATRIAL FIBRILLATION ABLATION: A META-ANALYSIS M Shurrab, L Di Biase, D Briceno, A Kaoutskaia, D Newman, I Lashevsky, H Nakagawa, E Crystal Nablus, Palestine
BACKGROUND:
Whether contact force (CF) sensing ablation technology is useful for CavoTricuspid Isthmus (CTI) ablation is unknown. We prospectively evaluated procedural parameters and outcomes of CF-Guided versus CFBlinded CTI ablation for atrial flutter in our academic institution.
Abstracts METHODS:
Sixty-six consecutive patients (mean age 6212 yrs) undergoing CTI ablation for atrial flutter were prospectively enrolled to CF-Blinded (n¼30) or CF-Guided (n¼36) groups. A ThermoCool SmartTouch catheter (power 25-35 W) was used in all. The procedural endpoint was bidirectional isthmus block following a 20-min waiting period. In the CFGuided group, CF target range was 10-25g whereas in the CF-Blinded group, the operator was blinded to CF data. Posthoc analyses of CF parameters were performed to evaluate the optimal CF. RESULTS: The procedural endpoint was achieved in all patients. No major complications were seen. Total radiofrequency (RF) energy delivery required to achieve bidirectional block was significantly lower in the CFGuided group compared to the CF-Blinded group (15.08.7 min vs 19.212.4 min, p¼0.01). Fluoroscopy duration was 8.66.2 min in the CF-Guided group vs 15.57.4 min in the CF-Blinded group (p¼0.02). Procedure duration was 8342 min in the CF-Guided group vs to 9437 min in the CF-Blinded group (p¼0.60). Posthoc analysis of all ablation procedures showed a significant correlation between CF and total RF delivery time (r¼-50; p¼0.0001). CONCLUSION: CTI ablation for atrial flutter using CF-Guided is associated with a significant reduction in RF delivery and fluoroscopy times. A significant correlation between CF and total RF delivery time was observed.
425 PHASED ARRAY PULMONARY VEIN ISOLATION VS RADIOFREQUENCY CATHETER ABLATION FOR ATRIAL FIBRILLATION: A NON-INFERIORITY SYSTEMATIC REVIEW AND META-ANALYSIS AG Carrizo, P Lamelas, N Pinilla Echeverri, P Gal, AG Elvan, CA Morillo Hamilton, Ontario BACKGROUND:
Pulmonary vein isolation using radiofrequency (RF) catheter ablation is the cornerstone for atrial fibrillation
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(AF) ablation. Newer RF energy delivery methods have become recently available. However, limited information is available regarding the non-inferiority efficacy and safety boundaries of duty-phased radiofrequency AF catheter ablation. OBJECTIVE: To conduct a meta-analysis of randomized clinical trials (RCTs) comparing the efficacy and safety of duty-cycled RF ablation using the circular multi-electrode catheter (MEA) to conventional RF catheter pulmonary vein isolation (cPVI) in patients with primarily paroxysmal/ persistant AF (PAF). METHODS: Two independent investigators searched MEDLINE, EMBASE, CENTRAL and clinicaltrials.gov databases for RCTs in patients with PAF that compared MEA vs cPVI (February 2015). The primary outcome was to determine whether MEA was non-inferior to cPVI, regarding Atrial tachyarrhythmia (AT) recurrence. We selected an absolute risk difference of 5% with a two sided 5% alpha error as threshold for non-inferiority. Procedural time, fluoroscopy time and potential technique-related adverse events (cardiac tamponade, vascular complications, pulmonary vein stenosis and stroke) were evaluated as well. Fixed effects were used unless there was significant heterogeneity (I2 > 50%). Cochrane tool for risk of bias was used for study quality assessment and GRADE for outcome specific quality across studies. RESULTS: Four RCTs were reviewed for an overall of 830 patients included of which, 709 (85.4%) had paroxysmal AF and 121(14.6%) persistent AF. The upper 95% confidence interval absolute risk limit of any AT recurrence in the MEA group was 3%, meeting criteria for non-inferiority (risk difference -3%; 95% CI -10% - 3%; relative risk 0.92; 95% CI 0.92 - 1.09; I2¼ 0%) Procedural time was significantly reduced during MEA procedures (weighted mean difference -54.3 minutes; 95% CI -83.7 - 25.3; p< 0.001; I2¼ 95%). Non-significant reductions in fluoroscopy time (weighted mean difference -6.42 minutes; 95% CI -13.8 - 0.96; p ¼ 0.09; I2¼ 95%) and adverse events (RR 0.47; 95% CI 0.21 1.08; p¼ 0.07; I2¼ 0%) were detected during MEA procedures. CONCLUSION: In patients with primarily PAF, duty cycled pulmonary vein isolation was non-inferior and appears to be superior to conventional RF ablation of PAF regarding freedom from AF. Multi-electrode ablation is associated with a favorable safety profile, and is comparable to cPVI. Further larger RCTs are needed to determine which technology is associated with the lowest recurrence and adverse event rate.
426 PREDICTORS OF ARRHYTHMIA RECURRENCE FOLLOWING PULMONARY VEIN ANTRUM ISOLATION P Alipour, Y Khaykin, M Pirbaglou, A Pantano, P Ritvo, P Brown, L Chun, S Olesovsky, A Verma Newmarket, Ontario
Canadian Cardiovascular Society (CCS) Oral ATRIAL FIBRILLATION ABLATION Monday, October 26, 2015 422 PROGRESSION OF PAROXYSMAL TO PERSISTENT AF IN PATIENTS AWAITING AF ABLATION S Kochhaeuser, DG Dechering, K Trough, P Hache, T Haig-Carter, Y Khaykin, Z Wulffhart, A Pantano, B Tsang, L Eckardt, A Verma Newmarket, Ontario
Atrial fibrillation (AF) is a progressive disease for which ablation has become an important treatment option. Success rates have been shown to be significantly higher while AF has not yet progressed to persistent. In a general AF-population the HATCH-score has been proposed to predict the risk of progression to persistent AF. However, little is known about predictors of progression in patients awaiting AF ablation. METHODS/RESULTS: We performed a retrospective, single centre investigation of patients with paroxysmal AF at the time they were placed onto our AF ablation waiting list and evaluated possible risk factors for the progression of AF until the time of the actual ablation of 564 patients (median age 60.4 (15.1) years, 194 (34.4%) female) 60 (11%) progressed from paroxysmal to persistent AF during a median waiting time of 291 (244.3) days. In patients that progressed to persistent AF, ablation took significantly longer (18099 min vs. 15785min; p 0.009), had a tendency to require longer RFenergy delivery (68.940 min vs. 61.844 min; p 0.052) and was associated with a higher rate of recurrence (53.3% vs. 39.1%; p<0.001). Patients that did progress to persistent AF had tied significantly more antiarrhythmic drugs (1 (2) vs. 1(1); p 0,048) and more frequently had a history of amiodaron treatment (21.7% vs. 11.9%; p 0.03). The previously proposed HATCH-score was only a poor predictor of AF progression (AUC 0.54). Furthermore, none of the individual HATCH-score parameters was a significantly predicted the progression of AF in our population. However, a left atrial (LA) diameter of more than 45mm (OR 3.46, p< 0.001) and heart failure (OR 3.11, p 0.036) were strong and independent predictors of AF progression in multivariable analysis. CONCLUSION: Patients with an increased LA-diameter or heart failure have a significantly increased risk to progress to persistent AF. If ablation is considered in such a patient it should be conducted as soon as possible to prevent progression to persistent AF. OBJECTIVE:
Canadian Journal of Cardiology Volume 31 2015 BACKGROUND: Catheter-tissue contact is essential for effective lesion formation hence there is a growing usage of contact force (CF) technology in atrial fibrillation (AF) ablation. Data regarding the efficacy and safety of CF for catheter ablation of AF are limited. We conducted a metaanalysis to assess the impact of CF on clinical outcomes and procedural parameters in comparison to conventional catheter (CC) for AF ablation. METHODS: An electronic search was performed using Cochrane central database, PubMed, Embase, and Web of Knowledge. References were searched manually. Outcomes of interest were: recurrence rate, major complications (including major bleeding, ischemic stroke, embolism or transient ischemic attack), total procedure, and fluoroscopic times. Continuous variables were reported as standardized difference in means (SDM); odds ratios (OR) were reported for dichotomous variables. RESULTS: Eleven studies (2 randomized controlled studies and 9 cohorts) involving 1428 adult patients (855 patients (60%) with paroxysmal AF) were identified. CF was deployed in 552 patients. The range of CF used was between 2 and 60 grams-force (Mean CF 175 g). Follow up period ranged between 10- 53 weeks. In comparison between CF and CC groups, a lower recurrence rate was noted with CF (35% vs. 46%, OR 0.62 (95% confidence interval [CI] 0.45; 0.86), P¼0.004). No significant heterogeneity was noted for the comparison (I2¼23%, P¼0.23). Shorter procedure and fluoroscopic times were achieved with CF (156 vs. 173 mins, SDM -0.85 (95% CI -1.48; -0.21), P¼0.009; 28 vs. 36 mins, SDM -0.94 (95% CI.66; -0.21), P¼0.01, respectively). Major complication rate was higher numerically in the CC group but this did not reach statistical significance (1.33% vs. 1.94%, OR 0.71 (95% CI 0.29; 1.73), P¼ 0.45). CONCLUSION: The use of CF technology results in a significant reduction of AF recurrence rate after AF ablation in comparison to CC group. CF technology is able to significantly reduce procedure and fluoroscopic times without compromising complication rate.
424 CONTACT FORCE-GUIDED VERSUS CONTACT FORCE-BLINDED CATHETER ABLATION OF TYPICAL ATRIAL FLUTTER: A PROSPECTIVE STUDY S Venier, J Andrade, M Dubuc, K Dyrda, P Guerra, P Khairy, B Mondésert, L Rivard, D Roy, M Talajic, B Thibault, N Malliet, S Gomes, R Tadros, L Macle Montréal, Québec
423 IMPACT OF CONTACT FORCE TECHNOLOGY ON ATRIAL FIBRILLATION ABLATION: A META-ANALYSIS M Shurrab, L Di Biase, D Briceno, A Kaoutskaia, D Newman, I Lashevsky, H Nakagawa, E Crystal Nablus, Palestine
BACKGROUND:
Whether contact force (CF) sensing ablation technology is useful for CavoTricuspid Isthmus (CTI) ablation is unknown. We prospectively evaluated procedural parameters and outcomes of CF-Guided versus CFBlinded CTI ablation for atrial flutter in our academic institution.
Abstracts METHODS:
Sixty-six consecutive patients (mean age 6212 yrs) undergoing CTI ablation for atrial flutter were prospectively enrolled to CF-Blinded (n¼30) or CF-Guided (n¼36) groups. A ThermoCool SmartTouch catheter (power 25-35 W) was used in all. The procedural endpoint was bidirectional isthmus block following a 20-min waiting period. In the CFGuided group, CF target range was 10-25g whereas in the CF-Blinded group, the operator was blinded to CF data. Posthoc analyses of CF parameters were performed to evaluate the optimal CF. RESULTS: The procedural endpoint was achieved in all patients. No major complications were seen. Total radiofrequency (RF) energy delivery required to achieve bidirectional block was significantly lower in the CFGuided group compared to the CF-Blinded group (15.08.7 min vs 19.212.4 min, p¼0.01). Fluoroscopy duration was 8.66.2 min in the CF-Guided group vs 15.57.4 min in the CF-Blinded group (p¼0.02). Procedure duration was 8342 min in the CF-Guided group vs to 9437 min in the CF-Blinded group (p¼0.60). Posthoc analysis of all ablation procedures showed a significant correlation between CF and total RF delivery time (r¼-50; p¼0.0001). CONCLUSION: CTI ablation for atrial flutter using CF-Guided is associated with a significant reduction in RF delivery and fluoroscopy times. A significant correlation between CF and total RF delivery time was observed.
425 PHASED ARRAY PULMONARY VEIN ISOLATION VS RADIOFREQUENCY CATHETER ABLATION FOR ATRIAL FIBRILLATION: A NON-INFERIORITY SYSTEMATIC REVIEW AND META-ANALYSIS AG Carrizo, P Lamelas, N Pinilla Echeverri, P Gal, AG Elvan, CA Morillo Hamilton, Ontario BACKGROUND:
Pulmonary vein isolation using radiofrequency (RF) catheter ablation is the cornerstone for atrial fibrillation
S223
(AF) ablation. Newer RF energy delivery methods have become recently available. However, limited information is available regarding the non-inferiority efficacy and safety boundaries of duty-phased radiofrequency AF catheter ablation. OBJECTIVE: To conduct a meta-analysis of randomized clinical trials (RCTs) comparing the efficacy and safety of duty-cycled RF ablation using the circular multi-electrode catheter (MEA) to conventional RF catheter pulmonary vein isolation (cPVI) in patients with primarily paroxysmal/ persistant AF (PAF). METHODS: Two independent investigators searched MEDLINE, EMBASE, CENTRAL and clinicaltrials.gov databases for RCTs in patients with PAF that compared MEA vs cPVI (February 2015). The primary outcome was to determine whether MEA was non-inferior to cPVI, regarding Atrial tachyarrhythmia (AT) recurrence. We selected an absolute risk difference of 5% with a two sided 5% alpha error as threshold for non-inferiority. Procedural time, fluoroscopy time and potential technique-related adverse events (cardiac tamponade, vascular complications, pulmonary vein stenosis and stroke) were evaluated as well. Fixed effects were used unless there was significant heterogeneity (I2 > 50%). Cochrane tool for risk of bias was used for study quality assessment and GRADE for outcome specific quality across studies. RESULTS: Four RCTs were reviewed for an overall of 830 patients included of which, 709 (85.4%) had paroxysmal AF and 121(14.6%) persistent AF. The upper 95% confidence interval absolute risk limit of any AT recurrence in the MEA group was 3%, meeting criteria for non-inferiority (risk difference -3%; 95% CI -10% - 3%; relative risk 0.92; 95% CI 0.92 - 1.09; I2¼ 0%) Procedural time was significantly reduced during MEA procedures (weighted mean difference -54.3 minutes; 95% CI -83.7 - 25.3; p< 0.001; I2¼ 95%). Non-significant reductions in fluoroscopy time (weighted mean difference -6.42 minutes; 95% CI -13.8 - 0.96; p ¼ 0.09; I2¼ 95%) and adverse events (RR 0.47; 95% CI 0.21 1.08; p¼ 0.07; I2¼ 0%) were detected during MEA procedures. CONCLUSION: In patients with primarily PAF, duty cycled pulmonary vein isolation was non-inferior and appears to be superior to conventional RF ablation of PAF regarding freedom from AF. Multi-electrode ablation is associated with a favorable safety profile, and is comparable to cPVI. Further larger RCTs are needed to determine which technology is associated with the lowest recurrence and adverse event rate.
426 PREDICTORS OF ARRHYTHMIA RECURRENCE FOLLOWING PULMONARY VEIN ANTRUM ISOLATION P Alipour, Y Khaykin, M Pirbaglou, A Pantano, P Ritvo, P Brown, L Chun, S Olesovsky, A Verma Newmarket, Ontario