Dr Eric Prystowsky

1

• Dr Eric Prystowsky
• Director
• Clinical Electrophysiology Laboratory
• St Vincent Hospital
• Indianapolis
• Dr Mel Scheinman
• Professor of Cardiology
• University of California
• San Francisco

2

• In the late 70s, the only option for refractory
  supraventricular tachycardia was surgical
  cryosurgery or direct surgical division of the AV
  junction.
• This arrhythmia was most commonly atrial
  fibrillation refractory to drug therapy.

3

• Experimental techniques and their pitfalls at the
  time included both laser energy, which suffered
  from lack of precision and radiofrequency, which
  was poorly refined.
• Early studies led to AV junctional ablation using
  electrical energy discharges
• Scheinman MM, Morady F, Hess DS, Gonzalez R.
  Catheter-induced ablation of the
  atrioventricular junction to control refractory
  supraventricular arrhythmias. JAMA 1982248851-5

4

• Before performing the first human procedure,
  studies in 10 dogs were successful, and under
  pathological examination, damage in the heart was
  limited to the region of the atrium and
  contiguous areas around the summit of the
  ventricular septum. No valvular or coronary
  lesions were seen.
• Energies levels in the range of 200-300 joules
  were required to produce complete AV block.

5

• Radiofrequency was the next best step in the
  sense that we could use titratable energy to
  selectively destroy accessory pathways without
  inordinate barotrauma, which was the big problem
  with DC shock.
• Dr Mel Scheinman
• Professor of Cardiology
• University of California
• San Francisco

6

• Flexible catheter tips were developed to deliver
  the correct amount of radiofrequency energy,
  since small electrode tips were associated with
  failure in the earliest RF experiments.
• A 4 mm tip gives the largest amount of tissue
  damage for a given amount of delivered energy.

7

• I think that the ordinary electrophysiologist is
  going to have to learn about complex mapping
  because I don't think you're going to be able to
  really intelligently handle some of the complex
  cases, the complex atrial tachycardias, atrial
  flutters without state-of-the-art multi-electrode
  mapping.
• Dr Mel Scheinman
• Professor of Cardiology
• University of California
• San Francisco

8

• The adult electrophysiologist is now seeing very
  complicated arrhythmias including complex atrial
  flutter and incisional reentry.
• In order to understand these complicated
  circuits, an understanding of advanced imaging
  and complex mapping techniques is required.
• Future systems will likely involve noncontact
  mapping systems that give perfect endocardial
  mappings within a few beats.

9

• In flutter ablation, future catheter systems may
  involve only 1 burn across the isthmus through
  multiple electrodes, allowing for the creation of
  linear lesions.
• Preliminary work in the animal model incorporates
  the use of magnetic catheter systems.
• Additional experimental energy systems include
  microwave, ultrasound and cryoenergy.

10

• Where do you think we should be heading with a
  fib? One concern is that it's the first time I've
  seen in our field people doing things without
  fundamental knowledge of why they're doing it It
  seems to me we don't have a fundamental knowledge
  of why a particular line in a particular place
  makes any difference. I'm a little concerned
  about that.
• Dr Eric Prystowsky
• Director, Clinical Electrophysiology Laboratory
• St Vincent Hospital
• Indianapolis

11

• Surgeons, in proof of principle, have shown that
  you can correct atrial fibrillation using a
  series of atrial lesions.
• The pulmonary vein area appears to be a critical
  area, although lesions here may lead to pulmonary
  stenosis, perforation, tamponade and stroke.
  Longterm follow-up suggests recurrence rates of
  up to 50.
• Standardization of atrial fibrillation ablation
  may take decades.

12

• I think molecular biology and genetics are going
  to have a tremendous impact and I see that as the
  next big step forward. We're all thinking of
  devices and making it better and cheaper and
  we're thinking about ablation tools, but I think
  that in the long haul it's going to be the
  molecular jocks that are going to point the way.
• Dr Mel Scheinman
• Professor of Cardiology
• University of California
• San Francisco