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Atrial Fibrillation: Unanswered Questions and Future Directions Atrial Fibrillation: Unanswered Questions and Future Directions VivekY.Reddy, MD KEYWORDS Atrial fibrillation Ablation New technology Just over a decade ago, Haissaguerre and The poor efficacy of ablating AF triggers stems colleagues1 provided the seminal demonstration from the difficulty in inducing these initiating foci of the role of pulmonary vein (PV) triggers in the during any given electrophysiology ablation proce- pathogenesis of atrial fibrillation (AF) and the dure. During these early procedures, electrophys- potential therapeutic role of catheter ablation to iologists often spent many hours with multiple treat patients who have paroxysmal AF. This initial catheters positioned in various PVs waiting for observation ushered in the modern era of catheter AF-initiating premature ectopic depolarizations to ablation to treat patients who have AF, and occur. Beyond this prolonged case duration, these tremendous progress has been made in under- procedures were often followed by clinical recur- standing its pathogenesis and the catheter rences related to additional initiating foci at sites approaches to treating this rhythm. Although the completely unelicited during the index ablation current state of AF catheter ablation is well de- procedure. By empirically ablating around the PV scribed elsewhere in this issue, this article reflects ostia to isolate all veins electrically, however, one on some of the major unanswered questions about could ensure that no PV triggers would affect the AF management, and the future technologic and left atrium, proper. investigational directions being explored in the Empiric PV isolation also has one very important nonpharmacologic management of AF. safety advantage compared with focal ablation of AF triggers. Briefly, ablation deep within the PVs CATHETER ABLATION OF PAROXYSMAL can result in PV stenosis, a dreaded complication ATRIAL FIBRILLATION that has a strong tendency to recur as restenosis after balloon venoplasty. If the circumferential iso- After the initial demonstration that the PVs harbor lating ablation lesion set is placed outside the PVs, most of the triggers for paroxysmal AF, the however, the risk for stenosis is minimized. approach to catheter ablation in this patient popu- Based on the improved efficacy and safety of lation evolved considerably. The initial approaches empiric PV isolation, several approaches have centered on inducing and identifying the specific been forwarded to achieve this electrophysiologic AF triggering sites within the PVs and targeting end point. These approaches include using con- these for catheter ablation.1,2 From a safety and trast angiography to identify and target the PV efficacy perspective, empiric isolation of all PVs ostia; targeting the ostia using electroanatomic was clearly a much more suitable strategy.3–6 mapping systems to localize the catheter tip A version of this article originally appeared in Medical Clinics of North America, volume 92, issue 1. This work was supported in part by the Deane Institute for Integrative Research in Atrial Fibrillation and Stroke. Dr. Reddy has received grant support or served as a consultant to Biosense-Webster, CardioFocus, Cry- ocath Technologies, GE Medical Systems, Hansen Medical, Philips Medical Systems, ProRhythm, St. Jude Med- ical, and Stereotaxis. University of Miami Hospital Cardiovascular Clinic, Electrophysiology, So. Building, 1295 NW 14th Street, Miami, FL 33125, USA E-mail address: [email protected] Cardiol Clin 27 (2009) 201–216 doi:10.1016/j.ccl.2008.10.002 0733-8651/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved. cardiology.theclinics.com 202 Reddy (with or without the incorporation of preacquired navigation technology to provide for precise navi- three-dimensional CT scans or MRIs); and using gation with the hope that this translates to im- intracardiac echocardiography to position a circu- proved lesion contiguity, and balloon ablation lar mapping catheter at the PV ostia and target the catheter technology using various ablation energy electrograms for ablation. Regardless of the ap- sources designed to isolate the PVs in a facile proach used during the index procedure, the manner. mechanism of arrhythmia recurrence is virtually always caused by electrical PV reconnection.7 REMOTE NAVIGATION TECHNOLOGY That is, point-to-point ablation lesions are placed completely to encircle the PVs during the initial Currently, two remote navigation systems are ablation procedure. Because the ablation lesions available for clinical use: a magnetic navigation cannot be directly visualized, however, a surrogate system (Niobe II system, Stereotaxis, St. Louis, marker for lesion integrity is used: the lack of Missouri) and a robotic navigation system (Sensei electrical conduction across the ablation lesions system, Hansen Medical, Mountain View, at the end of the procedure. If the tissue at one California). of these sites is damaged but not fully necrotic Remote Magnetic Navigation from the ablation, however, PV to left atrial conduction can recur several weeks later after tis- The magnetic navigation system (Fig. 1) uses two sue healing is complete, leading to clinical AF large external magnets positioned on either side of recurrences. The difference in clinical outcome the fluoroscopy table to generate a uniform mag- after ablation of paroxysmal AF is very likely netic field (0.08 T) of approximately 15-cm diame- related directly to the ability of the operator to ter within the patient’s chest.8 Specialized ablation manipulate and stably position the ablation cathe- catheters are used with this system; briefly, these ter with the requisite force to generate effective catheters are extremely floppy along their distal ablation lesions. end, and have magnets embedded at the tip of The most important goal during catheter abla- the catheter. When placed within the patient’s tion of paroxysmal AF is to achieve permanent heart, the catheter tip aligns with the orientation PV isolation. To improve the technical feasibility of the generated magnetic field. The operator of the procedure and thereby improve the continu- uses a software interface to manipulate the mag- ity of the isolating ablation lesion sets, extensive netic field, and by extension, the tip of the ablation effort has been made to improve the ablation tech- catheter. This ability to manipulate the magnetic nology. These various technologic advances can field provides the first level of freedom of move- be broadly separated into two groups: remote ment with this system. The other level of freedom Fig.1. (A) The magnetic navigation system uses two large magnets positioned on either side of the fluoroscopy table. (B) These magnets can generate a uniform magnetic field in virtually any direction so that magnetically enabled catheters orient in the same direction as the field. (C) A disposable catheter advancement system is po- sitioned at the femoral puncture site to advance or retract the catheter remotely. (Courtesy of Stereotaxis, St. Louis, Missouri; with permission.) Atrial Fibrillation 203 of movement is the ability remotely to advance or accuracy of these automatic software solutions, retract the catheter tip. This function is possible however, remain to be determined. The other sig- using a computer-controlled catheter advancer nificant advance is the ability to incorporate preac- system consisting of a disposable plastic unit po- quired three-dimensional MRIs or CT scans into sitioned at the femoral catheter insertion site. The the system to allow mapping on a realistic model catheter shaft is affixed to this unit where it enters of the heart. the sheath, and can transduce the remote opera- With the current generation software, some clin- tor instructions to advance or retract the catheter ical data are available on its efficacy for AF abla- appropriately. This combination of remote cathe- tion. In a consecutive series of 40 patients, ter advancement-retraction and magnetic field Pappone and colleagues9 used the mapping and manipulation allows the operator a great deal of navigation systems in tandem to determine the flexibility in intracardiac catheter manipulation. feasibility of circumferential PV ablation in patients This magnetic navigation system is now inte- undergoing catheter ablation of AF. Using a 4-mm grated with one of the electroanatomic mapping tip ablation catheter (with the requisite embedded systems (CARTO RMT, Biosense Webster, Dia- magnets), they showed that the left atrium and PVs mond Bar, CA). The mapping system can precisely could be successfully mapped in 38 of 40 patients. localize the catheter tip in space to a submillimeter Ablation lesions were placed in a circumferential resolution (Fig. 2A). Through precisely tracking the fashion for a maximum of 15 seconds at any endo- catheter location, this combination of mapping cardial ablation site. They reported that procedure and navigation systems allows for a novel capabil- times decreased significantly with increased oper- ity: automated chamber mapping. Briefly, the op- ator experience. Although this study clearly erator remotely manipulates the catheter within showed the feasibility of remote mapping of the the left atrium to a few defined anatomic locations left atrium and PVs, the procedural end point (eg, the ostia of the various PVs, the mitral valve was not electrical PV isolation in the standard elec- annulus) and, based on these parameters, the sys- trophysiologic sense. Instead, the end point was tem automatically manipulates
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