Interesting read from web.

[www.eplabdigest.com]

That is an extremely interesting article !!

Great Article, Thanks for Posting!

Looks like a nice device to do epicardial box lesion for persistent and long-term persistent folks that failed endoscopic ablation. Significantly less invasive than the Sirak approach that's been discussed here before. Still the best path to take is not to let your AF progress to persistent. Get it while it is still paroxysmal.

researcher Wrote:
-------------------------------------------------------
> Looks like a nice device to do epicardial box
> lesion for persistent and long-term persistent
> folks that failed endoscopic ablation.
> Significantly less invasive than the Sirak
> approach that's been discussed here before. Still
> the best path to take is not to let your AF
> progress to persistent. Get it while it is still
> paroxysmal.

I some how "skipped" the paroxysmal phase of AFIB. When I was diagnosed with AFIB, I was in Persistent AFIB. I have to be cardioverted to get back to NSR. I guess its possible I just ignored the Paroxysmal phase of AFIB.

Hi Smackman and Tsco.

Thanks for the article posting Smackman. This new wrinkle in using the nContact epicardial ablation tool is a modification of the hybrid approach which has proven successful for difficult cases, especially those who did not have the advantage of a top tier ablationist skilled in doing more extensive endocardial ablation protocol for persistent and long-standing persistent AFIB. Or just the more typical ablationist who is very challenged in getting durable and lasting transmural PVI block in their standard procedure and thus will have too many reconnections inherently, not to mention if they fail to address the posterior wall, SVC and any other active sources found during a first, second, third and so on ablation.

The overall process Drs Steinberg and Sperling describe here is almost a textbook description of Natale's general persistent AFIB protocol, and Im sure that long term success Dr N, and others like Bordeaux's step-wize persistent AFIB protocol for doing more extensive ablation sets for challenging cases have had inspired them to adopt these same general concepts.

Natale and Bordeaux does it all endocardially and with great skill, which it takes to do it well, and for years now I know Natale has promoted 'coloring in' or 'filling in' the whole posterior wall in addition to full electrical isolation of the posterior wall in for more challenging persistent or long standing persistent cases. So that part is not brand new at all, only the choice of using an epicardial tool solely to fill in the posterior wall is a new an interesting wrinkle.

However, I have heard there have been some trials using this nContact vacuum sealed ablation tool in hybrid ablation procedures in which this tool was used first to do a surgical modestly invasive through the ribs or under the sternum access hybrid ablation, and with mixed results and some significant complications as well in at least some cases from the scuttle butt at these conferences I have heard. Whether that was from a limitation in an earlier version of this ablation tool that has been improved now, or due to other factors not as much related to the tool itself will be good to clarify. In any event, from this report it seems that perhaps in the more limited role they are using it here it might be better suited. We can't know yet without seeing more of the details of their experience here until reading their full study.

Natale gets rid of the posterior wall contribution to arrhythmia in a similar way approach to their general description, but endocardially by dragging the lasso circular mapping catheter across the full surface area of the posterior wall with either the new ThermocoolSmartTouch or SF ablation catheter attached right at the outer edge of the lasso an an angle and ablating all the active areas as he criss crosses in a kind of like 'mowing the lawn' type pattern, across the antral and posterior wall spaces. This prevents the risks from a 'dot per dot' tip pressure pushing into the back wall as in typical ablation burns, where you could get potentially more risk for heat damage to the esophagus or rarely a perforation tamponade. Instead, using the dragging technique with the catheter so oriented dramatically lowers trigger activation voltage output across the full posterior wall similar to the aim with this nContact epicardial ablation tool, but while avoiding the need for an epicardial access and surgical member of the team. And while sparing those areas that are not electrically triggering.

Apparently, Steinberg and his team haven't had the complications with this more limited use of a hybrid approach with this tool, than earlier attempts to use it for more extensive epicardial maze procedure, so thats a plus.

Also, I'm not surprised they are getting good early results from the first 1.5 to 2 year period of doing patients. Though, I don't know how many cases this amounts too that have been followed for 1.5 years or more? He mentions 30 cases somewhere, but were those the numbers followed for the whole time period of 2 years or the total number they have used this process on so far?

In any event, if their numbers pan out in review of their study this is one more confirmation of the general approach those trail blazers in CC, Austin, San Fran and Bordeaux that have been fostering with this overall conceptual approach for some years now have urged people to adopt and make their own so its good to see more and more centers discovering the value of taking a more thoughtful and extensive approach beyond just a PVI and a few burns here or there when it comes to addressing more advanced cases of AFIB.

The thing this group above did not mention much, except in passing, in this article is the need to address other non-PV areas as well beyond the PVI, such as the coronary sinus and LAA in more difficult cases. With the full endocardial approach that already full isolated and 'colors in' not only the pulmonary vein sleeves and antrum roof area as well as the full posterior wall area, but also isolates the SVC and does focal CAFE ablation along the septal wall as needed, and other anterior area of the LA while also isolating when called for the CS and LAA. They did imply one may need to use CARTO or FIRM mapping to ferret out other non-PV triggers to get the job well done, but as the number of difficult cases mount the need to fully address and isolate the CS and LAA will only grow.

At this early stage for this particular version of the hybrid ablation, I'd suggest to wait and see how this particular angle with the nContact epicardial aspect of the procedure for posterior wall access all pans out longer term and if you have persistent AFIB or have failed one to two standard ablations and have the same or worse arrhythmia still, to consider trying once more to get this done right with a purely endocardial comprehensive persistent AFIB protocol by a truly top tier ablationist at one of the centers mentioned above who does mostly these kind of more comprehensive ablations every day with great success and see if that doesn't do the trick for you. At least until we can see a larger body of long term data on sing this novel epicardial ablation tool for removing electrical triggering from the posterior wall.

If that endocardial process done right still doesn't do the trick, then you could always go in for what, at most, would likely just be the epicardial posterior wall 'touch up' that probably wouldn't even require any transeptal puncture, if that seems reasonable at the time and only if you are having ongoing issues still and have already addressed the CS and LAA as well as the endocardial aspects of the posterior wall in addition to PVI.

Odds are high, if you make the right choice up front for the persistent endocardial ablationist you choose, that if you are not 'one and done' then almost certainly 'one plus a relatively simple touch up and done' as it is without the added issues of factoring in an epicardial approach.

Also, if any of you prefer doing the hybrid ablation here up front, then by all means discuss having an Atriclip or Lariat done for the LAA at the same time as the first step in the process, at the same time before they penetrate the pericardial sack with the nContact catheter such that you might then be disqualified from a Lariat, for example. The Atri-clip might offer more flexibility in such regard, but if you have serious enough AFIB to be discussing this hybrid approach as an index procedure, then your odds are MUCH higher that you either have now, or soon will have, active triggering migration to the LAA.

As such, having a clip or ligation type device to seal off the LAA not only eliminates or greatly diminishes the stroke risk and drop all OAC drugs, but will also insure electrical isolation of the LAA such that is will then not become an on-going source of arrhythmia in the future to spoil the party down the road, as it is so prone to do otherwise.

Anyway, Im pleased to see this team recognize the major effort needed to properly address persistent AFIB more effectively. The reason for the lower results up until recently with ablation in this group of challenging persistent patients, is largely due to the substrate remodeling that makes it a tougher and a more extensive animal to corral, not to mention the need for a highly skilled man or women behind the catheter with a solid track record of very few reconnections found on repeat ablations. This group in the article is certainly approaching this issue from the right overall philosophical basis in my book, and I wish them well in their on-going refinement of their new hybrid wrinkle in this overall tried and true approach done endocardially for the most part so far.

Whether or not using this nContact tool to ablate the posterior wall actually buys us anything over and above an expert full posterior wall isolation plus 'coloring in' the electrically active triggers across he full posterior wall endocardial, in terms of even more consistent results with these difficult cases remains to be seen.

It may well prove preferable to those EPs not as experienced or successful in silencing the posterior wall inside and would rather turn that aspect over to the surgical team which very much could make for much better consistency. The only thing there is that if the EP isn't confident and skilled at safely silencing the posterior wall then will they fair much better around the LAA and a as when those not uncommon areas are found to be active in advanced cases?

Ideally, this new technique will prove to be a net plus, both in terms of safety, ease of recovery for the patient, and with even better long term results than the very best of purely endocardial persistent aAFIB ablation experts get, and then it might really be seen as a significant step forward and we'll likely see even the top volume centers including this angle in their own persistent protocols. Time will tell.

Shannon



Edited 3 time(s). Last edit at 03/27/2014 10:21AM by Shannon.