Outcome after practical isthmus ablation of scar-related atrial tachycardia guided by high-density mapping

Abstract Background High-density mapping (HDM) has been found to precisely identify the practical isthmus of scar-related atrial tachycardia (AT) circuits. Since practical isthmuses have been found to be shorter than the usual anatomical isthmuses targeted ablation has been proposed. However, outcome data are sparse. Here we describe HDM-guided catheter ablation by targeting the practical isthmus in patients with scar-related ATs. Methods and results In 250 consecutive patients with scar-related ATs HDM-guided catheter ablation with the support of a 64-electrode mini-basket catheter has been performed. Most patients underwent a prior catheter ablation (98%) while 13% had a prior cardiac valve surgery and 6% an underlying congenital heart disease. A total of 355 ATs occurred in the index procedure, of which 64% had a macro-, 26% a micro-reentry and 10% a focal mechanism. The ATs had a mean cycle length of 304±4.3 ms and in 237 patients (95%) an acute termination into sinus rhythm was achieved. They were mainly located in the left atrium (72%) but also in the right atrium (25%), bi-atrially (5%) or in the CS (3%) (see figure). Targeting the practical isthmus revealed arrhythmia freedom in 53% of patients after a single procedure during a mid-term follow-up (median 489 days, range 95–1407 days). Freedom from any arrhythmia could be achieved in 74% of patients after multiple procedures and in 93% of patients after multiple procedures and optimal clinical therapy, including pharmaceutical or electrical cardioversion. Conclusions HDM-guided catheter ablation of the practical isthmus in patients with scar-related ATs leads to a high acute success rate. Nevertheless, multiple procedures are necessary in a relevant number of patients resulting in a low recurrence rate. Funding Acknowledgement Type of funding source: None

Download Full-text

P957Characteristics of atrial tachycardia after mitral surgey via biatrial trans-septal approach using high density mapping system

EP Europace ◽

10.1093/europace/euaa162.222 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

C Cataldi ◽

M Andronache ◽

R Eschalier ◽

F Jean ◽

R Bosle ◽

...

Keyword(s):

Atrial Tachycardia ◽

Sinus Node ◽

Pulmonary Veins ◽

High Density ◽

Congenital Defects ◽

Density Mapping ◽

Mapping System ◽

Oblique Incision ◽

Pace Maker ◽

The Right

Abstract Background The biatrial trans-septal approach (BTSa) ameliorates mitral valve (MV) exposure in difficult cases when routine left atriotomy doesnt"t allow it. Main steps are an oblique incision on the right atrium (RA), reaching medially the right pulmonary veins (PV), a septal incision from the fossa ovalis, extended up to reach the first incision, then on the left atrium (LA). Purpose We aim to study the arrhythmic burden in this post-surgical context, focusing on atrial tachycardia (AT), to investigate the complexity of several possible circuits. Methods All patients (>18yo) with previous MV surgery via BTSa for MV repair or replacement, who underwent ablation of AT from January 2017 to September 2019, were enrolled. Patients ablated for persistent or paroxysmal AF, or with AF during the index procedure were excluded. Patients with associated surgery on other valves or congenital defects, coronary, surgical or percutaneous rhythm interventions weren’t excluded. Electroanatomical mapping was created using 2 different high-density mapping system. Substrate and activation map and radio-frequency (RF) ablation (25-50W, Ablation Index target 400) were realized. Cartographies were analysed to evaluate AT re-entry circuit, critical isthmus (CI) location and characterization, atrial vulnerability. Procedural outcomes (AT termination, sinus rhythm (SR) restoration, anti-arrhythmic drugs (AAD) withdrawal), and peri-procedural complications were also evaluated. Results We enrolled 49 patients (median age 57 ± 15), finding a maximum of 5 AT per procedure (2 ± 1). A total of 112 AT were mapped: the majority (72%) were persistent AT, 8,2% common atrial flutter. Cycle length was 314 ± 74 msec, with proximal-distal activation of coronary sinus (78%). A multiple re-entry circuit was observed in 70% of index AT. We identified 152 critical isthmus (maximum 5 per procedure). Only 27,9% of our patients had a single CI; CTI was the most frequent one (n = 37), envolved in 33% of all AT, while BTS scars altogether were envolved in 65% AT. A complete AT circuit was mapped in the RA, the LA and both atria in respectively 49%, 11,5% and 39%AT. The distribution of CIs is shown in figure 1. Biatrial and left AT leads to superior procedure, RF and fluoroscopy duration (p <0,05). SR was restored in 93,4%of patients, requiring a DC shock in 4 cases. Immediate AAD withdrawal was achieved after 41%procedures. No pericardial, oesophageal, vascular or phrenic complication occurred. 4 pace-maker implantations were realized because of 3 interatrial, 2 AV block and a sinus node dysfunction. Conclusions AT occurring after a BTSa have a high prevalence of multiple re-entry circuits with multiple critical isthmus. Ablation in this context is feasible and safe but often requires a left atrial access. Mapping of both atria should be considered to identify critical isthmus and tailored ablation strategy. Abstract Figure 1. Critical Isthmus Distribution

Download Full-text

Single‐center experience of ultra‐high‐density mapping guided catheter ablation of focal atrial tachycardia

Clinical Cardiology ◽

10.1002/clc.23774 ◽

2022 ◽

Author(s):

Antonia Kellnar ◽

Stephanie Fichtner ◽

Michael Mehr ◽

Thomas Czermak ◽

Moritz F. Sinner ◽

...

Keyword(s):

Catheter Ablation ◽

Atrial Tachycardia ◽

High Density ◽

Single Center ◽

Density Mapping ◽

Single Center Experience ◽

Focal Atrial Tachycardia

Download Full-text

Basket catheter-guided ultra-high-density mapping of cardiac arrhythmias: a systematic review and meta-analysis

Future Cardiology ◽

10.2217/fca-2020-0032 ◽

2020 ◽

Author(s):

Fares-Alexander Alken ◽

Shaojie Chen ◽

Mustafa Masjedi ◽

Helmut Pürerfellner ◽

Philippe Maury ◽

...

Keyword(s):

Systematic Review ◽

Catheter Ablation ◽

Cardiac Arrhythmias ◽

Atrial Tachycardia ◽

Meta Analysis ◽

High Density ◽

Term Outcome ◽

Long Term Outcome ◽

Density Mapping

Aim: Ultra-high-density mapping (HDM) is increasingly used for guidance of catheter ablation in cardiac arrhythmias. While initial results are promising, a systematic evaluation of long-term outcome has not been performed so far. Methods: A systematic review and meta-analysis was conducted on studies investigating long-term outcome after Rhythmia HDM-guided atrial fibrillation (AF) or atrial tachycardia catheter ablation. Results: Beyond multiple studies providing novel insights into arrhythmia mechanisms, follow-up data from 17 studies analyzing Rhythmia HDM-guided ablation (1768 patients, 49% with previous ablation) were investigated. Cumulative acute success was 100/90.2%, while 12 months long-term pooled success displayed at 71.6/71.2% (AF/atrial tachycardia). Prospective data are limited, showing similar outcome between HDM-guided and conventional AF ablation. Conclusion: Acute results of HDM-guided catheter ablation are promising, while long-term success is challenged by complex arrhythmogenic substrates. Prospective randomized trials investigating different HDM-guided ablation strategies are warranted and underway.

Download Full-text

Outcome after tailored catheter ablation of atrial tachycardia using ultra‐high‐density mapping

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.14703 ◽

2020 ◽

Vol 31 (10) ◽

pp. 2645-2652 ◽

Cited By ~ 1

Author(s):

Christiane Jungen ◽

Ruken Akbulak ◽

Ann‐Kathrin Kahle ◽

Christian Eickholt ◽

Benjamin Schaeffer ◽

...

Keyword(s):

Catheter Ablation ◽

Atrial Tachycardia ◽

High Density ◽

Density Mapping

Download Full-text

Regional isolation in the right atrium with disruption of intra‐atrial conduction after catheter ablation of atrial tachycardia

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.14037 ◽

2019 ◽

Vol 30 (10) ◽

pp. 1773-1785 ◽

Cited By ~ 3

Author(s):

Steven M. Markowitz ◽

Daniel Y. Choi ◽

Foysal Daian ◽

Christopher F. Liu ◽

Jim W. Cheung ◽

...

Keyword(s):

Catheter Ablation ◽

Right Atrium ◽

Atrial Tachycardia ◽

The Right

Download Full-text

Simultaneous orthogonal bipole mapping compared to conventional electrode configurations and impact on ablation strategies: results from a real world observational study

EP Europace ◽

10.1093/europace/euab116.061 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

L Fiedler ◽

F Roithinger ◽

I Roca ◽

F Lorgat ◽

A Roux ◽

...

Keyword(s):

Catheter Ablation ◽

Observational Study ◽

Real World ◽

Low Voltage ◽

High Density ◽

Electrode Configuration ◽

Density Mapping ◽

Substrate Identification ◽

Myocardial Substrate ◽

Vt Ablation

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abbott Background 3D mapping systems are pivotal to identify low voltage areas and to define ablation strategies. In this context, high-density multipolar mapping catheters with varying electrode configurations are used for accurate myocardial substrate definition. High density mapping using a grid shaped catheter allows for use of simultaneous analysis of adjacent orthogonal bipolar signals that may assist in more accurate substrate characterization and ablation strategy decisions. Purpose This was a prospective, multicenter observational study to characterize the utility of electroanatomical mapping with a high density grid-style mapping catheter (HD Grid) in subjects undergoing catheter ablation for persistent atrial fibrillation (PersAF) or ventricular tachycardia (VT) in real-world clinical settings. Methods Mapping was performed with the HD Grid catheter to generate high-density maps of cardiac chambers in order to assess the potential influence of the simultaneous orthogonal bipole configuration on PersAF and VT ablation strategies. Differences in substrate identification between simultaneous orthogonal bipole configuration and standard along-the-spline electrode configuration, and potential effects on ablation strategies were investigated. Results During the study period (January 2019 through April 2020), 367 subjects underwent catheter ablation for PersAF (N = 333, average age 64.1yr, 75% male) or VT (N = 34, average age = 64.3yr, 85.3% male). In total, 494 maps were generated to treat patients undergoing PersAF ablation and 57 to treat patients undergoing VT ablation. Compared to standard along-the-spline configuration, mapping with the simultaneous orthogonal bipole configuration showed differences in 57.8% (178/308) of maps generated, with the greatest difference noticed in surface area of low voltage (62.9%) and location of low voltage (55.6%). In comparisons performed live during the procedure (n = 50), simultaneous orthogonal bipole configuration assisted in identification of ablation targets in 70.0% of cases, changing the ablation strategy compared to that identified with along-the-spline configuration in 34.3%. In comparisons performed retrospectively after the procedure (n = 258), the ablation strategy identified with simultaneous orthogonal bipole configuration differed from along-the-spline configuration in 21.7% of maps. Even compared to a higher-density electrode configuration using all-bipoles rather than along-the-spline bipoles, simultaneous orthogonal bipole configuration identified differences in 57.1% of maps. Conclusion The HD grid catheter combined with simultaneous orthogonal bipole configuration can define myocardial substrate more accurately compared to standard along-the-spline configuration. The difference in substrate identification has potential impact on ablation strategy. Further clinical trials are needed to elucidate the role of orthogonal bipole configuration mapping and improved ablation success rates.

Download Full-text

Abstract 5690: Idiopathic Catecholamine-sensitive Epicardial Ventricular Tachycardia At The Crux Of The Heart

Circulation ◽

10.1161/circ.118.suppl_18.s_985-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Harish Doppalapudi ◽

Karthik Ramaswamy ◽

Joon Ahn ◽

Takumi Yamada ◽

G Neal Kay

Keyword(s):

Ventricular Tachycardia ◽

Catheter Ablation ◽

Coronary Sinus ◽

Clinical Syndrome ◽

Epicardial Surface ◽

Surface Ecg ◽

Coronary Venous System ◽

The Right ◽

Mean Cycle ◽

Middle Cardiac Vein

Idiopathic ventricular tachycardia (VT) has been described from the epicardial surface of the left ventricle (LV), usually near the summit of the LV in the outflow tract. Ablation of these VTs may be possible by delivery of energy within the coronary venous system or directly on the epicardial surface. We describe a distinct syndrome of focal epicardial VT induced by catecholamine infusion that arises from the crux of the heart. Among 340 cases of idiopathic VT referred for catheter ablation, 4 patients were identified with a clinical syndrome of catecholamine sensitive VT that was mapped to the epicardial surface at the crux of the heart. There were 3 males and 1 female (age 31–79 yrs, mean 58). VT was sustained in all patients and associated with syncope or near syncope in 3 of 4 pts. The LVEF was >0.55 in 3 pts and mildly depressed (0.45) in 1 pt. In all pts VT could be induced with programmed stimulation or burst pacing from the right ventricular apex but required the infusion of isoproterenol for induction in 3. The VT was very rapid with a mean cycle length of 264 msec. The surface ECG during VT demonstrated a left superior axis QRS morphology in all pts, with an abrupt precordial tansition from V1 to V2 in 3 pts and R waves across the precordium in one. The precordial maximal deflection index was > 0.55 in all pts (mean 0.67). The site of earliest activation during intracardiac mapping occurred at the crux of the heart with activation in the middle cardiac vein or proximal coronary sinus recorded 20 –50 msec (mean −38 msec) prior to the onset of the surface QRS. Catheter ablation with irrigated RF was attempted within the middle cardiac vein or proximal coronary sinus in all pts and was successful in 1. In 2 of 3 remaining pts, percutaneous epicardial RF ablation was attempted and was successful. Simultaneous coronary angiography demonstrated the site of earliest activation within 5–10 mm of the proximal posterior descending coronary artery (PDA). There was no acute narrowing of the PDA in any pt following ablation. Idiopathic VT may arise from the epicardial surface at the crux of the heart in close proximity to the PDA. This syndrome can result in very rapid, catecholamine sensitive VT, and may require careful attention to the PDA during ablation.

Download Full-text

P3778Long-term outcome of non-pharmacologial treatment of atrial fibrillation in hypertrophic cardiomyopathy: a large single-centre experience

European Heart Journal ◽

10.1093/eurheartj/ehz745.0627 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

L Dinshaw ◽

M Lemoine ◽

J Hartmann ◽

B Schaeffer ◽

N Klatt ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Left Atrial ◽

High Density ◽

Term Outcome ◽

Long Term Outcome ◽

Density Mapping ◽

Ablation Success

Abstract Introduction Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM) and is generally associated with a significant deterioration of clinical status. Non-pharmacological treatment such as surgical and catheter ablation has become an established therapy for symptomatic AF but in patients with HCM often having a chronically increased left atrial pressure and extensive atrial cardiomyopathy the long-term outcome is uncertain. Purpose The present study aimed to analyse the long-term outcome of AF ablation in HCM and the mechanism of recurrent atrial arrhythmias using high-density mapping systems. Methods A total of 65 patients (age 64.5±9.9 years, 42 (64.6%) male) with HCM undergoing AF ablation for symptomatic AF were included in our study. The ablation strategy for catheter ablation included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines if appropriate. In patients with suspected atrial tachycardia (AT) high-density activation and substrate mapping were performed. A surgical ablation at the time of an operative myectomy for left ventricular outflow tract obstruction was performed in 8 (12.3%) patients. The outcome was analysed using clinical assessment, Holter ECG and continuous rhythm monitoring of cardiac implantable electric devices. Results Paroxysmal AF was present in 27 (41.6%), persistent AF in 37 (56.9%) and primary AT in 1 (1.5%) patients. The mean left atrial diameter was 54.1±12.5 ml. In 11 (16.9%) patients with AT high-density mapping was used to characterize the mechanism of the ongoing tachycardia. After 1.9±1.2 ablation procedures and a follow-up of 48.5±37.2 months, ablation success was demonstrated in 58.9% of patients. The success rate for paroxysmal and persistent AF was 70.0% and 55.8%, respectively (p=0.023). Of those patients with AT high-density mapping guided ablation was successful in 44.4% of patients. The LA diameter of patients with a successful ablation was smaller (52.2 vs. 58.1 mm; p=0.003). Conclusion Non-pharmacological treatment of AF in HCM is effective during long-term follow-up. Paroxysmal AF and a smaller LA diameter are favourable for successful ablation. In patients with complex AT the use of high-density mapping can guide ablation resulting in further ablation success in a reasonable number of patients.

Download Full-text

Micro-reentry right atrial tachycardia originating from fossa ovalis: a case report of high-density mapping by PentaRay catheter

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz141 ◽

2019 ◽

Vol 3 (3) ◽

Author(s):

Jin-Yi Li ◽

Xiang-Wei Lv ◽

Guo-Qiang Zhong ◽

Hong-Hong Ke

Keyword(s):

Atrial Tachycardia ◽

Mapping Method ◽

High Density ◽

Right Atrial ◽

Ablation Therapy ◽

Density Mapping ◽

Mapping System ◽

Conventional Mapping ◽

Electrophysiological Examination

Abstract Background Micro-reentry tachycardia usually emerges in scar tissues related to post-atrial fibrillation ablation and cardiomyopathy. It is difficult to identify the micro-reentry circuit accurately by conventional mapping method. Case summary A 74-year-old man presented with paroxysmal atrial tachycardia (AT) presenting as palpitations. He was evaluated by an electrophysiological examination using a high-density CARTO mapping system. The mapping results showed the AT with a cycle length of 184 ms was focused on his right atrial fossa ovalis (FO). In this small area, the high-density mapping demonstrated a significant micro-reentrant tachycardia. Radiofrequency ablation at the centre of the micro-reentrant circuit successfully terminated the AT. No recurrences were observed during a 12-month follow-up. Discussion This case demonstrated a micro-reentrant AT originates from the FO without cardiomyopathy or previous ablation with specific loops. This is an unusual location for AT though and can cause difficulty for operators if it terminates or is non-sustained. High-density mapping using a PentaRay catheter can effectively characterize micro-reentrant circuits and determine the real target for ablation therapy.

Download Full-text

High-density mapping in patients undergoing ablation of atrial fibrillation with the fourth-generation cryoballoon and the new spiral mapping catheter

EP Europace ◽

10.1093/europace/euaa160 ◽

2020 ◽

Vol 22 (11) ◽

pp. 1653-1658

Author(s):

Giulio Conte ◽

Kyoko Soejima ◽

Carlo de Asmundis ◽

Jolie Bruno ◽

Fabio Cattaneo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Persistent Atrial Fibrillation ◽

High Density ◽

Fourth Generation ◽

Cryoballoon Ablation ◽

Density Mapping ◽

Basket Catheter ◽

Significant Difference ◽

Discrepancy Rate ◽

Mapping Catheter

Abstract Aims To assess the value of high-density mapping (HDM) in revealing undetected incomplete pulmonary vein isolation (PVI) after the fourth-generation cryoballoon (CB4G) ablation compared to the previous cryoballoon’s versions. Methods and results Consecutive patients with paroxysmal or early-persistent atrial fibrillation (AF) undergoing CB ablation as the index procedure, assisted by HDM, were retrospectively included in this study. A total of 68 patients (52 males; mean age: 60 ± 12 years, 58 paroxysmal AF) were included, and a total of 272 veins were mapped. Fourth-generation cryoballoon with the new spiral mapping catheter (SMC) was used in 35 patients (51%). Time to PVI was determined in 102/132 (77%) and in 112/140 (80%) veins during second-generation cryoballoon/third-generation cryoballoon (CB2G/CB3G) and CB4G ablation, respectively (P = 0.66). There was a statistically significant difference in terms of discrepancy rate between the SMC and the mini-basket catheter in PV detection after CB4G and CB2G/CB3G ablation(1.4% vs. 7.6%; P = 0.01). A total of 57 patients (84%) remained free of symptomatic AF during a mean follow-up of 9.8 ± 4.6 months. Conclusion High-density mapping after cryoballoon ablation using CB4G and the new SMC identifies incomplete PVI, not detected by the new SMC, in a significantly lower proportion of veins compared to HDM performed after the other generation CB ablation.

Download Full-text