scholarly journals 703 Koch’s triangle voltage mapping for cryoablation of slow pathway in children: preliminary data of a novel high density technique

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Ilaria Cazzoli ◽  
Pietro Paolo Tamborrino ◽  
Luigina Porco ◽  
Marta Campisi ◽  
Veronica Fanti ◽  
...  
Keyword(s):  
Low Voltage ◽  
Three Dimensional ◽  
High Density ◽  
Slow Pathway ◽  
Voltage Mapping ◽  
Acute Success ◽  
Procedural Time ◽  
Conventional Mapping ◽  
Mapping Point

Abstract Aims Different authors have described three-dimensional (3D) voltage mapping of the Koch’s triangle (KT) in order to find low-voltage bridges (LVBs) as targets for a successful transcatheter ablation (TCA) of the slow pathway (SP) in children. Recently, the advisor high density (HD) Grid™ mapping catheter was introduced as new multipolar catheter for HD mapping. The aim of the study was to describe our preliminary experience with the use of HD Grid™ catheter in LVB and electrophysiologically guided cryoablation of SP in children. Methods and results Twenty-one children (mean age 13 ± 3 years) with atrioventricular nodal re-entrant tachycardia (AVNRT) underwent cryoablation of SP guided by voltage HD mapping of the KT using HD Grid™ catheter. In order to better highlight the differences with conventional mapping, point collection was performed in each patient with this new multipolar catheter and with a quadripolar catheter. The conventional mapping collected 871 ± 262 points and used 211 ± 80 points in 887 ± 275 s, whereas HD mapping collected 7468 ± 2947 points, using 604 ± 165 points in 513 ± 181 s (P < 0.001). Moreover, the LVB area mapped with HD Grid™ was about one-half smaller and clearly delineated. Cryoablation acute success rate was 100%. Overall median fluoroscopy exposure was 0.08 (0.01–5.42) µGy/m2, with a median fluoroscopy time of 0.1 (0.0–0.6) min. During the follow-up (4.8 ± 3.7 months), there were no recurrences. No complications occurred. Conclusions Our preliminary experience shows that HD mapping is faster and offers higher spatial resolution and definition. Procedural time can be reduced maintaining the TCA safe, with reduced fluoroscopy use, and successful.

scholarly journals Radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia using standardized voltage mapping system protocol

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
F Bulian ◽  
M Manfrin ◽  
W Rauhe
Keyword(s):  
Low Voltage ◽  
Three Dimensional ◽  
Anatomical Variations ◽  
Right Atrial ◽  
Voltage Gradient ◽  
Slow Pathway ◽  
Atrioventricular Nodal Reentrant Tachycardia ◽  
Radio Frequency Energy ◽  
European Guidelines

Abstract Funding Acknowledgements Type of funding sources: None. Background  according to European guidelines, ablation has become the treatment of choice in patients with symptomatic atrioventricular nodal reentry tachycardia (AVNRT). Despite the high procedure success rate, anatomical variations can affect the outcome in terms of relapses and complications. As recently demonstrated, low-voltage bridge visualization allows low pathway identification and therefore a new ablation strategy. Purpose our purpose was the validation of standardized ablation protocol within the low-voltage bridge area.  Methods 70 consecutive patients with inducible AVNRT were evaluated and a three-dimensional voltage map of the right atrial septum and Koch Triangle was constructed by means of contact mapping. Ablation site was identified as the low-voltage area below the His bundle, adjusting the high-voltage slider to 1,5 mV and dynamically adjusting the slider of low-voltage. Radio-frequency energy (with an average number of nine lesions per patient) was then delivered within this area until the appearance of junctional beats. The results were tested at the end of the procedures and during the observational period (the mean follow-up was 10,5 months).  Results the slow pathway was identified by the low-voltage bridge in 60 patients (85,6%) and in these patients, the target lesions in that area finally prevented induction of AVNRT in 100% of cases. A zero-fluoroscopy approach was possible for 50 patients (83%). Compared with standard AVNRT ablation, no complications as well as no statistical differences in terms of total procedure time were observed (p = 0,056). 59 patients (98%) had no relapses during the follow-up.  Conclusions voltage gradient mapping successfully targeted the slow pathway in most of our cases. Lesions on the voltage bridge led to effective ablation of AVNRT and to a drastic x-ray exposure reduction in the absence of acute or long-term complications. Abstract Figure. Last lesion on low-voltage bridge.

scholarly journals Endocardial vs endo-epicardial ablation of ventricular arrhythmia in arrhythmogenic right ventricular cardiomyopathy: a single center experience

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K.A Simonova ◽  
A.V Kamenev ◽  
R.B Tatarskiy ◽  
M.A Naymushin ◽  
V.S Orshanskaya ◽  
...  
Keyword(s):  
Ventricular Arrhythmia ◽  
Low Voltage ◽  
Arrhythmogenic Right Ventricular Cardiomyopathy ◽  
Control Group ◽  
Definite Diagnosis ◽  
Premature Ventricular Contractions ◽  
Single Center Experience ◽  
Voltage Mapping ◽  
Epicardial Access

Abstract Background The majority of patients have a sub-epicardial scar as a substrate for VT episodes. Purpose We sought to compare the efficacy of endocardial (ENDO) and epicardial (EPI) substrate modification in patients with ARVC. Methods 20 consecutive ARVC patients (mean age 41,4±13,8, 70% males; ICD previously implanted in 10 patients) with indications to ventricular arrhythmia ablation (RFA) were included into a prospective observational study. The EPI group consisted of 10 patients with sustained ventricular tachycardia (VT) (definite diagnosis ARVC – 8 patients; borderline – 1, possible – 1) who signed an informed consent to epicardial access. The ENDO group included 10 patients (definite diagnosis ARVC – 9 patients), five of them demonstrated sustained VT and 5 patients had frequent symptomatic premature ventricular contractions (PVC). Epicardial access in the EPI group was obtained through subxyphoid puncture. Bi- and unipolar voltage mapping of endocardial and epicardial surfaces was performed. Maps were evaluated for the presence of local abnormal ventricular electrical activity (LAVA, low-voltage areas and sites with highly fractionated or late activity). Ablation was performed at sites of LAVA on either side of the ventricular wall. In the ENDO group endocardial only ablation at LAVA sites was performed. RF energy ablation was 40W at the epicardial surface and 40–50W at the endocardial surface. Results In the EPI group endocardially mapped area of unipolar endocardial low voltage zone (LVZ) significantly prevailed over bipolar endocardial area of LVZ: 75.4 cm2 [IQR: 23.2; 211.9] vs 6.7 cm2 [IQR: 4.4; 35.5](P=0.009). Epicardial bipolar LVZ area prevailed over unipolar epicardial LVZ area: 65.3 cm2 [IQR: 55.6; 91.3] vs 6.7 cm2 [IQR: 4.4; 35.3] (P=0.005). Endocardial unipolar LVZ area in the EPI group was larger than in the ENDO group (P>0,05). After ablation non-inducibility of any ventricular arrhythmia was achieved in 90% of patients in the EPI group and in 80% of cases in the ENDO group. During a mean follow-up period of 22.3±10.5 months freedom of ventricular arrhythmia recurrence was 70% in the EPI group and 100% in the control group. Conclusions Although epicardial area of abnormal potentials significantly prevails over endocardial area, endocardial unipolar mapping and higher RF ablation power allow performing successful ventricular arrhythmia treatment in the majority of ARVC patients. Funding Acknowledgement Type of funding source: None

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

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.

Catheter Ablation of Low-Voltage Areas for Persistent Atrial Fibrillation: Procedural Outcomes Using High-Density Voltage Mapping

2020 ◽  
Vol 36 (12) ◽  
pp. 1956-1964 ◽  
Author(s):  
Pablo B. Nery ◽  
Wael Alqarawi ◽  
Girish M. Nair ◽  
Mouhannad M. Sadek ◽  
Calum J. Redpath ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Low Voltage ◽  
Persistent Atrial Fibrillation ◽  
High Density ◽  
Voltage Mapping ◽  
Procedural Outcomes

P839Long-term follow-up after atrial fibrillation ablation using 3D high-density voltage mapping with a single-puncture approach

EP Europace ◽  
2018 ◽  
Vol 20 (suppl_1) ◽  
pp. i155-i155
Author(s):  
M M Oliveira ◽  
P S Cunha ◽  
B Valente ◽  
N Silva ◽  
G Portugal ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Density ◽  
Atrial Fibrillation Ablation ◽  
Voltage Mapping

scholarly journals Evaluation of a real-time magnetic resonance imaging-guided electrophysiology system for structural and electrophysiological ventricular tachycardia substrate assessment

EP Europace ◽  
2019 ◽  
Vol 21 (9) ◽  
pp. 1432-1441 ◽  
Author(s):  
Rahul K Mukherjee ◽  
Caroline Mendonca Costa ◽  
Radhouene Neji ◽  
James L Harrison ◽  
Iain Sim ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Real Time ◽  
Low Voltage ◽  
Three Dimensional ◽  
Predictive Ability ◽  
Dice Similarity Coefficient ◽  
Resonance Imaging ◽  
Voltage Mapping ◽  
Procedural Guidance

Abstract Aims Potential advantages of real-time magnetic resonance imaging (MRI)-guided electrophysiology (MR-EP) include contemporaneous three-dimensional substrate assessment at the time of intervention, improved procedural guidance, and ablation lesion assessment. We evaluated a novel real-time MR-EP system to perform endocardial voltage mapping and assessment of delayed conduction in a porcine ischaemia–reperfusion model. Methods and results Sites of low voltage and slow conduction identified using the system were registered and compared to regions of late gadolinium enhancement (LGE) on MRI. The Sorensen–Dice similarity coefficient (DSC) between LGE scar maps and voltage maps was computed on a nodal basis. A total of 445 electrograms were recorded in sinus rhythm (range: 30–186) using the MR-EP system including 138 electrograms from LGE regions. Pacing captured at 103 sites; 47 (45.6%) sites had a stimulus-to-QRS (S-QRS) delay of ≥40 ms. Using conventional (0.5–1.5 mV) bipolar voltage thresholds, the sensitivity and specificity of voltage mapping using the MR-EP system to identify MR-derived LGE was 57% and 96%, respectively. Voltage mapping had a better predictive ability in detecting LGE compared to S-QRS measurements using this system (area under curve: 0.907 vs. 0.840). Using an electrical threshold of 1.5 mV to define abnormal myocardium, the total DSC, scar DSC, and normal myocardium DSC between voltage maps and LGE scar maps was 79.0 ± 6.0%, 35.0 ± 10.1%, and 90.4 ± 8.6%, respectively. Conclusion Low-voltage zones and regions of delayed conduction determined using a real-time MR-EP system are moderately associated with LGE areas identified on MRI.

scholarly journals Delayed radiofrequency ablation efficacy in slow pathway ablation: a case report

2021 ◽  
Vol 5 (2) ◽  
Author(s):  
Ivan Zeljković ◽  
Nikola Pavlović ◽  
Vjekoslav Radeljić ◽  
Šime Manola
Keyword(s):  
Accessory Pathway ◽  
Three Dimensional ◽  
Premature Ventricular Contraction ◽  
Slow Pathway ◽  
Rf Ablation ◽  
Delayed Effect ◽  
Mapping Procedure ◽  
Junctional Rhythm ◽  
Slow Pathway Ablation

Abstract Background The delayed effect of radiofrequency (RF) ablation was described in cases of accessory pathway and premature ventricular contraction ablation, as well as delayed atrioventricular (AV) block after slow pathway ablation. Case summary We report a case of a female patient with AV nodal re-entry tachycardia (AVNRT), in whom the first electrophysiology study ended with acute failure of slow pathway ablation, despite using long steerable sheath, both right and left-sided ablation with >15 min of RF energy application and repeatedly achieving junctional rhythm. Six weeks afterwards, during scheduled three-dimensional electroanatomical mapping procedure, there was no proof of dual AV nodal conduction nor could the tachycardia be induced. Also, the patient did not have palpitations between the two procedures nor during the 12-month follow-up period. Discussion This case illustrates that watchful waiting for delayed RF ablation efficacy in some cases of AVNRT ablation could be reasonable, in order to reduce the risk of complications associated with slow pathway ablation.

scholarly journals Comparison of Unipolar and Bipolar Voltage Mapping for Localization of Left Atrial Arrhythmogenic Substrate in Patients With Atrial Fibrillation

2020 ◽  
Vol 11 ◽  
Author(s):  
Deborah Nairn ◽  
Heiko Lehrmann ◽  
Björn Müller-Edenborn ◽  
Steffen Schuler ◽  
Thomas Arentz ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Low Voltage ◽  
High Density ◽  
Border Zone ◽  
Electrode Spacing ◽  
Bipolar Voltage ◽  
Voltage Mapping ◽  
Arrhythmogenic Substrate ◽  
The Impact

Background: Presence of left atrial low voltage substrate in bipolar voltage mapping is associated with increased arrhythmia recurrences following pulmonary vein isolation for atrial fibrillation (AF). Besides local myocardial fibrosis, bipolar voltage amplitudes may be influenced by inter-electrode spacing and bipole-to-wavefront-angle. It is unclear to what extent these impact low voltage areas (LVA) in the clinical setting. Alternatively, unipolar electrogram voltage is not affected by these factors but requires advanced filtering.Objectives: To assess the relationship between bipolar and unipolar voltage mapping in sinus rhythm (SR) and AF and identify if the electrogram recording mode affects the quantification and localization of LVA.Methods: Patients (n = 28, 66±7 years, 46% male, 82% persistent AF, 32% redo-procedures) underwent high-density (>1,200 sites, 20 ± 10 sites/cm2, using a 20-pole 2-6-2 mm-spaced Lasso) voltage mapping in SR and AF. Bipolar LVA were defined using four different thresholds described in literature: <0.5 and <1 mV in SR, <0.35 and <0.5 mV in AF. The optimal unipolar voltage threshold resulting in the highest agreement in both unipolar and bipolar mapping modes was determined. The impact of the inter-electrode distance (2 vs. 6 mm) on the correlation was assessed. Regional analysis was performed using an 11-segment left atrial model.Results: Patients had relevant bipolar LVA (23 ± 23 cm2 at <0.5 mV in SR and 42 ± 26 cm2 at <0.5 mV in AF). 90 ± 5% (in SR) and 85 ± 5% (AF) of mapped sites were concordantly classified as high or low voltage in both mapping modes. Discordant mapping sites located to the border zone of LVA. Bipolar voltage mapping using 2 vs. 6 mm inter-electrode distances increased the portion of matched mapping points by 4%. The unipolar thresholds (y) which resulted in a high spatial concordance can be calculated from the bipolar threshold (x) using following linear equations: y = 1.06x + 0.26mV (r = 0.994) for SR and y = 1.22x + 0.12mV (r = 0.998) for AF.Conclusion: Bipolar and unipolar voltage maps are highly correlated, in SR and AF. While bipole orientation and inter-electrode spacing are theoretical confounders, their impact is unlikely to be of clinical importance for localization of LVA, when mapping is performed at high density with a 20-polar Lasso catheter.

scholarly journals Catheter ablation of difficult accessory pathways guided by three-dimensional electroanatomic mapping: first experience

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
N Vecchio ◽  
A Bochoeyer ◽  
JC Lopez Diez ◽  
N Schnetzer ◽  
J Dorado ◽  
...  
Keyword(s):  
Catheter Ablation ◽  
Success Rate ◽  
Three Dimensional ◽  
Electroanatomic Mapping ◽  
Av Block ◽  
Accessory Pathways ◽  
Primary Success ◽  
Acute Success ◽  
One Year

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation of paraseptal accessory pathways (PAP)  is associated with longer fluoroscopy and procedure times, more radiofrequency lesions, as well as a higher rate of recurrence and complications. In anteroseptal or midseptal PAP, recurrence and risk of AV block is even higher. Guided ablations with a three-dimensional  electroanatomic mapping system  (3D) report greater efficacy and safety. Purpose To assess the acute success rate and complications of PAP 3D catheter ablation. Report the recurrence rate at one year of follow-up. Methods Descriptive analysis that included patients with difficult PAP 3D catheter ablation between 2017 and 2019. Acute success was defined as the disappearance of ventricular pre-excitation 15 seconds after starting the application and the absence of retrograde conduction (Figure). In all cases, a one-year follow-up was performed with ECG and 24-hour Holter. Results 25 patients were included during the mentioned period. The average age was 23 years, 60% (15 p) were men and 56% (14 p) were symptomatic due to palpitations. 1 patient had previous heart disease (ebstein"s anomaly). 36% (9 p) had a previous procedure: 5 patients with previous failed radiofrequency ablation, 1 patient with failed anteroseptal cryoablation and 3 patients with suspended ablation due to risk of AV block. The most frequent location was the posteroseptal. (Table) The primary success rate was 92% (23 of 25 p). Ablation was unsuccessful in two patients, one with Ebstein"s disease and the other with a left posteroseptal PAP. None of the patients presented complications associated with the procedure. During the one-year follow-up, one patient was registered with asymptomatic recurrence (1 of 23; 4.35%: right posteroseptal location), demonstrated by manifest preexcitation on the control ECG. Conclusion In our first experience, catheter ablation of difficult accessory pathways guided by three-dimensional electroanatomic mapping showed a high primary success rate without associated complications. Recurrence during follow-up was similar to that reported in the literature. Accessory Pathway locationPatientsRight Posteroseptal11 (44%)Left Posteroseptal5 (20%)Anteroseptal5 (20%)Midseptal4 (16%)Abstract Figure

scholarly journals Clinical Outcomes of low-voltage area-guided left atrial linear ablation for non-paroxysmal atrial fibrillation patients

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0260834
Author(s):  
Hao-Tien Liu ◽  
Chia-Hung Yang ◽  
Hui-Ling Lee ◽  
Po-Cheng Chang ◽  
Hung-Ta Wo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Paroxysmal Atrial Fibrillation ◽  
Left Atrial ◽  
Low Voltage ◽  
Reverse Remodeling ◽  
Voltage Mapping ◽  
Linear Ablation

Background The therapeutic effect of low-voltage area (LVA)-guided left atrial (LA) linear ablation for non-paroxysmal atrial fibrillation (non-PAF) is uncertain. We aimed to investigate the efficacy of LA linear ablation based on the preexisting LVA and its effects on LA reverse remodeling in non-PAF patients. Methods We retrospectively evaluated 145 consecutive patients who underwent radiofrequency catheter ablation for drug-refractory non-PAF. CARTO-guided bipolar voltage mapping was performed in atrial fibrillation (AF). LVA was defined as sites with voltage ≤ 0.5 mV. If circumferential pulmonary vein isolation couldn’t convert AF into sinus rhythm, additional LA linear ablation was performed preferentially at sites within LVA. Results After a mean follow-up duration of 48 ± 33 months, 29 of 145 patients had drugs-refractory AF/LA tachycardia recurrence. Low LA emptying fraction, large LA size and high extent of LVA were associated with AF recurrence. There were 136 patients undergoing LA linear ablation. The rate of linear block at the mitral isthmus was significantly higher via LVA-guided than non-LVA-guided linear ablation. Patients undergoing LVA-guided linear ablation had larger LA size and higher extent of LVA, but the long-term AF/LA tachycardia-free survival rate was higher than the non-LVA-guided group. The LA reverse remodeling effects by resuming sinus rhythm were noted even in patients with a diseased left atrium undergoing extensive LA linear ablation. Conclusions LVA-guided linear ablation through targeting the arrhythmogenic LVA and reducing LA mass provides a better clinical outcome than non-LVA guided linear ablation, and outweighs the harmful effects of iatrogenic scaring in non-PAF patients.

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