endocardial mapping
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2022 ◽  
Vol 12 (1) ◽  
Author(s):  
Björn Müller-Edenborn ◽  
Jan Minners ◽  
Cornelius Keyl ◽  
Martin Eichenlaub ◽  
Nikolaus Jander ◽  
...  

AbstractThromboembolism and stroke are dreaded complications in atrial fibrillation (AF). Established risk stratification models identify susceptible patients, but their discriminative properties are poor. Atrial cardiomyopathy (ACM) is associated to thromboembolism and stroke in smaller studies, but the modalities used for ACM-diagnosis (MRI and endocardial mapping) are unsuitable for widespread population screening. We aimed to investigate an ECG-based diagnosis of ACM using amplified p-wave analysis (APWA) for stratification of thromboembolic risk and cardiovascular outcome. In this case–control study, ACM-staging was performed using APWA on digital 12-lead sinus rhythm-ECGs in patients with LAA-thrombus and a propensity-score-matched control-cohort. Left atrial contractile function and thrombi were evaluated by transesophageal echocardiography (TEE). Outcome for MACCE including death was assessed using official registries and structured phone interviews. Left-atrial appendage [LAA]-thrombi and appropriate sinus rhythm-ECGs for ACM-staging were found in 109 of 4086 patients that were matched 1:1 to control patients without thrombus (218 patients in total). Both cohorts were comparable regarding cardiovascular risk factors, anticoagulants and CHA2DS2-VASC-score. ACM-stages 1 to 3 (equivalent to no, moderate and extensive ACM) were found in 63 (57.8%), 36 (33.0%) and 10 (9.2%) of patients without and 3 (2.8%), 23 (21.1%) and 83 (76.1%) of patients with LAA-thrombi. Atrial contractile function decreased from ACM-stages 1 to 3 (LAA-flow velocities 38 ± 16 cm/s, 31 ± 15 cm/s and 21 ± 12 cm/s; p < 0.0001), while the likelihood for LAA-thrombus increased (2.8%, 21.1% and 76.1%, p < 0.001). Multivariable analysis confirmed an independent odds ratio for LAA-thrombus of 24.6 (p < 0.001) per ACM-stage. Two-year survival free of stroke/TIA, hospitalization for heart failure, myocardial infarction or all-cause death was strongly reduced in ACM-stage 3 (53.8%) compared to no or moderate ACM (82.8% and 84.7%, respectively; p < 0.0001). Electrocardiographic diagnosis of ACM identifies patients with atrial contractile dysfunction and atrial thrombi at risk for adverse cardiovascular outcomes and death.


Author(s):  
Weizhu Ju ◽  
jinlin zhang ◽  
Linsheng Shi ◽  
Kai Gu ◽  
Ming Chu ◽  
...  

Aims Idiopathic epicardial ventricular arrhythmias (VAs) are clustered in the areas of the summit and crux. This study was to report a group of idiopathic epicardial VAs remote from the summit and crux areas. Methods In total, 9 patients (6 males, mean age 32±13 years) were enrolled. The locations were identified by epicardial mapping and ablation. The electrocardiographic and electrophysiological characteristics were compared to those of 9 patients who had VAs ablated at the opposite endocardial site. Results VAs were identified at the epicardium, with 4 patients had VAs located at the inferior wall, one at the anterior wall, one at the apex and 3 patients had VAs at the lateral wall. A “QS” type at the location-related leads was the only identified surface electrocardiogram indication suggesting epicardial origin (compared to that of the controls, 100% vs 0%, p<0.001). Endocardial and epicardial mapping revealed pre-maturities of -11±4 ms and -25±8 ms, respectively (VS. -28±8 ms revealed by endocardial mapping in control patients, p<0.001 and p=0.389, respectively). All of the study cases demonstrated an “rS” pattern in the endocardial unipolar electrogram. Acute and long-term successful ablation (a median of 11 months of follow-up) was achieved in all patients without complications. Conclusion A distinct group of idiopathic VAs remote from the summit and crux areas warranting ablation by a subxiphoid approach were identified. Morphological ECG features of a “QS” type among the location-related grouped leads combined with the mapping findings helped in the identification of the epicardial site of origin.


Author(s):  
Ahmad Halawa ◽  
Paul Zei ◽  
Neal Lakdawala ◽  
William Sauer ◽  
Usha Tedrow ◽  
...  

Lamin Cardiomyopathy (LC) is associated with refractory ventricular arrhythmias. Catheter ablation success rate is low due to presence of multiple circuits and intramural substrate. We present a LC case presented with electrical storm. During catheter ablation, arrhythmia was easily inducible but activation mapping, including full epicardial and endocardial mapping, failed to demonstrate the full tachycardia cycle length (70% only) suggesting intramural activation. Critical isthmus was not identified even with successful concealed entrainment on both Endo/epicardial surfaces. This case shows that even combined endocardial and epicardial catheter approach can be ineffective in identifying the full arrhythmogenic substrate in LC.


2021 ◽  
Vol 28 (1) ◽  
pp. 33-37
Author(s):  
E. V. Dedukh ◽  
E. A. Artyukhina

Aims. To determine the role of the prevalence of low-voltage areas in the occurrence of arrhythmia recurrence after interventional treatment of atrial fibrillation (AF).Methods. The study included 38 patients with paroxysmal (52.6%) and persistent (47.4%) forms of AF who underwent interventional treatment of AF using high-density electroanatomical mapping (at least 10,000 EGM points). Analysis of electroanatomical maps was performed after the completion of the ablation procedure. The area of the low-voltage zones was measured manually. Then, the areas of all regions of low-voltage activity were summed up; the resulting value was expressed as a percentage of the total surface area of the left atrium (LA).Results. The observation period was 12.8±3.2 months. Based on the results of endocardial mapping, all patients were divided into 2 groups according to the prevalence of low-voltage areas in the LA. The first group included patients with an area of low-voltage zones less than 5% of the total surface of the left atrium, and the second with an area of low-voltage areas of more than 5% of the total surface of the left atrium. The patients of the first group had a lower LA volume compared to patients from the second group, with mean values of 119.87±16.35 ml and 154.57±33.23 ml, respectively (p=0.007). In the first group, AF recurrence was recorded in one patient after catheter treatment, in the second group in 5 patients.Conclusion. Common areas of low-voltage activity in the left atrium, detected by high-density mapping before the procedure for catheter treatment of AF, are a predictor of arrhythmia recurrence after interventional treatment.


Author(s):  
Chen Chun-hui

A 63-year-old female patient with a history of pulmonary heart disease underwent radiofrequency ablation because ofa persistent atrial flutter. Endocardial mapping with the carto3 system confirmed atrial flutter counterclockwise reentryaround the tricuspid annulus. Routine ablation of the cavo-tricuspid isthmus line to bi-directional block was performed.However, tachycardia with the same cycle length was induced again. After remapping, the tachycardia was confirmedto be focal atrial tachycardia located in the crista terminalis. After ablation, the tachycardia was terminated and couldnot be induced again.


Heart Rhythm ◽  
2020 ◽  
Vol 17 (12) ◽  
pp. 2154-2163 ◽  
Author(s):  
Ramanathan Parameswaran ◽  
Geoffrey Lee ◽  
Gwilym M. Morris ◽  
Alistair Royse ◽  
John Goldblatt ◽  
...  

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Schenk ◽  
A Terne ◽  
B Keweloh ◽  
C Lenz ◽  
U Zacharzowsky ◽  
...  

Abstract Background Whereas pulmonary vein isolation lays the groundwork of endocardial atrial fibrillation (AF) ablation, it leaves patients undertreated. Additional substrate modification of the left atrium is often required, but lesion gaps and non-transmurality limit restoration of sinus rhythm. Moreover, some low voltage areas and conduction abnormalities are located exclusively on the epicardial aspect, and endocardial ablation alone does not address these issues. Our hybrid endo-/epicardial ablation strategy overcomes all these shortcomings. Purpose To test if the combination of epicardial cryo and radiofrequency (RF) ablation (dual) further improves the quality of ablation lines, and if the combined endo-/epicardial ablation can treat intractable cases of AF. Methods Twenty-six patients (13 paroxysmal, 13 long-persistent; 20 patients with 1–5 prior endocardial AF ablations) first underwent epicardial, total thoracoscopic beating heart ablation (TTA). Lesion sets included bilateral PVI, left atrial appendage closure, as well as superior (roof) and inferior (floor) interpulmonary vein lines. Roof and floor lines were alternatingly ablated by dual energy or RF only. Three months post TTA, endocardial mapping with optional gap closure completed this two-stage hybrid concept. Results Intraoperatively, 24 of 40 (60%) previous left or right endocardial PVIs were found incomplete. Apart from two post-TTA pacemaker insertions and one mini-thoracotomy for bleeding, respectively, no major morbidity was observed during follow up. The full protocol of the hybrid concept was applied in 24 patients. Forty-five of 47 (96%) epicardial PVIs were found gap-less during endocardial mapping, and the remaining 2 PVIs were readily re-ablated. In contrast, only 32 of 46 (70%) roof and floor lines were complete, and endocardial touch up was required in one of three patients. Of note, dual energy lines were more likely to be complete than RF only lines (17 of 22, 77%, vs. 15 of 24, 62%; p NS). Among 19 patients with continuous monitoring, only 4 (21%) had any AF burden including two patients within blanking period and before endocardial gap closure. The remaining 7 patients without continuous monitoring never experienced any symptoms related to recurrent AF, and serial Holter EKG were without pathology. Conclusions Hybrid ablation and dual energy provides a strong armamentarium for extra-pulmonary venous triggers of AF. Linear ablation lines were more likely to be gap-less and transmural, if dual energy sources were used. Dual energy TTA is highly efficient to restore sinus rhythm in patients with prior failed endocardial AF ablation. However, one of three patients will require endocardial gap closure to realize the full benefit of our two-stage hybrid concept. Further study will evaluate if dual energy lines outside the box can improve outcome in these challenging cases of intractable AF. Funding Acknowledgement Type of funding source: None


2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
H Delasnerie ◽  
F Mandel ◽  
G Domain ◽  
Q Voglimacci ◽  
P Mondoly ◽  
...  

Abstract Introduction Relations between voltage mapping and diagnosis or genetic background in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) have not been investigated so far. Objective We investigate if diagnosis or genetic background were linked to voltage mapping in ARVC. Method 70 patients with proved or suspected ARVC undergoing 3D endocardial mapping and genetic testing have been retrospectively included. Localisation and extension of bipolar low voltage areas were correlated to ARVC diagnosis and presence of a culprit mutation. Results 44/70 fulfilled ARVC Task Force criteria and 25/70 had culprit mutations. Endocardial (38/44 vs 16/26, p=0.02) and especially infero-lateral scars (31/44 vs 9/26, p=0.003) were more often present in patients fulfilling Task force criteria vs suspected ARVC, with larger scars (area 23±27 vs 8±11 cm2, p=0.04, perimeter 17±10 vs 11±7 cm, p=0.03) (sensitivity 86%). Mutated patients had more infero-lateral (19/25 vs 21/45, p=0.01), multiple (12/20 vs 11/34, p=0.04) and larger scars (perimeter 21±10 vs 12±7 cm, p=0.01) vs non mutated patients. In patients with ARVC diagnosed according to the Task Force criteria, there was a trend toward more infero-lateral (p=0.09) and larger scars (p=0.08) in mutated cases. PKP2-mutated cases tended to have less ourflow tract (p=0.08) and less multiple scars (p=0.09) vs other mutations. Conclusion 3D endocardial mapping could have an important role for ARVC diagnosis and may be able to detect minor forms with otherwise insufficiant criteria for diagnosis. More frequent and larger infero-lateral scars are present in mutated patients with bordeline differences according to the mutated genes. Funding Acknowledgement Type of funding source: None


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