Role of Automation and Integrated Workflow in the Efficient Treatement of AF Carlo Pappone, MD, PhD, FACC

Transcription

1 Role of Automation and Integrated Workflow in the Efficient Treatement of AF Carlo Pappone, MD, PhD, FACC San Raffaele University Hospital, Milan, Italy

2 INTEGRATION & AUTOMATION

3 A rudimental system

4 PreABL PostABL Not effective for PV isolation

5 No PVI no cure!

6 What more? potentially dangerous

7 The role of misleading signs

8 All technologies, if used in a wrong way, Become unuseful

9 Although created by Him, we are not totally in his image and likelyness The truth? WE REPRESENT THE MAIN LIMITATION FOR OUR PATIENT TO BE CURED

10 FEASIBILITY CASE LOAD Biv 7% n = 1354 pts SVT 57% AFib 36% Right AP 31% Left AP 20% AVNRT 49%

11 ATRIAL FIBRILLATION OUR EXPERIENCE Population: 517 patients Mean Age 55 years Male 75% Paroxysmal AFib 70% Lone AFib 65% AFib history 5 years Hypertension 35%

12 HOW AUTOMATION CAN OPTIMIZE ABLATION WORKFLOW 1.Learning curve & Reproducibility A. Anatomical reconstruction B. Autonavigation C. Autoablation D. Automatic endpoint

13 LEARNING CURVE Learning curve represents the major limitation to widespread application of AF programs and to reproduce clinical results High costs Time consuming Volume dependent Operator dependent (gifted hands?)

14 REPRODUCIBILITY Reproducibility may depend from: Learning curve point Attitude of the operator/team Personal experience Sometimes it s easier to change technique than change yourself or to advance in ourself learning curve

15 REPRODUCE IN A FEW WEEKS Standard Robotic Years Weeks

16 HOW AUTOMATION CAN OPTIMIZE ABLATION WORKFLOW A.Anatomical reconstruction High interpolation, no tip/heart synchronization are major obstacles to obtain harmonic and detailed anatomical reconstruction currently not able to navigate in real-time anatomy

17 HOW AUTOMATION CAN OPTIMIZE ABLATION WORKFLOW Manual map Robotic map

18 HOW AUTOMATION CAN OPTIMIZE ABLATION WORKFLOW B. AutoNavigation Autonavigation permit to navigate fully automatically to reconstruct the true anatomy and not what the operator has in his mind

19 AutoNavigation PVs can be automatically acquired by applying vector presets also in difficult anatomies

20 AutoNavigation It provides: Detailed anatomies Homogeneous maps Presets for all anatomical structures Electrical memory of acquired points Automatic validation of endpoints

21 AutoNavigation LIMITATIONS: Autonavigation should be 3D & respiration-compensated (now 2D & based on fluoro) Closed system (i.e. CARTO only-compatible) CARTO still represents a limitation with his gating without respiratory compensation Catheter tip design still suboptimal (i.e. too rigid)

22 HOW AUTOMATION CAN OPTIMIZE ABLATION WORKFLOW C. AutoAblation Automatic ablation permit to keep the catheter in stable contact with the tissue all around the left atrium, and not only where the operator is able to do

23 AutoAblation Pappone JACC 2006

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25 AutoAblation LIMITATIONS: Low magnetic force at the mitral isthmus and at the septum Algorhythm to automatize fully the ablation and recognize in an intelligent way ablation parameters still under development Lack of CARTO respiratory compensation may limit catheter

26 HOW AUTOMATION CAN OPTIMIZE ABLATION WORKFLOW D. AutoValidation Validation of what we do is no currently as stringent as should be beyond the procedure itself, validation of the operator is the main part of procedure validation!

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28 AutoValidation LIMITATIONS: Autovalidation still under development Specific approach-dependent

29 Do integration translate into clinical benefits? Lesion generation Safety Efficacy Learning Reproducibility Which techniques?

30 Lesion Generation Lesion Gap Extreme catheter stability enhance the RF delivery trough 8mm and irrigated catheter

31 Systo-Diastolic Contact All-cycle contact improve RF efficiency RF time RF applications

32 Acute Efficacy CPVA endpoints respected in all cases

33 Safety (n=517) No Stroke No tamponade Post-ablation AT 3%

34 Safety Magnetic field up/down amplification enable contact strength modulation ( T)

35 Results KEY POINTS: Compared with historical controls: Similar efficacy 84% vs 83% (f/u 8±5 months, endpoint no AF/AT)

36 The new irrigated tip ROBOTIC IRRIGATED 4 MM: Initial experience in 52 patients Lasso validation of PV isolation (N=28) WPW ablation (N=6)

37 Thermocool RTM OUR EXPERIENCE Population: 52 patients Mean Age 58 years Male 59% Paroxysmal AFib 61% Lone AFib 39% AFib history 2 years Hypertension 29%

38 The new irrigated tip

39 The new irrigated tip 100% PV Isolation as validated with Lasso 100% Lasso/CARTO correspondence

40 The new irrigated tip

41 The new irrigated tip Extreme stability of T

42 The new irrigated tip Impedende fall can be avaluated to assess transmurality of each lesion

43 WHICH TECHNIQUES * PVI - 1 LASSO CPVA CFE ABLATION Vagal

44 The odyssey of a human beings The travel, far apart from our limitations, to reach a deeper consciousness and new capabilities

45 THE FUTURE EP LAB Integration Simplification Communication

46 INTEGRATION Computer-assisted nav Remote Control Live 4D anatomy

47 SIMPLIFICATION

48 COMMUNICATION Create high-speed, private, secure network Provide remote viewing and control

49 COMMUNICATION

50 COMMUNICATION Work with others worldwide for research and case consultations

51 The future EP lab should Lower differences among operators and procedures Favor therapy use Prolong EP operator lifes Enhance communication between doctors and hospitals Offer worldwide the appropriate know how the democracy of the science