P975Composite electroanatomical maps locate rapid activity within low voltage zones in persistent AF

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
S Nagy ◽  
P Kasi ◽  
V Afonso ◽  
I Mann ◽  
S Kim ◽  
...  
Keyword(s):  
Pattern Recognition ◽  
Catheter Ablation ◽  
Pulmonary Vein ◽  
Cycle Length ◽  
Low Voltage ◽  
Complex Pattern ◽  
Extensive Experience ◽  
Mean Values ◽  
Double Spiral ◽  
Automated Algorithms

Abstract Funding Acknowledgements Our research group receives an educational grant from Abbott Inc. Introduction. Outcomes from catheter ablation of persistent AF (psAF) are not favourable. The two prevailing major directions to improve success are left atrial (LA) substrate ablation, and non pulmonary vein driver ablation. In LA substrate ablation guided by intracardiac voltage, there is debate on the most fitting mapping rhythm and the appropriate cut offs for low voltage zones (LVZ). Non pulmonary vein driver ablation requires extensive experience and relies on complex pattern recognition by the operator, introducing subjectivity, that may lead to reduced reproducibility. AF drivers have been shown to localise to LVZs. We propose an objective, patient-tailored method of identifying rapid activity within LVZs to locate drivers of psAF.  Methods. Eleven patients (61 ± 10.8 years of age, 9 male) undergoing first time catheter ablation for psAF were included. 3D maps were collected with a double spiral 20 pole catheter, in non-cardiac triggered mode, recording 8s segments at each bipole. Mean AF voltage (AFV) a AF cycle length (AFCL) was calculated for each 8s segment using automated algorithms. Grades of rapid activity and low voltage were defined as the 10th 20th and 30th percentile of all collected points within a patient. Percentile-matched composite LVZ-ARA maps were created on a research platform.  Results. Mean LVZ percentage of the total mapped area was 4.67 ± 2.4%, 13.95 ± 3.8%, 23.81 ± 5.7% for the 10th, 20th and 30th percentiles respectively (Table 1). Mean, percentile matched LVZ-ARA overlap area percentage of the total mapped area was 0.3 ± 0.25% (10th-10th), 0.86 ± 0.58 (20th-20th), 3.1 ± 1.9% (30th-30th). ARAs represented a small proportion of all LVZs. Location of overlap areas differed significantly between patients and were marked with colours. Multi-colour areas including purple represent LVZ, multi-colour areas excluding purple, show LVZ-ARA overlap (examples in Fig 1).  Conclusion. Analysis of LVZ-ARA overlap by mean AFV and AFCL provides an objective method of identifying potential drivers that localise to LVZs. The identified overlap areas constituted small, occasionally disparate areas within the LVZ of the LA. By adjusting the AFCL and AFV percentiles, the overlap areas can be tailored at the operator’s discretion, maintaining reproducible, objective decision making, without the need for complex pattern recognition. If ablation is planned, established techniques can be used to target the overlap areas, such as homogenisation or transection and connection to anatomical or ablative non-conductive tissues. AFCL 10th AFCL 20th AFCL 30th AFV 10th AFV 20th AFV 30th All patients 128 ± 13 ms 144 ± 10 ms 150 ± 9 ms 0.15 ± 0.02 mV 0.19 ± 0.03 mV 0.24 ± 0.04 mV Mean values of percentile cut offs. AFCL: AF cycle length; AFV: AF voltage Abstract Figure. Fig 1

scholarly journals Atypical atrial flutter: a new methodology for critical isthmi identification?

2020 ◽  
Author(s):  
Pedro Adragão ◽  
Daniel Matos ◽  
Francisco Moscoso Costa ◽  
Pedro Carmo ◽  
Diogo Cavaco ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Atrial Flutter ◽  
Cycle Length ◽  
Low Voltage ◽  
Supraventricular Arrhythmia ◽  
Low Density ◽  
Electroanatomical Mapping ◽  
Activation Times ◽  
Density Zone

ABSTRACTIntroductionAtypical atrial flutter is a supraventricular arrhythmia that can be treated with catheter ablation. However, the best approach is still to be defined and this strategy has suboptimal results. The Carto® electroanatomical mapping (EAM) system can display a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL). This study aimed to assess the ability of this new tool to identify the critical isthmus of this arrhythmia.MethodsRetrospective analysis of a unicentric registry of individuals who underwent left AFL ablation during a 1-year period with Carto® EAM. All patients with non-left AFL, lack of high-density EAM, less than 2000 collected points or lack of mapping in any of the left atrium walls or structures were excluded. We compared the ablation sites of arrhythmia termination to the sites of histogram valleys (LAT-Valleys), defined as areas of low-voltage (<0.3mV) with 10% or more of the TCL and less than 20% density points relative to the highest density zone. The longest LAT-Valley was designated as the primary valley, while additional valleys were named as secondary.ResultsA total of 9 patients (6 men, median age 75 IQR 71-76 years) were included. All patients presented with left AFL and 66% had a previous atrial fibrillation and/or flutter ablation. The median TCL and number collected points were 254 (220─290) milliseconds and 3300 (IQR 2410─3926) points, respectively. All AFL presented with at least 1 LAT-Valley in the analysed histograms, which corresponded to heterogeneous low-voltage areas (<0.3mV). All arrhythmias were effectively terminated after undergoing radiofrequency ablation in the primary LAT-Valley location.ConclusionA low-density and prolonged LAT-Valley in a heterogeneous low-voltage area compose an electrophysiologic triad that allows the identification of the AFL critical isthmus. Further studies are needed to assess the usefulness of this tool for improving catheter ablation outcomes.

scholarly journals Electrophysiological predictors of ventricular tachycardia recurrence in patients with structural heart disease after combined endo-epicardial substrate catheter ablation

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
K A Simonova ◽  
R B Tatarskiy ◽  
A V Kamenev ◽  
V S Orshanskaya ◽  
V K Lebedeva ◽  
...  
Keyword(s):  
Heart Disease ◽  
Ventricular Tachycardia ◽  
Catheter Ablation ◽  
Cycle Length ◽  
Low Voltage ◽  
Heart Diseases ◽  
Structural Heart Disease ◽  
Substrate Modification ◽  
Structural Heart Diseases ◽  
Late Potential

Abstract Background Although there is a tremendous improvement in mapping and ablation techniques over the last decades, the recurrence rate of ventricular tachycardia (VT) in patients with structural heart diseases following endo-epicardial catheter ablation remains high. Purpose To determine predictors of VT recurrence in patients with structural heart disease after combined endo-epicardial radiofrequency (RF) VT ablation. Methods This prospective single-center study included 39 patients (34 men and 5 women, mean age 49.6±16.0 years), who underwent endo-epicardial mapping and ablation of the VT substrate. Etiology of structural heart diseases included: previous myocardial infarction (n=15); non-ischemic cardiomyopathy (n=24: 15 – arrhythmogenic right ventricular cardiomyopathy (ARVC), 6 – myocarditis, 3 – unspecified). First-line epicardial access was performed in 16 patients, as a second approach – in 23 subjects. We evaluated total ventricular myocardial areas, epi- and endocardial areas with bipolar low voltage (&lt;1.5mV), scar area (bipolar &lt;0.5mV), and unipolar low voltage (&lt;5.0mV) and transient (&lt;8.0mV) areas; areas of late potential registration were evaluated. Ratios of transient, low amplite and late-potential areas were calculated for endo- and epicardial surfaces, bipolar and unipolar maps. The following procedural electrophysiology characteristics were considered: inducibility of clinical VT, the number and morphology of induced VT, QRS width on sinus rhythm and VT, tachycardia cycle length, pseudo-delta wave extant and width, internal activation time, intrisicoud deflection time, and RS length. Clinical data such as echocardiography parameters, comorbidity and antiarrhythmic drug therapy were also taken into account. VT recurrences were documented using ICD/CRT-D interrogation, event ECG monitoring. Follow-up included mandatory visits at 6 and 12 months and unscheduled visits. Results Epicardial late potentials were registered in 69% of cases before ablation. Epicardial RF applications were delivered in 67% of patients; while only endocardial RF applications (including cases with intended epicardial substrate modification by endocardial ablation) were present in 28% cases. Non-inducibility of any VT plus abatement of local abnormal electrical activity was achieved in 32 (82%) of cases. The ratio epi/endo bipolar areas &lt;0.5mV was much higher in patients with vs without VT recurrence at 6 months (4.3 (IQR: 2.5; 8.2) vs 0.75 (IQR:0.4; 1.6), P=0.001). A strong negative correlation was found between the induced VT cycle length and the ratio epi/endo bipolar areas &lt;0.5mV: the shorter induced VT cycle length -the larger the area of the epicardial low voltage area (r=−0,52). Conclusion Regardless of epicardial substrate modification, patients with a larger epicardial low voltage area are more likely to have VT recurrence at 6 months after index ablation. A shorter induced VT cycle length is associated with a larger epicardial low-voltage area. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Electrical anatomy of the left atrium during atrial fibrillation

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
P Adragao ◽  
D Nascimento Matos ◽  
F Costa ◽  
P Galvao Santos ◽  
G Rodrigues ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Left Atrium ◽  
Pulmonary Vein ◽  
Refractory Period ◽  
Cycle Length ◽  
Low Voltage ◽  
Pulmonary Veins ◽  
Short Cycle ◽  
Superior Pulmonary Vein

Abstract Introduction Twenty years ago, pulmonary veins (PV) ostia were identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Today, a special tool using the Carto® electroanatomical mapping (EAM) allows for AF cycle length mapping (CLM), to identify the areas in the left atria with shortest refractory period, during atrial fibrillation. Using this EAM tool, our study aimed to find the LA areas with the shortest refractory period to better recognize electrical targets for catheter ablation. Methods Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI with Carto® EAM. CLM was performed with a high-density mapping Pentaray® catheter before and after PVI and in 4 redo procedures. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV). Results A total of 18 patients (8 men, median age 63 IQR 58–71 years) were included. Most patients presented with persistent AF (n=12, 67%), and 4 patients (22%) had a previous PVI. The mean shortest measured cycle length in AF was 140ms (SD ±27ms). All patients presented areas of SCL located in the PVs or their insertion, 70% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) (figure 1) and 60% in the anterior region of the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (17%). SCL were related to low-voltage areas in 94% and were adjacent to CFAE. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL. Conclusion We confirmed in 3D mapping that PVs are the LA zones with shortest refractory period, not only in sinus rhythm but also during AF. The persistence of SCL areas in the border zones of the PVI lines suggest the benefit of a more extensive CLM guided ablation. Larger studies are needed. FUNDunding Acknowledgement Type of funding sources: None. Short cycle length mapping

Abstract 11670: Presence of Dissociated Pulmonary Vein Activity After Isolation Depends on Fibrillatory Excitation in Pulmonary Vein

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Takashi Kaneshiro ◽  
Hitoshi Suzuki ◽  
Yoshiyuki Matsumoto ◽  
Minoru Nodera ◽  
Yoshiyuki Kamiyama ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Pulmonary Vein ◽  
Significant Relationship ◽  
Clinical Implication ◽  
Cycle Length ◽  
Electrophysiological Property ◽  
Successful Isolation ◽  
Mean Cycle ◽  
Af Recurrence

Background: Circumferential pulmonary vein (PV) isolation has been widely accepted as catheter ablation for atrial fibrillation (AF). Dissociated PV activity (DPVA) may appear after PV isolation, however, the electrophysiological property and clinical implication of DPVA have not been revealed. Methods and Results: The study subjects were consecutive 37 patients (62±8 years, 28 men) with drug-refractory AF who underwent successful PV isolation. Electrophysiological property of left atrium (LA) and PV during and after PV isolation were investigated. Excluded 21 PVs without LA-PV connection before procedure, all of 112 PVs with successful isolation were analyzed. DPVA appeared in 14 PVs (13%) after PV isolation, from left superior PV in 7 (50%), right superior PV in 5 (36%) and left inferior PV in 2 (14%). Mean cycle length (CL) of DPVA was 5180±3080 ms. DPVA appeared in 9 of 37 PVs (24%) without existence of AF, but in 5 of 75 PVs (7%) with existence of AF during procedure (P=0.008). There was the tendency that the CL of DPVA was shorter with existence of AF compared to that without existence of AF (3792±1815 vs. 6682±3041 ms, P=0.08), and the suppression of DPVA was observed by over drive pacing inside of PV with PV capture in several cases. There was not significant relationship between the presence of DPVA and AF recurrence with 2-month blanking period after PV isolation. Conclusions: The presence of DPVA after PV isolation depended on the existence of AF during procedure, but was not significantly related to the AF recurrence after PV isolation. The long CL and suppressive maneuver with PV over drive pacing suggested the vulnerability of DPVA. Thus, these findings suggest that passive and/or spontaneous fibrillatory excitation in PV might suppress the automatic activity of myocardial sleeves in PV.

P991Pattern of rapid activity is preserved in persistent AF in selected locations after pulmonary vein isolation

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
S Nagy ◽  
P Kasi ◽  
V Afonso ◽  
I Mann ◽  
S Kim ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Cycle Length ◽  
Driving Mechanisms ◽  
Automated Algorithm ◽  
Educational Grant ◽  
Cumulative Duration ◽  
Double Spiral ◽  
Number Of Segments ◽  
Funding Acknowledgements

Abstract Funding Acknowledgements Our research group receives an educational grant from Abbott Inc. Introduction. There is evidence to suggest that structural remodelling in psAF potentially gives rise to areas of rapid cycle length activity that may act as driving mechanisms. We describe a new method to compare rapid activity (RA) in psAF prior to and after pulmonary vein isolation, in extended AF segments (EAFS). We focus on patterns of RA, based on the hypothesis that AF drivers are transient but recur in the same locations.  Methods. Five patients (61 ± 8 years of age, 3 male) for catheter ablation of psAF were included. 3D maps were collected with a double spiral 20 pole catheter. In stable locations, pre and post PVI, 37s EAFS were recorded using 8s segments, automatically every 1s, creating a 7s overlap between segments. Dominant cycle length (DCL) was determined for every 8s segment by a fully automated algorithm. RA was defined as the rapidest 20th percentile for each patient. RA episodes consisted of continuous segments with rapid DCL (black lines in Fig 1) and terminated with a non-rapid segment (red lines on Fig 1). Episodes were truncated where overlap occurred (Box 1 and Box 2 in Fig 1). The pattern of RA was assessed by the number, cumulative duration and mean duration of RA episodes within an EAFS pre and post PVI. Results. Mean DCL of EAFS increased significantly in 4/5 patients after PVI, the number of EAFS with rapid activity showed a reduction in all patients.  The percentage of new sites with RA post PVI was 27%. The number of sites that retained RA post PVI was 14 ± 11.3 (58.3%; Table 1).  Of these, number and cumulative duration of RA did not change in 4/5 patients, and mean duration of RA remained stable in 5/5. Conclusion. An automated DCL algorithm shows that, in most cases, global AFCL prolongs significantly with PVI overall, but selected foci retain RA and RA patterns. These may represent active drivers, as their activity appears to be independent of their surroundings. Table 1 Patient ID Number of segments Mean AFCL ± SD of all segments Number of EAFS with rapid activity Pre-PVI Post-PVI P Pre-PVI Post-PVI New sites 1 145 135 ± 8.9 141 ± 9.8 &lt;0.001 94 62 15 2 121 154 ± 12.9 162 ± 15.0 &lt;0.001 94 72 11 3 172 148 ± 13.7 160 ± 16.6 &lt;0.001 108 82 25 4 301 172 ± 22.9 174 ± 21.5 0.418 198 189 58 5 200 177 ± 9.9 215 ± 18.1 &lt;0.001 87 43 14 Pre and Post PVI cycle length and EAFS with rapid activity. (AFCL: AF cycle length; EAFS: Extended AF segments; PVI: Pulmonary vein isolation) Abstract Figure.

scholarly journals Electrical anatomy of the left atrium during atrial fibrillation

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
P Adragao ◽  
D Nascimento Matos ◽  
F Costa ◽  
P Galvao Santos ◽  
G Rodrigues ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Left Atrium ◽  
Pulmonary Vein ◽  
Refractory Period ◽  
Cycle Length ◽  
Low Voltage ◽  
Pulmonary Veins ◽  
Density Mapping ◽  
Superior Pulmonary Vein

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Twenty years ago, pulmonary veins (PV) ostia were identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Today, a special tool using the Carto® electroanatomical mapping (EAM) allows for AF cycle length mapping (CLM), to identify the areas in the left atria with shortest refractory period, during atrial fibrillation. Using this EAM tool, our study aimed to find the LA areas with the shortest refractory period to better recognize electrical targets for catheter ablation. Methods Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI with Carto® EAM. CLM was performed with a high-density mapping Pentaray® catheter before and after PVI and in 4 redo procedures. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV). Results A total of 18 patients (8 men, median age 63 IQR 58-71 years) were included. Most patients presented with persistent AF (n = 12, 67%), and 4 patients (22%) had a previous PVI. The mean shortest measured cycle length in AF was 140ms (SD ±27ms). All patients presented areas of SCL located in the PVs or their insertion, 70% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) (figure 1) and 60% in the anterior region of the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (17%). SCL were related to low-voltage areas in 94% and were adjacent to CFAE. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL. Conclusion   We confirmed in 3D mapping that PVs are the LA zones with shortest refractory period, not only in sinus rhythm but also during AF. The persistence of SCL areas in the border zones of the PVI lines suggest the benefit of a more extensive CLM guided ablation. Larger studies are needed. Abstract Figure 1

TIMELY DIAGNOSTICS OF CATHETER ABLATION COMPLICATIONS: CLINICAL CASE OF PULMONARY VEIN STENOSIS

2018 ◽  
Vol 8 (4) ◽  
pp. 248-255
Author(s):  
O.V. Sapelnikov ◽  
◽  
E.V. Merkulov ◽  
O.A. Nikolaeva ◽  
D.I. Cherkashin ◽  
...  
Keyword(s):  
Catheter Ablation ◽  
Pulmonary Vein ◽  
Clinical Case ◽  
Pulmonary Vein Stenosis ◽  
Vein Stenosis

Point ablation for macro-reentrant ventricular tachycardia associated with Ebstein’s anomaly and pulmonary atresia: a case report

2020 ◽  
pp. 1-3
Author(s):  
Keiko Toyohara ◽  
Yasuko Tomizawa ◽  
Morio Shoda
Keyword(s):  
Ventricular Tachycardia ◽  
Case Report ◽  
Catheter Ablation ◽  
Right Ventricle ◽  
Low Voltage ◽  
Pulmonary Atresia ◽  
Ebstein’S Anomaly ◽  
Ebstein's Anomaly ◽  
Slow Conduction ◽  
Hypoplastic Right Ventricle

Abstract We report a case with Ebstein’s anomaly and pulmonary atresia with sustained monomorphic ventricular tachycardia in a patient without a ventriculotomy history. In the low voltage area between the atrialised right ventricle and hypoplastic right ventricle, there was a ventricular tachycardia substrate and slow conduction. The tachycardia circuit was eliminated by a point catheter ablation at the area with diastolic fractionated potentials.

scholarly journals Echocardiographic diagnosis of atrial cardiomyopathy allows outcome prediction following pulmonary vein isolation

2021 ◽  
Author(s):  
Martin Eichenlaub ◽  
Bjoern Mueller-Edenborn ◽  
Jan Minners ◽  
Martin Allgeier ◽  
Heiko Lehrmann ◽  
...  
Keyword(s):  
Sinus Rhythm ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Validation Cohort ◽  
Low Voltage ◽  
Predictive Values ◽  
Contact Mapping ◽  
Non Invasive ◽  
Increased Risk ◽  
Echocardiographic Parameters

Abstract Background Relevant atrial cardiomyopathy (ACM), defined as a left atrial (LA) low-voltage area ≥ 2 cm2 at 0.5 mV threshold on endocardial contact mapping, is associated with new-onset atrial fibrillation (AF), higher arrhythmia recurrence rates after pulmonary vein isolation (PVI), and an increased risk of stroke. The current study aimed to assess two non-invasive echocardiographic parameters, LA emptying fraction (EF) and LA longitudinal strain (LAS, during reservoir (LASr), conduit (LAScd) and contraction phase (LASct)) for the diagnosis of ACM and prediction of arrhythmia outcome after PVI. Methods We prospectively enrolled 60 consecutive, ablation-naive patients (age 66 ± 9 years, 80% males) with persistent AF. In 30 patients (derivation cohort), LA-EF and LAS cut-off values for the presence of relevant ACM (high-density endocardial contact mapping in sinus rhythm prior to PVI at 3000 ± 1249 sites) were established in sinus rhythm and tested in a validation cohort (n = 30). Arrhythmia recurrence within 12 months was documented using 72-h Holter electrocardiograms. Results An LA-EF of < 34% predicted ACM with an area under the curve (AUC) of 0.846 (sensitivity 69.2%, specificity 76.5%) similar to a LASr < 23.5% (AUC 0.878, sensitivity 92.3%, specificity 82.4%). In the validation cohort, these cut-offs established the correct diagnosis of ACM in 76% of patients (positive predictive values 87%/93% and negative predictive values 73%/75%, respectively). Arrhythmia recurrence in the entire cohort was significantly more frequent in patients with LA-EF < 34% and LASr < 23.5% (56% vs. 29% and 55% vs. 26%, both p < 0.05). Conclusion The echocardiographic parameters LA-EF and LAS allow accurate, non-invasive diagnosis of ACM and prediction of arrhythmia recurrence after PVI. Graphic abstract

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