Comparative use of different electroanatomical mapping systems for circumferential left atrial PV ablation

P. Sommer, C. Piorkowski, A. Bollmann, A. Arya, D. Husser, M. Esato, S. Weiss, T. Gaspar, C. Eitel, G. Hindricks
University of Leipzig - Heart Center, Cardiology - Dept. of Electrophysiology, Struempellstr. 39; 04289 Leipzig, Germany

Procedure data
250

Purpose

215
200

183,6
170,3

175,9
150,2

150

Precise orientation is mandatory for successful catheter ablation of

atrial fibrillation (AF). Electroanatomical mapping systems were
designed to enable placement of complex left atrial (LA) ablation line
concepts by providing 3D anatomical orientation. In this prospective
study procedural data and ablation results were compared between
patients ablated with Carto-Merge and EnSite-NavX.

100,4
100

74,6
58,6

53,1

51,7

37,7 37,1

50

0
Procedure
time (min)

Number RF
pulses

RF burning
time (min)

delivered RF
energy (kJ)

CARTO

Methods

fluo time
(min)

fluo dose (Gy/

sqcm)

NavX

Follow up: SR only

Figure 2: Reconstruction of left atrium (left); registration of 3D CT and ablation (right) with Carto Merge
100

90

90
77,8

76,9

80
67,2

70

60,7

60

129 consecutive patients with highly symptomatic AF (5710 years,

66% male, 66% paroxysmal AF, AF history for 92 months, 28% prior
AF ablation, 33% lone AF) received a circumferential PV ablation
using radiofrequency (RF) energy. In 59 patients 3D orientation was
provided by Carto-Merge, in 70 patients by EnSite-NavX. Both
groups were similar with respect to patient and arrhythmia
characteristics. In Carto ablation was performed after LA
reconstruction with subsequent 3D CT image integration. In NavX
ablation was performed directly within the integrated 3D CT image
without additional LA reconstruction. Complete PV isolation with
bidirectional block as demonstrated on a multipolar mapping catheter
was the procedural endpoint. Follow up was performed after ablation
and at 3/ 6 month with sequential 7-day-holter-ECG.

84,6

PA

50
40
30

PA

20
10
0

RPO

post ablation

3 months
CARTO

6 months

NavX

AAD post ablation

LPO

RPO
100

100

Fig. 3: Reconstruction of PV (left), registration of 3D CT (middle), ablation in 3D model (right) with Ensite NavX

90

92,9

91,3

88,9

86,4
76,7

80
70

Patient number
Age

CARTO

NavX

p-value

59

70

n.s.

55,6

58,8

n.s.

Male

40 (67,8%)

46 (65,7%)

n.s.

DCM

4 (6,8%)

2 (2,9%)

n.s.

Art. Hypertension

33 (55,9%)

48 (68,6%)

n.s.

Diabetes mellitus

5 (8,5%)

11 (15,7%)

n.s.

CAD

7 (11,9%)

8 (11,4%)

n.s.

Structural heart disease

38 (64,4%)

50 (71,4%)

n.s.

41

39,7

n.s.

55,2%

62,9%

n.s.

66,1%/ 33,9%

67%/ 33%

n.s.

AF history in months

93

91,1

n.s.

Previous AF ablations

20 (33%)

17 (24%)

n.s.

LA diameter in mm
LV-EF
Paroxysmal/ Persistent

Tabl.1: Baseline characteristics of the 129 consecutive patients treated for AF with 3D mapping
systems- either Carto Merge or Ensite NavX

Results

60
50
40
30
20

Procedure duration with NavX was lower as compared to Carto (17524

min vs. 21526; p<0.001). Total RF duration and total RF energy delivery
were significantly, number of RF pulses tended to be lower on NavX
(5311 vs. 7511 min, p<0.001; 10040 vs. 15051 kJoule, p<0.001;
5212 vs. 5911, p=0.06). No differences could be found with respect to
radiation time and radiation dosage (37.18 vs. 37.78 min, p=0.883;
17065 vs. 183120 G/cm2, p=0.402). Bidirectional conduction block in
all PVs was achieved in 57/59 (96%) of the Carto patients and in 80/90
(89%) of the NavX patients (p=0.220). On 7-day-Holter immediately after
ablation 60/90 (67%) of the NavX patients and 36/59 (61%) of the Carto
patients were free from AF and atrial macroreentrant tachycardia (MRT)
(p=0.849). The difference at 3 month follow up (70/90, 78% vs. 45/59,
77%) and at 6 month follow up (81/90, 90% vs. 50/59, 85%) remained
unsignificant. At 6 month 95% of the patients were treated with
betablockers, but only <2% with specific antiarrhythmic drugs (flecainid or
amiodaron).

11,9
7,1

10

16,3

13,6

8,7

7 8,7

1,4

3,7

0
BB post

Am iodaron
post

Flecainid
post

BB 3 m onth

Am iodaron
3 m onth

CARTO

Flecainid 3 BB 6 m onth Am iodaron

m onth
6 m onth

Flecainid 6
m onth

NavX

Figure 4: Procedural data of the 129 ablations, follow up results monitored by sequential
7-day-holter-ECG, medical treatment after ablation and at 3/ 6 month

Conclusion
Carto-Merge as well as NavX-EnSite provides the basis for
effective circumferential left atrial PV ablation with proven
isolation of all PVs. Early follow-up data do not indicate
differences in clinical efficacy. Ablation with NavX-EnSite shows
significantly reduced procedure times, lower RF burning time
and RF energy delivery with comparable efficacy.