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Yamashita K, Furuya K, Sato Y, Kinebuchi Y, Funayama K, Masano T, Maeda M, Kumazawa D, Mizuno Y, Onodera K, Nomura T. Intracardiac electrogram-based atrial pace mapping for detecting the earliest activation site in atrial arrhythmias. Heart Rhythm 2024:S1547-5271(24)00199-1. [PMID: 38369035 DOI: 10.1016/j.hrthm.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/27/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Kennosuke Yamashita
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan.
| | - Kenichi Furuya
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Yasuhiro Sato
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Yasuhiro Kinebuchi
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Keisuke Funayama
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Tomohisa Masano
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Manabu Maeda
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Daiki Kumazawa
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Yosuke Mizuno
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Kosuke Onodera
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Takehiro Nomura
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
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Koneru JN, Ellenbogen KA. When the Trigger Becomes the Target: Zeroing-In on Nonpulmonary Vein Triggers of Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:2288-2290. [PMID: 37831034 DOI: 10.1016/j.jacep.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Jayanthi N Koneru
- Cardiology Division, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Kenneth A Ellenbogen
- Cardiology Division, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA.
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Yamashita K, Furuya K, Kumazawa D, Mizuno Y, Onodera K, Nomura T. Novel atrial pace-mapping technique based on dual-chamber electrograms to detect non-pulmonary vein foci. HeartRhythm Case Rep 2023; 9:723-727. [PMID: 38047201 PMCID: PMC10691955 DOI: 10.1016/j.hrcr.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Kennosuke Yamashita
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Kenichi Furuya
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Daiki Kumazawa
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Yosuke Mizuno
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Kosuke Onodera
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Takehiro Nomura
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
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Chen M, Yang M, Li W, Zhang PP, Zhang R, Mo BF, Gong CQ, Han YQ, Sun XH, Wang QS, Lu QF, Sun J, Li YG. Novel dual-reference approach facilitates the activation mapping and catheter ablation of premature atrial complexes with non-pulmonary vein and non-superior vena cava origins. Europace 2023; 25:146-155. [PMID: 35942655 PMCID: PMC10103565 DOI: 10.1093/europace/euac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/30/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Activation mapping of premature atrial complexes (PACs) proves challenging due to interference by mechanical bumping and non-targeted ectopies. This study aims to compare the mapping efficacy, instant success, and long-term recurrence of catheter ablation for PACs with non-pulmonary vein (PV) and non-superior vena cava (SVC) origins between the novel dual-reference approach (DRA) and the routine single-reference approach (SRA) of mapping. METHODS AND RESULTS Patients with symptomatic, drug-refractory PACs, or frequent residual PACs after atrial tachyarrhythmia ablation were enrolled. During activation mapping, the coronary sinus (CS) catheter was used as the only timing reference in the SRA group. In the DRA group, another catheter, which was spatially separated from the CS catheter, was used as the second reference. The timing difference between the two references was used to discriminate the targeted PACs from the uninterested rhythms. Procedural parameters and long-term recurrence were compared. A total of 188 patients (109 in SRA and 79 in DRA) were enrolled. The baseline characteristics were similar. Compared with the SRA group, the DRA group had less repeated mapping (1.2 ± 0.4 vs. 1.4 ± 0.5, P = 0.004), shorter mapping (15 ± 6 vs. 23 ± 7 min, P < 0.001) and procedural time (119 ± 28 vs. 132 ± 22 min, P = 0.001), similar procedural complication rates (3.6 vs. 3.8%, P > 0.999), higher instant success (96.2 vs. 87.2%, P = 0.039), and lower recurrence rate (15.2 vs. 29.3%, hazard ratio 1.943, P = 0.033) during a 24-month follow-up. CONCLUSION As a novel strategy, the DRA shortens the procedural time and improves both instant and long-term success of PAC ablation, serving as a promising approach in mapping PACs with non-PV and non-SVC origins.
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Affiliation(s)
- Mu Chen
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Mei Yang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Wei Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Peng-Pai Zhang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Rui Zhang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Bin-Feng Mo
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Chang-Qi Gong
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Ya-Qin Han
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Xiang-Hua Sun
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Qun-Shan Wang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Qiu-Fen Lu
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Jian Sun
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, 200092 Shanghai, China
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Electrocardiographic imaging (ECGI): What is the minimal number of leads needed to obtain a good spatial resolution? J Electrocardiol 2020; 62:86-93. [PMID: 32835985 DOI: 10.1016/j.jelectrocard.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/11/2020] [Accepted: 07/17/2020] [Indexed: 11/22/2022]
Abstract
AIMS Assess the minimal number of ECGI leads needed to obtain a good spatial resolution. METHODS We enrolled 20 patients that underwent ablation of premature ventricular or atrial contractions using Carto and ECGI with AMYCARD. We evaluated the agreement regarding the site of origin of the arrhythmia between the ECGI and Carto, the area and diameter of the earliest activation site obtained with the ECGI (EASa and EASd). Based on previous studies with pacemapping, we considered a good spatial resolution of the ECGI when the EASd measured on the isopotential map was less than 18 mm. In presence of agreement the ECGI was reprocessed: a) with half the number of electrode bands (8 leads per electrode band) and b) with 6 electrode bands. RESULTS The initial map was obtained with 23 (22-23) electrode bands per patient, corresponding to 143 (130-170) leads. Agreement rate was 85%, the median EASa and EASd were: 0.7 (0.5-1.3) cm2 and 9 (8-13) mm. With half the number of electrode bands including 73 (60-79) leads, agreement rate was 80%, the EASa and EASd were: 2.1 (1.5-6.2) cm2 and 16 (14 -28) mm. With only six electrode bands using 38 (30-42) leads, agreement rate was 55%, EASa and EASd were: 4.0 (3.3-5.0) cm2 and 23 (21-25) mm. The number of leads was a predictor of agreement with a good spatial resolution, OR (95% CI) of 1.138 (1.050-1.234), p = .002. According to the ROC curve, the minimal number of leads was 74 (AUC 0.981; 95% CI: 0.949-1.00, p < .0001). CONCLUSION Reducing the number of leads was associated with a lower agreement rate and a significant reduction of spatial resolution. However, the number of leads needed to achieve a good spatial resolution was less than the maximal available.
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Comparative spatial resolution of 12-lead electrocardiography and an automated algorithm. Heart Rhythm 2019; 17:324-331. [PMID: 31493590 DOI: 10.1016/j.hrthm.2019.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The spatial resolution of pacemapping using 12-lead electrocardiography (ECG) or PaSo software is unknown. OBJECTIVE The purpose of this study was to determine the spatial resolution of traditional ECG pacemapping and pacemapping using the PaSo coefficients. METHODS Seventeen patients undergoing ablation of supraventricular tachycardias or atrioventricular node were included. After ablation, chamber (right ventricular outflow tract/rest of the right ventricle/left ventricle) geometry was created with Carto 3. Pacingwas performed from any point in these cardiac regions, the QRS morphology being the template and the point being considered as arrhythmia "origin." Subsequently, pacing was performed from points around the "origin" (1538 points). The QRS of these tagged points were compared by traditional ECG pacemapping and PaSo coefficients. The spatial resolution was calculated using correlations between the distance away from the origin (measured by 3 computational methods) and traditional ECG pacemapping and PaSo coefficients, independently. RESULTS A 0.01-unit decrease in the PaSo coefficient resulted in 1.1 mm increased Cartesian distance (95% confidence interval [CI] 0.9-1.3 mm; P < .001) and 2.4 mm increased geodesic distance (95% CI 1.9-2.9 mm; P < .001) and 664 mm3 increase in convex hull volume (95% CI 423-906 mm3; P < .0001). For traditional ECG pacemapping, each decrease in lead match resulted in 1.7 mm increased Cartesian distance (95% CI 1.5-2.0 mm; P < .001) and 3.4 mm increased geodesic distance (95% CI 2.8-4.1 mm; P < .001) and 712 mm3 increase in convex hull volume (95% CI 599-830 mm3; P < .0001). Both PaSo coefficients and traditional pacemapping showed a significant inverse linear correlation with distance from the "origin." CONCLUSION The resolution of mapping using the Paso software is better than that of traditional pacemapping.
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Asvestas D, Melissi A, Ypsilanti E, Vardas P, Tzeis S. Atrial tachycardia arising from the tricuspid annulus - Insight into electrocardiographic and electrophysiologic features. J Electrocardiol 2019; 57:18-20. [PMID: 31450154 DOI: 10.1016/j.jelectrocard.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/17/2019] [Accepted: 08/06/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Dimitrios Asvestas
- Cardiology Department, Mitera General Hospital, Hygeia Group, Athens, Greece.
| | - Aimilia Melissi
- Cardiology Department, Mitera General Hospital, Hygeia Group, Athens, Greece
| | - Elisavet Ypsilanti
- Cardiology Department, Mitera General Hospital, Hygeia Group, Athens, Greece
| | - Panos Vardas
- Cardiology Department, Mitera General Hospital, Hygeia Group, Athens, Greece
| | - Stylianos Tzeis
- Cardiology Department, Mitera General Hospital, Hygeia Group, Athens, Greece
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Traykov V. Focal atrial tachycardias and atrial flutter: are they hot enough to make a thematic issue? Curr Cardiol Rev 2015; 11:101-2. [PMID: 25695115 PMCID: PMC4356715 DOI: 10.2174/1573403x10999141013122732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Lee JMS, Fynn SP. P wave morphology in guiding the ablation strategy of focal atrial tachycardias and atrial flutter. Curr Cardiol Rev 2015; 11:103-10. [PMID: 25308814 PMCID: PMC4356716 DOI: 10.2174/1573403x10666141013121252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 09/25/2013] [Accepted: 04/05/2014] [Indexed: 12/03/2022] Open
Abstract
Focal atrial tachycardias arise preferentially from specific locations within the atria. Careful analysis of the P wave can provide useful information about the chamber and likely site of origin within that chamber. Macro-reentrant atrial flutter also tends to occur over a limited number of potential circuits. In this case, the ECG usually gives a guide to the chamber of origin, but unless it shows a specific morphology it is less useful in delineating the circuit involved. Nonetheless, prior knowledge of the likely chamber of origin helps to plan the ablation strategy.
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Affiliation(s)
| | - Simon P Fynn
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom, CB23 3RE, UK.
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Traykov VB. Mapping strategies in focal atrial tachycardias demonstrating early septal activation: distinguishing left from right. Curr Cardiol Rev 2015; 11:111-7. [PMID: 25308813 PMCID: PMC4356717 DOI: 10.2174/1573403x10666141013121428] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 09/25/2013] [Accepted: 04/05/2014] [Indexed: 11/29/2022] Open
Abstract
Determining the chamber of origin of focal atrial tachycardias (FATs) arising at or close to the septum might require biatrial mapping. This review focuses on the available tools and methods used to distinguish right atrial from left atrial origin before left atrial access is obtained. These include analysis of P wave morphology, assessing the timing of right atrial septal activation, the sequence of right atrial and/or biatrial activation and analysis of earliest electrogram morphology. The electroanatomical properties of the interatrial septum and coronary sinus that provide the basis for the above mentioned tools have also been briefly described.
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Affiliation(s)
- Vassil B Traykov
- Clinic of Cardiology, Tokuda Hospital - Sofia, N.Vaptzarov blvd. 51B, 1407 Sofia, Bulgaria.
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Pace mapping in the atrium using bipolar electrograms from widely spaced electrodes. J Arrhythm 2015; 31:274-8. [PMID: 26550082 DOI: 10.1016/j.joa.2015.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 02/10/2015] [Accepted: 02/23/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pace mapping is a useful tool but is of limited utility for the atrium because of poor spatial resolution. We investigated the use of bipolar electrograms recorded from widely spaced electrodes in order to improve the resolution of pace mapping. METHODS This prospective study included patients undergoing a clinical electrophysiology study. Unipolar pacing from either the superior or inferior lateral right atrium was performed to simulate atrial tachycardia. Twelve-lead electrocardiograms were recorded during pacing as a template. In addition, three intracardiac bipolar electrograms from a set of widely spaced electrodes were also recorded. Subsequently, unipolar pacing was performed from electrodes at known distances from the initial pacing site, and the morphology of P waves in the electrocardiogram and bipolar electrograms were compared with that of the template. Morphological comparison was performed by a cardiologist and by automated computerized matching. Spatial resolution was calculated as the minimum distance at which there was no match. RESULTS Fifteen patients participated in the study. Distance at which differences in morphology were noted was smaller in the bipolar electrograms compared to that indicated by P waves in the electrocardiogram, when matched by the cardiologist (6.1±3.8 mm vs. 9.9±5.2 mm, p=0.012) or by automated analysis (4±0 mm vs. 9.9±4 mm, p<0.001). CONCLUSIONS Use of three bipolar electrograms recorded from a set of widely spaced electrodes in the right atrium improves the resolution of pace mapping compared to that using P waves from surface electrocardiograms alone.
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Garro HA, Elizari MV, Baranchuk A, Femenía F, Chiale PA. A reappraisal on lidocaine-sensitive repetitive, uniform atrial tachycardia. Ann Noninvasive Electrocardiol 2013; 18:1-11. [PMID: 23347021 DOI: 10.1111/anec.12014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Lidocaine sensitive, repetitive atrial tachycardia is an unusual arrhythmia whose electrophysiologic substrate remains undefined. We aimed to analyze the electropharmacologic characteristics of this arrhythmia with emphasis on its cellular substrate and response to drug challenges. METHODS We retrospectively analyzed a series of 18 patients from an electrocardiographic and electrophysiologic perspective and the response to pharmacological challenge. RESULTS There was no evidence of structural heart disease in 12 patients, 4 patients presented with systemic hypertension; one patient had a prior myocardial infarction and one a mitral valve prolapse. The arrhythmia depicted a consistent pattern in nine patients. The first initiating ectopic beat showed a long coupling interval, the cycle length of the second atrial ectopic beat presented the shortest cycle length and a further prolongation was apparent towards the end of the atrial salvos. Conversely, in the other nine cases, the atrial tachycardia cycle length was erratic. The arrhythmia was suppressed by asynchronous atrial pacing at cycle lengths longer than those of the atrial tachycardia. Intravenous lidocaine eliminated the arrhythmia in all patients, but intravenous verapamil suppressed the atrial tachycardia in only two patients while adenosine caused a transient disappearance in 2/8 patients. Only one patient responded to all the three agents. Radiofrequency ablation was successfully performed in 10 patients. CONCLUSIONS Repetitive uniform atrial tachycardia can be sensitive to lidocaine. In few cases, this rare focal arrhythmia may be also suppressed by adenosine and/or verapamil, which suggests a diversity of electrophysiologic substrates that deserve to be accurately identified.
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Affiliation(s)
- Hugo A Garro
- Centro de Arritmias Cardíacas de la Ciudad de Buenos Aires, Division of Cardiology, Hospital J. M. Ramos Mejía, and Pontificia Universidad Católica Argentina Santa María de los Buenos Aires, Buenos Aires, Argentina.
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Roberts-Thomson KC, Kistler PM, Haqqani HM, McGavigan AD, Hillock RJ, Stevenson IH, Morton JB, Vohra JK, Sparks PB, Kalman JM. Focal Atrial Tachycardias Arising from the Right Atrial Appendage: Electrocardiographic and Electrophysiologic Characteristics and Radiofrequency Ablation. J Cardiovasc Electrophysiol 2007; 18:367-72. [PMID: 17286568 DOI: 10.1111/j.1540-8167.2006.00754.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize the electrocardiographic and electrophysiological features and frequency of focal atrial tachycardia (AT) originating from the right atrial appendage (RAA). BACKGROUND The RAA has been described as a site of origin of AT, but detailed characterization of these tachycardias is limited. METHODS Ten patients (3.8%) of 261 undergoing radiofrequency ablation (RFA) for focal AT are reported. Endocardial activation maps (EAM) were recorded from catheters at the CS (10 pole), tricuspid annulus (20 pole Halo catheter), and His positions. P waves were classified as negative, positive, isoelectric, or biphasic. RESULTS The mean age was 39 +/- 20 years, nine males, with symptoms for 4.1 +/- 5.1 years. Tachycardia was incessant in seven patients, spontaneous in one patient, and induced by programmed extrastimuli in two patients. These foci had a characteristic P wave morphology. The P wave was negative in lead V(1) in all patients, becoming progressively positive across the precordial leads. The P waves in the inferior leads were low amplitude positive in the majority of patients. Earliest EAM activity occurred on the Halo catheter in all patients. Mean activation time at the successful RFA site =-38 +/- 15 msec. Irrigated catheters were used in six patients, due to difficulty achieving adequate power. RFA was acutely successful in all patients. Long-term success was achieved in all patients over a mean follow up of 8 +/- 7 months. CONCLUSIONS The RAA is an uncommon site of origin for focal AT (3.8%). It can be suspected as a potential anatomic site of AT origin from the characteristic P wave and activation timing. Irrigated ablation catheters are often required for successful ablation. Long-term success was achieved with focal ablation in all patients.
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Clyne CA, Athar H, Shah A, Kahr R, Rentas A. Thermal mapping of right ventricular outflow tract tachycardia. Pacing Clin Electrophysiol 2007; 30:343-51. [PMID: 17367353 DOI: 10.1111/j.1540-8159.2007.00674.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute and long-term success of catheter ablation of right ventricular outflow tract tachycardia (RVOT VT) may be limited by the inability to reproduce the arrhythmia at the time of activation (AM) and pace mapping (PM). We have observed early initiation of the clinical VT when subtherapeutic radiofrequency (RF) energy was applied to the target area (TA), defined as a 2-cm(2) area around a pace match. We describe a novel approach using thermal mapping (TM) to guide the ablation of RVOT VT. METHODS Thirteen patients (10 female, mean age 46.2 +/- 13.7 years) with symptomatic VT of left bundle branch block (LBBB) inferior axis morphology and no structural heart disease underwent standard electrophysiologic evaluation with PM (n = 13), AM (n = 13), and 3D noncontact mapping (n = 4). Thermal mapping was performed after standard techniques failed to induce stable sustained VT for mapping in all 13 patients: RF was applied for 5-10 seconds in the TA to achieve a tip temperature of 45-50 degrees C. At sites where morphologically consistent with the clinical VT was induced, RF was applied at target temperature between 50 and 60 degrees C for 30-60 seconds. TM was repeated before and after intravenous Isoproterenol infusion until no further VT could be induced by low temperature application. RESULTS Noninducibility was achieved in all 13 patients. During a mean follow-up of 29 months (9-69 months), all patients remain arrhythmia-free, off antiarrhythmic medications. CONCLUSION Thermal mapping is a safe and effective adjunctive technique for the mapping and ablation of RVOT VT when sustained tolerated clinical VT cannot be induced.
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Affiliation(s)
- Christopher A Clyne
- Henry Low Heart Center at Hartford Hospital, and University of Connecticut School of Medicine, Hartford, Connecticut, USA.
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15
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Kistler PM, Roberts-Thomson KC, Haqqani HM, Fynn SP, Singarayar S, Vohra JK, Morton JB, Sparks PB, Kalman JM. P-wave morphology in focal atrial tachycardia: development of an algorithm to predict the anatomic site of origin. J Am Coll Cardiol 2006; 48:1010-7. [PMID: 16949495 DOI: 10.1016/j.jacc.2006.03.058] [Citation(s) in RCA: 230] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Revised: 03/22/2006] [Accepted: 03/28/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this study was to perform a detailed analysis of the P-wave morphology (PWM) in focal atrial tachycardia (AT) and construct and prospectively evaluate an algorithm for identification of the anatomic site of origin. BACKGROUND Although smaller studies have described the PWM from particular anatomic locations, a detailed algorithm characterizing the likely location of a tachycardia associated with a P-wave of unknown origin has been lacking. METHODS The PWMs for 126 consecutive patients undergoing successful radiofrequency ablation of 130 ATs are reported. P waves were included only when the onset was preceded by a discernible isoelectric segment. P waves were classified as positive (+), negative (-), isoelectric, or biphasic. Sensitivity, specificity, and predictive values were calculated. On the basis of these results, an algorithm was constructed and prospectively evaluated in 30 new consecutive ATs. RESULTS The distribution of ATs was right atrial (RA) in 82 of 130 (63%) and left atrial (LA) in 48 of 130 (37%). Right atrial sites included crista (n = 28), tricuspid annulus (n = 29), coronary sinus (CS) ostium (n = 14), perinodal (n = 7), right septum (n = 1), and RA appendage (n= 3). Left atrial sites included pulmonary veins (n = 32), mitral annulus (n = 8), CS body (n= 3), left septum (n = 3), and LA appendage (n = 2). In electrocardiographic lead V1, a negative or +/- P-wave demonstrated a specificity of 100% for a RA focus, and a + or -/+ P-wave demonstrated a sensitivity of 100% for a LA focus. A characteristic PWM was associated with high sensitivity and specificity at common atrial sites for tachycardia foci. A P-wave algorithm correctly identified the focus in 93%. CONCLUSIONS Characteristic PWMs corresponding to known anatomic sites for focal AT are associated with high specificity and sensitivity. A P-wave algorithm correctly identified the site of tachycardia origin in 93%.
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Affiliation(s)
- Peter M Kistler
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
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Roberts-Thomson KC, Kistler PM, Kalman JM. Focal Atrial Tachycardia II: Management. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:769-78. [PMID: 16884515 DOI: 10.1111/j.1540-8159.2006.00433.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Over the last decade there have been significant changes in the treatment of focal atrial tachycardia (AT). This review concentrates on the different approaches to the treatment of focal AT. Initial therapies included antiarrhythmic medications and surgery. However, with the advent of radiofrequency ablation, and the poor efficacy of pharmacological therapy, there has been a shift toward a primary ablative approach. Several different mapping techniques have been proposed. The different techniques, including P-wave morphology and advanced three-dimensional mapping, are discussed in this review.
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Affiliation(s)
- Peter M Kistler
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
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Sippensgroenewegen A, Natale A, Marrouche NF, Bash D, Cheng J. Potential role of body surface ECG mapping for localization of atrial fibrillation trigger sites. J Electrocardiol 2004; 37 Suppl:47-52. [PMID: 15534799 DOI: 10.1016/j.jelectrocard.2004.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Catheter ablation has revolutionized the clinical management of atrial fibrillation (AF) by offering a curative treatment option for this highly prevalent arrhythmia. Ablation therapy is aimed at electrical isolation of the pulmonary veins (PVs) as a means to prevent rapidly firing focal activation within the PVs from penetrating into the left atrium (LA) and initiate reentrant wavelet propagation. However, non-PV AF trigger sites may be present and lead to unsuccessful ablation or post-ablation AF recurrences. Infrequent trigger firing and the difficulty or inability to induce focal trigger activity in the electrophysiology laboratory limits invasive catheter-based mapping of non-PV trigger sites. Identification of AF trigger sites using the surface electrocardiogram (ECG) P wave morphology is feasible but conventional 12-lead scalar recordings do not offer the resolving power to provide discrete regional localization to potentially target catheter ablation. The present paper includes a review of preliminary clinical data on the use of a 65-lead ECG mapping system (Resolution Medical, Inc) for the non-invasive localization of AF trigger sites. This method utilizes a unique previously developed reference database of 34 mean paced P wave integral map patterns which are each specific to activation arising from a discrete segment in the LA and right atrium (RA). Trigger site localization is obtained by matching the P wave integral map morphology of a premature atrial contraction (PAC) with the reference database of 34 mean paced P wave integral map patterns.
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Affiliation(s)
- Arne Sippensgroenewegen
- Heart Center for Excellence, Borgess Medical Center, Michigan State University, Kalamazoo, MI 49048, USA.
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19
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Abstract
The recognition of the ubiquitous role of short coupled ectopics in the initiation of paroxysmal atrial fibrillation has renewed interest in their localization with the ultimate aim of facilitating their neutralization by catheter ablation. The P-waves resulting from such ectopics are partly or completely concealed by the QRST of the preceding beat and therefore their morphology has been underutilized for localization purposes. Subtraction has been the most commonly used technique for QRST suppression and though an averaged template offers a higher signal-to-noise ratio, the immediately preceding QRST provides the best match between template and target and allows simple, nearly real-time, and accurate subtraction without distorting the underlying P-wave. Algorithms derived from clinical tachycardias as well as pacemapping have permitted a rational analysis and accurate prediction (81%) of the correct pulmonary vein of origin. Other nonpulmonary sources may also be similarly localized, particularly with the help of a catalogue of pacemaps from various sites. Incessant arrhythmia and frequent aberrancy limit the effectiveness of QRST suppression by subtraction. Further improvements in the localizing resolution of the P-wave may depend upon knowledge of the relationship between recording electrodes and the underlying atria.
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Affiliation(s)
- Dipen Shah
- Hopital Cantonal de Geneve, Geneva, Switzerland.
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Perez-Castellano N, Almendral J, Villacastin J, Arenal A, Gonzalez S, Moreno J, Morales R, Macaya C. Basic assessment of paced activation sequence mapping: implications for practical use. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:651-6. [PMID: 15125723 DOI: 10.1111/j.1540-8159.2004.00501.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Some experiences support the use of atrial paced activation sequence mapping, but there is no systematic study assessing its spatial resolution, reproducibility, and influence of pacing parameters. The aim of this study was to evaluate these issues by using a 24-pole catheter positioned at the atrial aspect of the tricuspid and mitral annuli in 15 patients. Bipolar pacing was performed at two sites (right and left atria), 2 cycle lengths (300 and 500 ms) and two outputs (twice and tenfold the late diastolic threshold voltage for 2-ms pulses). The elapsed time between the atrial activation at the two dipoles adjacent to the pacing dipole (activation time [AT]) was measured during each pacing sequence. Changes in cycle length did not modify the AT. The increase in voltage slightly modified the AT (maximum -2 ms at the RA; 95% CI -3 to -1 ms) due to a greater shortening of the conduction time to the dipole located next to the anode. The 95% limits of the intraobserver and interobserver agreements in the AT measurement were -2 to 3 ms and -3 to 3 ms, respectively. The spatial resolution was studied in ten patients by measuring the AT during pacing from each dipole of a 20-pole catheter with a 1-3-1 mm interelectrode distance. The mean AT change was 10 +/- 4 ms per 6 mm of pacing site displacement (95% CI 8-11 ms, range 2.5-20 ms). In conclusion, paced atrial activation sequence analysis is reproducible, accurate, and relatively independent of pacing parameters.
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Kuo JY, Tai CT, Tsao HM, Hsieh MH, Tsai CF, Lin WS, Lin YK, Ding YA, Hou CJY, Tsai CH, Chen SA. P wave polarities of an arrhythmogenic focus in patients with paroxysmal atrial fibrillation originating from superior vena cava or right superior pulmonary vein. J Cardiovasc Electrophysiol 2003; 14:350-7. [PMID: 12741704 DOI: 10.1046/j.1540-8167.2003.02513.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The superior vena cava (SVC) and right superior pulmonary vein (RSPV) are anatomically close structures. Using 12-lead ECG may facilitate identification of ectopic foci from SVC or RSPV. The aim of this study was to assess whether P wave polarity on surface ECG is helpful in distinguishing an arrhythmogenic focus of paroxysmal atrial fibrillation (AF) from SVC or RSPV. METHODS AND RESULTS Thirty-four patients with paroxysmal AF from the SVC (group I: 17 patients, 10 men and 7 women; mean age 57 +/- 12 years) or RSPV (group II: 17 patients, 15 men and 2 women, mean age 62 +/- 14 years) underwent electrophysiologic study and radiofrequency (RF) catheter ablation. All of the AF foci were confirmed by successful ablation. P wave polarities on surface ECG inferior leads were positive during sinus rhythm and ectopic beats in both groups. Leads I, aVR, aVL, and V1 were further analyzed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting an arrhythmogenic focus of AF from SVC or RSPV were provided. P wave polarity in lead aVR was negative in all 34 patients. P wave polarity in lead V1 was positive in 47.1% of SVC ectopy but positive in all RSPV ectopy. The combination of a biphasic or isoelectric P wave polarity in lead V1 or a biphasic P wave polarity in lead aVL had a sensitivity of 71%, specificity of 82%, PPV of 80%, and NPV of 74% in predicting an arrhythmogenic focus of AF from SVC. CONCLUSION P wave polarity in leads V1 and aVL may predict an arrhythmogenic focus of AF from SVC or RSPV.
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Affiliation(s)
- Jen-Yuan Kuo
- Division of Cardiology, Department of Medicine, National Yang-Ming University, School of Medicine, and Veterans General Hospital-Taipei, Taipei, Taiwan
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22
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Marenco JP, Nakagawa H, Yang S, MacAdam D, Xu L, He DS, Link MS, Homoud MK, Estes III NM, Wang PJ. Testing of a new T-wave subtraction algorithm as an aid to localizing ectopic atrial beats. Ann Noninvasive Electrocardiol 2003; 8:55-9. [PMID: 12848814 PMCID: PMC6931970 DOI: 10.1046/j.1542-474x.2003.08109.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Identifying the timing and morphology of an ectopic P wave from the surface electrogram can aid in the diagnosis and localization of atrial arrhythmias. Given the relatively short coupling interval of atrial ectopic beats, the P wave is often obscured by the larger amplitude QRS-T wave complex. A method to uncover such "buried" P waves using a standard 12-lead surface ECG would be clinically useful and could potentially be a noninvasive guide to catheter ablation of focal atrial tachycardia. METHODS We developed an automated computerized program (BARD DUO LAB SYSTEM trade mark ) designed to subtract the QRS-T wave complex from the surface electrogram and uncover a previously obscured P wave. The purpose of the present study was to validate this program. The surface ECG from 21 patients undergoing atrial pacing during electrophysiologic study (group I) and 10 patients with atrial tachycardia (group II) were analyzed and the derived P-wave morphology assessed using correlation waveform analysis (CWA) and visual grading by three reviewers. RESULTS The algorithm successfully uncovered the P wave in each surface ECG. For the 21 patients in group I, average CWA comparing the derived P wave with the previous paced P wave was 83%. Average CWA for group II was 82%. Visual grading of the match between derived P waves and paced P waves revealed a 21/21 match in group I patients and a 12/12 match in 9/10 of group II patients. CONCLUSIONS An ectopic atrial P wave obscured by a coincident QRS-T wave complex can be accurately uncovered using this new algorithm. Addition of this technique to existing methods may improve the diagnosis of atrial arrhythmias and aid in the localization and ablation of ectopic atrial foci.
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Affiliation(s)
- John P. Marenco
- Tufts University School of Medicine, New England Medical Center Hospitals, Boston, MA, USA
| | | | | | | | - Lucien Xu
- Bard Electrophysiology, Lowell, MA, USA
| | | | - Mark S. Link
- Tufts University School of Medicine, New England Medical Center Hospitals, Boston, MA, USA
| | - Munther K. Homoud
- Tufts University School of Medicine, New England Medical Center Hospitals, Boston, MA, USA
| | - N.A. Mark Estes III
- Tufts University School of Medicine, New England Medical Center Hospitals, Boston, MA, USA
| | - Paul J. Wang
- Tufts University School of Medicine, New England Medical Center Hospitals, Boston, MA, USA
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Yamane T, Shah DC, Peng JT, Jaïs P, Hocini M, Deisenhofer I, Choi KJ, Macle L, Clémenty J, Haïssaguerre M. Morphological characteristics of P waves during selective pulmonary vein pacing. J Am Coll Cardiol 2001; 38:1505-10. [PMID: 11691531 DOI: 10.1016/s0735-1097(01)01578-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We sought to assess the value of 12-lead electrocardiogram (ECG) P-wave morphology to recognize the paced pulmonary vein (PV). BACKGROUND Prediction of arrhythmogenic PVs producing ectopy or initiating atrial fibrillation (AF) using 12-lead ECG may facilitate curative ablation. METHODS In 30 patients P-wave configurations were studied during sinus rhythm and during pacing at six sites from the four PVs: top and bottom of each superior PV and both inferior PVs. The P-wave amplitude, duration and morphology were assessed, and predictive accuracies were calculated for the most significant parameters. An algorithm predicting the paced PV was developed and prospectively evaluated in a different population of 20 patients. RESULTS; Three criteria were used to distinguish right from left PV: 1) a positive P-wave in lead aVL and the amplitude of P-wave in lead I > or =50 microV indicated right PV origin (specificity 100% and 97%, respectively); 2) a notched P-wave in lead II was a predictor of left PV origin (specificity 95%); and 3) the amplitude ratio of lead III/II and the duration of positivity in lead V(1) were also helpful in distinguishing left versus right PV origin. In addition, superior PVs could be distinguished from inferior according to the amplitude in lead II (> or =100 microV). In prospective evaluation, an algorithm based on the above four criteria identified 93% of left versus right PV and totally 79% of the specific PVs paced. CONCLUSIONS Pacing from the different PVs produced a P-wave with distinctive characteristics that could be used as criteria in an algorithm to identify the PV of origin with an accuracy of 79%.
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Affiliation(s)
- T Yamane
- Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France
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Chen SA, Tai CT, Tsai CF, Hsieh MH, Ding YA, Chang MS. Radiofrequency catheter ablation of atrial fibrillation initiated by pulmonary vein ectopic beats. J Cardiovasc Electrophysiol 2000; 11:218-27. [PMID: 10709719 DOI: 10.1111/j.1540-8167.2000.tb00324.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ectopic beats from the pulmonary veins (PVs) have been demonstrated to initiate atrial fibrillation (AF). This article describes the conceptual approach to mapping, interpretation of different electrograms, and ablation of AF initiated by PV ectopic beats.
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Affiliation(s)
- S A Chen
- Department of Medicine, National Yang-Ming University, School of Medicine, and Veterans General Hospital-Taipei, Taiwan, Republic of China.
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Man KC, Knight B, Tse HF, Pelosi F, Michaud GF, Flemming M, Strickberger SA, Morady F. Radiofrequency catheter ablation of inappropriate sinus tachycardia guided by activation mapping. J Am Coll Cardiol 2000; 35:451-7. [PMID: 10676693 DOI: 10.1016/s0735-1097(99)00546-x] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the value of activation mapping for radiofrequency modification of the sinus node and the long-term success rate of the procedure in a series of patients with inappropriate sinus tachycardia. BACKGROUND The results of radiofrequency ablation of inappropriate sinus tachycardia have been reported in only a small number of patients. METHODS The subjects of this study were 29 consecutive drug-refractory patients who underwent catheter ablation of inappropriate sinus tachycardia. Target sites were selected by activation mapping during sinus tachycardia. RESULTS The ablation procedure was successful acutely in reducing the baseline sinus rate to <90/min and the sinus rate during isoproterenol infusion by >20% in 22 of 29 patients (76%). In 13 of 22 patients (59%) with a successful acute outcome, successive applications of radiofrequency energy at the site of earliest endocardial activation resulted in a cranial-caudal migration of earliest endocardial activation from the high lateral right atrium, along with a step-wise reduction in heart rate. In the other nine patients (41%) with a successful acute outcome, the reduction in sinus rate occurred abruptly, unaccompanied by migration of the site of earliest activation. Symptoms due to inappropriate sinus tachycardia recurred at a mean of 4.4+/-; 3 months after the ablation procedure in 6 of 22 patients (27%). After additional procedures in three patients, symptoms of inappropriate sinus tachycardia ultimately were successfully eliminated over the long-term in 19 of 29 patients (66%). CONCLUSIONS In conclusion, radiofrequency ablation is at best only modestly effective for managing patients with inappropriate sinus tachycardia. The two different responses of heart rate to radiofrequency ablation may reflect differences in the number and/or multicentricity of subsidiary sites of impulse generation within the sinus node and/or atrium in patients with inappropriate sinus tachycardia.
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Affiliation(s)
- K C Man
- Department of Internal Medicine, University of Michigan, Ann Arbor 48109-0022, USA
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SippensGroenewegen A, Roithinger FX, Peeters HA, Linnenbank AC, van Hemel NM, Steiner PR, Lesh MD. Body surface mapping of atrial arrhythmias: atlas of paced P wave integral maps to localize the focal origin of right atrial tachycardia. J Electrocardiol 1999; 31 Suppl:85-91. [PMID: 9988010 DOI: 10.1016/s0022-0736(98)90298-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Successful curative treatment of right atrial tachycardia (AT) can be obtained provided detailed catheter activation mapping of the target site for radiofrequency energy application has been accomplished. However, right AT mapping may be difficult with a single roving catheter due to infrequent presence or noninducibility of the arrhythmia. The present report describes the preliminary clinical use of body surface mapping as an adjunctive noninvasive method to identify the region of AT origin prior to catheter ablation. This technique has been previously applied to develop a reference data base of 17 different paced P wave integral map patterns. The data base was designed by performing right atrial pace mapping in patients without structural heart disease. Each P wave integral map pattern in the data base is unique to ectopic activation onset in a circumscribed right atrial endocardial segment. Localization of the segment of AT origin is accomplished by matching the P wave integral map of a single AT beat with the data base of paced P wave integral maps. The use of body surface mapping as an integral part of the mapping protocol during radiofrequency catheter ablation of right AT offers the possibility to: (1) noninvasively determine the arrhythmogenic target area for ablation using a single beat analysis approach; (2) confine detailed catheter activation mapping to a limited area; and (3) accelerate the overall procedure and limit fluoroscopic exposure by reducing the time required for mapping.
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Affiliation(s)
- A SippensGroenewegen
- Department of Medicine and the Cardiovascular Research Institute, University of California at San Francisco, 94143-1354, USA
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Rautaharju PM, Park LP, Chaitman BR, Rautaharju F, Zhang ZM. The novacode criteria for classification of ECG abnormalities and their clinically significant progression and regression. J Electrocardiol 1998. [DOI: 10.1016/s0022-0736(98)90132-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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