af ablasyonunda kullanılan yöntemler -...
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AF ablasyonunda kullanılan yöntemler
(haritalama – enerji)
Prof. Dr. Fethi KILIÇASLAN
İstanbul Medipol Üniversitesi
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AF ablasyonu=PVİ • Pulmoner ven izolasyonu AF ablasyonunun temel taşıdır.
• Hedef PV ile LA’nın elektriksel izolasyonudur.
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AF ABLASYONU
Konvansiyonel
nokta-nokta RF
ablasyonu
- Ensite
- CARTO
Balon temelli
ablasyon
- CRYO
- Ultrasound, Laser, HIFU
- Hotballoon RF
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3 boyutlu anatominin belirlenmesi
LA, PV, LAA, CS, RA anatomisi
PV ostiumunun belirlenmesi
Özefagus ve aorta lokalizasyonu
Substrat (voltaj) haritalama
Fluoroskopisiz kateter navigasyonu
RF ablasyon hattının belirlenmesi
PV etrafında ablasyon hattı
İlave RF ablasyon hattı (Mitral anulus, roof line ablasyon hattı vs)
CFAE mapping
AF’ye eşlik eden aritmilerin (Tipik AFL, AT) ablasyonu
Transseptal ponksiyon
AF AF ablasyonundaablasyonunda elektroanatomikelektroanatomik mappingmapping
sistemleri (CARTO ve sistemleri (CARTO ve EnSiteEnSite) )
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Lasso
Kateteri
Ablasyon
Kateteri
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EnSiteEnSite
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CARTOCARTO
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Arctic Front Advance™ Cryoballoon
and
AchieveTM Mapping Catheter
3. Occlude and
ablate
1. Access
targeted vein
2. Inflate and
position
4. Assess PVI
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Paroksismal AF’da CRYO
• RF ile benzer başarı oranları
• Avantaj – Nispeten kolay, son-noktası basit, öğrenim eğrisi dik
– Tek transseptal ponksiyon
– Daha kısa işlem ve LA süresi
– Majör komplikasyon oranları daha az
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CRYO ile AF
ablasyonunun limitasyonları
• Anatomik kısıtlılıklar • PV ostiumu dar veya çok geniş
• PV ostiumu açılı
• PV varyasyonları: Aksesuvar PV, Common os
• Voltaj ve aktivasyon mapping yapılamaması
• PV antrumu dışında ablasyon kısıtlıdır • Lineer ablasyon, CFAE ablasyonu , non-PV tetikleyicilerin ablasyonu, fokal impulse ve
rotor modulasyonu (FIRM), sağ atriyal ablasyon yapılamaması
• Nüks vakalarda farklı bir ablasyon metodolojisine
imkan vermemesi
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In Arctic Front Cryoballoon, the most
concentrated cooling zone occurs near the equator
of the balloon. Aligning the balloon coaxially with
the PV may be an important factor, but may be
difficult in some vein anatomies.
Arctic Front Advance Cryoballoon with
EvenCool Cryo Technology is designed to allow
more flexibility in balloon positioning to ablate
the PVs.
Arctic Front Cryoballoon Arctic Front Advance Cryoballoon
13
CRYOBALON
1st generation 2nd generation
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Sağ üst ven: Achieve distalde
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Sağ üst ven: Achieve proksimalde
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RF vs CRYO
FIRE AND ICE
Some say the world will end in fire,
Some say in ice.
From what I’ve tasted of desire
I hold with those who favor fire.
But if it had to perish twice,
I think I know enough of hate
To say that for destruction ice
Is also great
And would suffice.
By Robert Frost
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Yenilikler
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HOTBALLOON
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• An agitation device designed to “stir” the fluid within the balloon to achieve a uniform temperature at the tissue interface, and a RF generator with a maximum output of 200 W. • The balloon can be inflated to 25–35 mm in diameter using an ionized contrast medium diluted 1:1 with physiologic saline. • RF is delivered between the coil electrode inside the balloon and the 4 cutaneous electrode patches placed on the patient’s back. • Tissue is heated thermally at the interface to the balloon membrane, and that thermal transfer is the primary mechanism for ablation, not RF current flow.
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HotBalloon Ablation of the Pulmonary Veins for Paroxysmal
AF. A Multicenter Randomized Trial in Japan
Sohara M et al., J Am Coll Cardiol 2016;68:2747–57.
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Rhythmia haritalama sistemi
• Hızlı ve yüksek çözünürlükte elektroanatomik ve
aktivasyon haritalama
• Minibasket kateter ile haritalama
• Manüel anotasyona iht,yaç olmadan haritalama
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Mini-basket (Orion) catheter - 2.5 mm center to center spacing
- 0.9 x 0.45mm electrodes
- 0.4mm2 surface area
22 mm
8 splines with 8 mini electrodes
64 electrodes in total
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Signal comparison • LA and PV potentials were consistent (concordant
100%) in all PV’s between Orion and Lasso
Left atrial
potential
PV
potential Lasso
Orion
LA potential in
Orion later than in
Lasso: due to the
Orion more distal
position
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Signal comparison • After ablation: There is poor signal concordance between Lasso and
Orion (low and fragmented PV signals not visible to Lasso)
Orion
Lasso
Lasso
overestimation of
PVI
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* Evaluation of a novel high-resolution mapping technology for ablation of
recurrent scar-related atrial tachycardias.
Anter, E et.al. (Heart Rhythm2016;13:2048–2055
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Contact Force Sensing Kateterler
• Ablasyon esnasında kateter ile doku temasını
gerçek zamanlı olarak gösterirler.
• İki CF sensing kateter:
– TactiCath (St. Jude Medical, St. Paul, MN, USA): 7 Fr,
open irrigation kateter, 3.5-mm tip electrode.
– SmartTouch Thermocool (Biosense Webster, Diamond
Bar, CA, USA): Steerable, 3.5-mm six-hole open-
irrigated tip ablasyon kateteri
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