Management of macro-reentrant right atrial tachycardia around multiple leads aided by high-density mapping

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.

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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

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High-density Mapping Facilitates Successful Ablation of Postincisional Right Atrial Flutter After Previous Mechanical Mitral Valve Replacement

Journal of Innovations in Cardiac Rhythm Management ◽

10.19102/icrm.2021.120101s ◽

2020 ◽

Vol 12 (S1) ◽

pp. 9-10

Author(s):

Bernnard Strohmer ◽

Franz Danmayr ◽

Johannes Kraus ◽

Markus Lassnig ◽

Uta Hoppe

Keyword(s):

Mitral Valve ◽

Atrial Flutter ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

High Density ◽

Right Atrial ◽

Density Mapping ◽

Successful Ablation

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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

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.0427 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

C Jungen ◽

R Akbulak ◽

A Kahle ◽

C Eickholt ◽

B Schaeffer ◽

...

Keyword(s):

Catheter Ablation ◽

Atrial Tachycardia ◽

Outcome Data ◽

High Density ◽

Density Mapping ◽

Number Of Patients ◽

Basket Catheter ◽

Acute Success ◽

The Right ◽

Mean Cycle

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

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A Direction-independent, High-density Mapping Catheter Provides Electrophysiological Advantage in Complex Atrial Tachycardia Ablation Following Pulmonary Vein Isolation

Journal of Innovations in Cardiac Rhythm Management ◽

10.19102/icrm.2021.121203 ◽

2021 ◽

Vol 12 (12) ◽

pp. 4785-4788

Author(s):

GREGORY WOO ◽

CATHERINE MARKERT ◽

REBEKAH MONTGOMERY

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Atrial Tachycardia ◽

High Density ◽

Density Mapping ◽

Mapping Catheter

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P4838Endocardial diagnosis of clockwise ridge-related atrial tachycardia utilizing ultra-high-density mapping system

European Heart Journal ◽

10.1093/eurheartj/ehy563.p4838 ◽

2018 ◽

Vol 39 (suppl_1) ◽

Author(s):

T Kajiyama ◽

Y Kanno ◽

Y Sumino ◽

A Sugano ◽

K Yamao ◽

...

Keyword(s):

Atrial Tachycardia ◽

High Density ◽

Density Mapping ◽

Mapping System

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Benefit of ultra-high-density mapping-guided radiofrequency reablation in pulmonary vein isolation non-responders after initial cryoballoon procedure

EP Europace ◽

10.1093/europace/euaa055 ◽

2020 ◽

Vol 22 (6) ◽

pp. 906-915

Author(s):

Florian Straube ◽

Uwe Dorwarth ◽

Stefan Hartl ◽

Benedikt Brueck ◽

Janis Pongratz ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Left Atrial ◽

Atrial Tachycardia ◽

Antiarrhythmic Drugs ◽

High Density ◽

Right Atrial ◽

Atrial Arrhythmias ◽

Electroanatomical Mapping ◽

Septal Wall

Abstract Aims Symptomatic atrial arrhythmias despite complete pulmonary vein isolation (PVI) are common. The purpose was to evaluate ultra-high-density multi-electrode electroanatomical mapping-guided radiofrequency ablation (RFA) in PVI non-responders. Methods and results Ultra-high-density multi-electrode electroanatomical mapping-guided RFA in consecutive symptomatic atrial fibrillation (AF) patients after initial cryoballoon PVI was performed. Patients were included if all pulmonary veins (PVs) were still isolated. Radiofrequency targets were atrial tachycardia (AT), extra-PV trigger, and/or substrate. Procedural results and outcome were evaluated. Of 95 patients, 67 (70.5%) with complete PVI were included (70 years, CHA2DS2Vasc 2.9, left atrium 45 mm, persistent AF 45%, AT 45%). The median time to reablation was 26 months. One hundred and seven maps (1.6/patient) and 11.890 ± 9.018 electrograms were acquired in 33 ± 12 min. Twenty-eight percent of the left atrial (LA) wall showed pathological voltage signals, predominantly at the anterior (37%) and septal wall (26%). Atrial tachycardia (49 left, 4 right) were ablated in 35 patients (52%), extra-PV trigger in two patients (3%). One atrioventricular nodal re-entry tachycardia and seven right atrial isthmus ablation (10%) were performed. In 32 patients (48%), no AT was present and substrate-based ablation was performed. Mean LA area ablated was 7 ± 6 cm2 (7%). No major complication occurred. The mean follow-up time was 772 ± 317 days. Freedom from atrial arrhythmia recurrence off antiarrhythmic drugs was 49% at 12 months. Conclusion Pulmonary vein isolation non-responders are older, mainly suffering from complex atrial arrhythmias. Left atrial substrate is predominantly located at the anterior and septal wall. Ultra-high-density multi-electrode electroanatomical mapping-guided RFA is safe and effective. At 1 year, 5 out of 10 patients were in stable sinus rhythm off antiarrhythmic drugs.

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