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Devecchi C, Matta M, Magnano M, Dell'Era G, Galiffa VA, Renaudo D, Negro A, Occhetta E, Patti G, Rametta F. Voltage and propagation mapping: New tools to improve successful ablation of atrioventricular nodal reentry tachycardia. J Cardiovasc Electrophysiol 2024; 35:942-949. [PMID: 38462681 DOI: 10.1111/jce.16234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/25/2024] [Accepted: 02/19/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Mapping system is useful in ablation of atrioventricular nodal reentry tachycardia (AVNRT) and localization of anatomic variances. Voltage mapping identifies a low voltage area in the Koch triangle called low-voltage-bridge (LVB); propagation mapping identifies the collision point (CP) of atrial wavefront convergence. We conducted a prospective study to evaluate the relationship between LVB and CP with successful site of ablation and identify standard value for LVB. MATERIALS AND METHODS Three-dimensional (3D) maps of the right atria were constructed from intracardiac recordings using the ablation catheter. Cut-off values on voltage map were adjusted until LVB was observed. On propagation map, atrial wavefronts during sinus rhythm collide in the site representing CP, indicating the area of slow pathway conduction. Ablation site was selected targeting LVB and CP site, confirmed by anatomic position on fluoroscopy and atrioventricular ratio. RESULTS Twenty-seven consecutive patients were included. LVB and CP were present in all patients. Postprocedural evaluation identified standard cut-off of 0.3-1 mV useful for LVB identification. An overlap between LVB and CP was observed in 23 (85%) patients. Procedure success was achieved in all patient with effective site at first application in 22 (81%) patients. There was a significant correlation between LVB, CP, and the site of effective ablation (p = .001). CONCLUSION We found correlation between LVB and CP with the site of effective ablation, identifying a voltage range useful for standardized LVB identification. These techniques could be useful to identify ablation site and minimize radiation exposure.
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Affiliation(s)
- Chiara Devecchi
- Division of Cardiology, Ospedale Sant'Andrea, Vercelli, Italy
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
| | - Mario Matta
- Division of Cardiology, AOU Città della Salute e della Scienza, Torino, Italy
| | - Massimo Magnano
- Division of Cardiology, Ospedale Sant'Andrea, Vercelli, Italy
| | | | | | | | | | - Eraldo Occhetta
- Division of Cardiology, Ospedale Sant'Andrea, Vercelli, Italy
| | - Giuseppe Patti
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
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Hayase J, Salama G. A Catheter With a View: Characterizing the Conventional and Microelectrode Intracardiac "Field of View". JACC Clin Electrophysiol 2024; 10:651-653. [PMID: 38520435 DOI: 10.1016/j.jacep.2024.102336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 03/25/2024]
Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
| | - Guy Salama
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Omara S, Glashan CA, Tofig BJ, Leenknegt L, Dierckx H, Panfilov AV, Beukers HKC, van Waasbergen MH, Tao Q, Stevenson WG, Nielsen JC, Lukac P, Kristiansen SB, van der Geest RJ, Zeppenfeld K. Multisize Electrode Field-of-View: Validation by High Resolution Gadolinium-Enhanced Cardiac Magnetic Resonance. JACC Clin Electrophysiol 2024; 10:637-650. [PMID: 38276927 DOI: 10.1016/j.jacep.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Voltage mapping to detect ventricular scar is important for guiding catheter ablation, but the field-of-view of unipolar, bipolar, conventional, and microelectrodes as it relates to the extent of viable myocardium (VM) is not well defined. OBJECTIVES The purpose of this study was to evaluate electroanatomic voltage-mapping (EAVM) with different-size electrodes for identifying VM, validated against high-resolution ex-vivo cardiac magnetic resonance (HR-LGE-CMR). METHODS A total of 9 swine with early-reperfusion myocardial infarction were mapped with the QDOT microcatheter. HR-LGE-CMR (0.3-mm slices) were merged with EAVM. At each EAVM point, the underlying VM in multisize transmural cylinders and spheres was quantified from ex vivo CMR and related to unipolar and bipolar voltages recorded from conventional and microelectrodes. RESULTS In each swine, 220 mapping points (Q1, Q3: 216, 260 mapping points) were collected. Infarcts were heterogeneous and nontransmural. Unipolar and bipolar voltage increased with VM volumes from >175 mm3 up to >525 mm3 (equivalent to a 5-mm radius cylinder with height >6.69 mm). VM volumes in subendocardial cylinders with 1- or 3-mm depth correlated poorly with all voltages. Unipolar voltages recorded with conventional and microelectrodes were similar (difference 0.17 ± 2.66 mV) and correlated best to VM within a sphere of radius 10 and 8 mm, respectively. Distance-weighting did not improve the correlation. CONCLUSIONS Voltage increases with transmural volume of VM but correlates poorly with small amounts of VM, which limits EAVM in defining heterogeneous scar. Microelectrodes cannot distinguish thin from thick areas of subendocardial VM. The field-of-view for unipolar recordings for microelectrodes and conventional electrodes appears to be 8 to 10 mm, respectively, and unexpectedly similar.
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Affiliation(s)
- Sharif Omara
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Claire A Glashan
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bawer J Tofig
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lore Leenknegt
- Department of Mathematics, KU Leuven campus Kortrijk, Kortrijk, Belgium
| | - Hans Dierckx
- Department of Mathematics, KU Leuven campus Kortrijk, Kortrijk, Belgium
| | | | - Hans K C Beukers
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Qian Tao
- Department of Imaging Physics, Delft University of Technology, Delft, the Netherlands
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jens C Nielsen
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Lukac
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen B Kristiansen
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rob J van der Geest
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands
| | - Katja Zeppenfeld
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
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Nordin AP, Jensen-Urstad M, Charitakis E, Carnlöf C, Drca N. Predictors of low-voltage zones in patients with persistent atrial fibrillation eligible for catheter ablation: An observational study. J Cardiovasc Electrophysiol 2024. [PMID: 38561951 DOI: 10.1111/jce.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/05/2024] [Accepted: 03/16/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION The presence of low-voltage zones (LVZs) in the left atrium (LA) is associated with the recurrence of atrial fibrillation (AF) following pulmonary vein isolation (PVI). However, there is variability and conflict in the data regarding predictors of LVZs as reported in previous studies. The objective of this study was to identify predictors for the presence of LVZs in a cohort of patients with persistent AF. METHODS The study prospectively enrolled 439 patients with persistent AF who were scheduled for ablation. Voltage map of the LA was collected using a multipolar catheter. An LVZ was defined as an area of ≥3 cm2 exhibiting a peak-to-peak bipolar voltage of <0.5 mV. RESULTS The mean age of the cohort was 65.3 ± 8.6 years and 26.4% were female. Additionally, 25.7% had significant LVZs, most frequently located in the anterior wall of the LA. Multivariable analysis identified the following independent predictors for LVZ: advanced age (OR [odds ratio] = 1.08, 95% CI [confidence interval] = 1.03-1.13, p = .002); female sex (OR = 4.83, 95% CI = 2.66-8.76, p < .001); coronary artery disease (CAD) (OR = 3.20, 95% CI = 1.32-7.77, p = .01) and enlarged LA diameter (OR = 1.10, 95% CI = 1.04-1.17, p = .001). The area under the curve (AUC) of the receiver operating characteristic (ROC) curve for the final model was 0.829. CONCLUSION Approximately 25% of the patients with persistent AF had LVZs. Advanced age, female sex, CAD, and a larger LA were independent predictors for LVZs with the model demonstrating a very good AUC for the ROC curve. These findings hold the potential to be used to tailor the ablation procedure for the individual patient.
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Affiliation(s)
- Astrid Paul Nordin
- Heart and Lung Disease Unit, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Jensen-Urstad
- Heart and Lung Disease Unit, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Emmanouil Charitakis
- Department of Cardiology, Linköping University Hospital and Linköping University, Linköping, Sweden
| | - Carina Carnlöf
- Heart and Lung Disease Unit, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Nikola Drca
- Heart and Lung Disease Unit, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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Somasundaram N, Von Bergen NH. High-density "APLE" Mapping-Activation, Propagation, Low Voltage, and Electrogram Evaluation with the HD Grid for Atrioventricular Nodal Re-entry Tachycardia Ablation. J Innov Card Rhythm Manag 2024; 15:5787-5793. [PMID: 38584748 PMCID: PMC10994155 DOI: 10.19102/icrm.2024.15034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/02/2023] [Indexed: 04/09/2024] Open
Abstract
This is the first case series to evaluate high-density mapping of the triangle of Koch (TOK) using the HD Grid to guide slow-pathway ablation integrating activation, propagation (with wave collision), low-voltage signals, and atrial electrogram appearance. We will describe our technique and the results in this case series. Using three-dimensional mapping and the HD Grid, patients underwent high-density voltage mapping of the TOK. Ablation site selection was based on properties during sinus rhythm with late activation, at or above the propagation wave collision, over low voltage, and with appropriate electrogram appearance. Five patients underwent mapping of the slow pathway using the HD Grid. Their median age was 14 years, their median weight was 54.1 kg, and their median height was 161.5 cm. The TOK was mapped with the HD Grid for a median of 3 min. The procedure was successful in all patients using this technique. The median lesion number to the site of success was 3, with a median total number of cryotherapy lesions of 11. No radiation was used. There were no recurrences. Using activation, propagation wave, low voltage, and electrogram appearance when mapping for slow-pathway localization and ablation with the HD Grid can be successful, results in high-density maps, and is relatively faster.
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Affiliation(s)
| | - Nicholas H. Von Bergen
- Department of Pediatrics, The University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Ribes F, Ferrero‐de‐Loma‐Osorio Á, Sánchez‐Gómez JM, Bondanza L, Martínez‐Brotons Á, Ruiz‐Granell R. Identification of cavotricuspid isthmus voltage patterns in typical atrial flutter ablation. J Arrhythm 2024; 40:191-194. [PMID: 38333391 PMCID: PMC10848585 DOI: 10.1002/joa3.12982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024] Open
Abstract
Background Electroanatomical mapping is an essential tool in the ablation of typical AFL. Objectives To identify the existence of voltage patterns in the CTI voltage maps and their relevance for typical AFL ablation. Methods A voltage map of the CTI was made prior to ablation, identifying the areas of maximum voltage and their location along the CTI, allowing classification into patterns according to their distribution. A stepwise ablation approach targeting the areas of maximum voltage was conducted. The ablation characteristics were compared based on the pattern obtained. Results Two voltage patterns were identified, with differences in ablation time to bidirectional CTI block. No complications occurred. Conclusions Voltage mapping identifies patterns in the CTI with implications for typical AFL ablation.
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Affiliation(s)
- Francisco Ribes
- Department of Cardiology, Arrhythmia UnitHospital Clínico Universitario ValenciaValenciaSpain
| | | | | | - Lourdes Bondanza
- Department of Cardiology, Arrhythmia UnitHospital Clínico Universitario ValenciaValenciaSpain
| | - Ángel Martínez‐Brotons
- Department of Cardiology, Arrhythmia UnitHospital Clínico Universitario ValenciaValenciaSpain
| | - Ricardo Ruiz‐Granell
- Department of Cardiology, Arrhythmia UnitHospital Clínico Universitario ValenciaValenciaSpain
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Watanabe T, Watanabe H, Hachiya H, Sato M, Mitama T, Okuyama T, Yokota A, Kamioka M, Komori T, Kabutoya T, Imai Y, Kario K. Impact of unipolar voltage criteria for left atrial posterior wall on atrial fibrillation recurrence after pulmonary vein isolation. J Cardiovasc Electrophysiol 2023; 34:849-859. [PMID: 36738145 DOI: 10.1111/jce.15838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/04/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Beyond pulmonary vein isolation (PVI), additional therapeutic strategies for atrial fibrillation (AF) have not been established. Remodeling of the left atrium (LA) could impact AF recurrence post-PVI. We investigated the impact of unipolar voltage (UV) criteria for the LA posterior wall (LA-PW) on AF recurrence post-PVI. METHODS We reviewed the cases of 106 AF patients (mean age 63.8 years, non-paroxysmal AF: 59%) who underwent extensive encircling PVI by radiofrequency ablation guided by a 3-dimension mapping system, investigating the impact on AF recurrence of the UV criteria of the LA. RESULTS Out of all patients, 26 patients had AF recurrence during post-PVI follow-up [median 603 days]. They showed a higher percentage of non-paroxysmal AF (80.8 vs. 52.5%, P=0.011), longer AF duration (2.9±2.7 vs. 1.0±1.7years, P=0.002), and larger area size of UV < 2.0mV in LA-PW (2.8±1.8 vs. 1.0±1.5cm2 , P<0.001) than those without recurrence. Cox Hazard analysis for AF recurrence adjusted by age, gender, AF duration, body mass index and left atrial volume index revealed that an area size over 2.0cm2 of UV < 2.0mV in LA-PW (HR 6.9 [95% CI:1.3-35.5], P=0.021) posed independent risks for AF recurrence post-PVI. The atrial arrhythmia-free survival rate was higher in those with no area of UV < 3.0mV in LA-PW compared to those with a sizable area (>2.0cm2 ) of UV <3.0mV and <2.0mV (95.0% vs. 74.2% vs. 57.1%, Log-Rank: P<0.001). In the AF etiology of patients with AF recurrence, 9 of 14 patients who underwent the 2nd procedure had no PV reconnection, and 8 patients required the LA-PW isolation for their non-PV AF. CONCLUSION UV criteria of LA-PW is a useful parameter for AF-recurrence post-PVI. Lower UV in LA-PW as an indication of electrical remodeling could indicate a higher risk of AF recurrence and the need for further therapeutic strategies. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tomonori Watanabe
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Hiroaki Watanabe
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Hitoshi Hachiya
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Masafumi Sato
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Tadayuki Mitama
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Takafumi Okuyama
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Ayako Yokota
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Masashi Kamioka
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Takahiro Komori
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Tomoyuki Kabutoya
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Yasushi Imai
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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Albarrán‐Rincón R, García ÁR, Ramos P, García‐Bolao I. A rare case of unusual scar in atrial fibrillation ablation: The "Yin-Yang" left atrium. J Arrhythm 2022; 39:82-83. [PMID: 36733328 PMCID: PMC9885315 DOI: 10.1002/joa3.12799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/27/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Ramón Albarrán‐Rincón
- Department of Cardiology and Cardiac Surgery, Arrhythmia UnitClínica Universidad de Navarra, IdiSNA, Navarra Institute for Health ResearchPamplonaSpain
| | - Álvaro Riesgo García
- Department of Cardiology and Cardiac Surgery, Arrhythmia UnitClínica Universidad de Navarra, IdiSNA, Navarra Institute for Health ResearchPamplonaSpain
| | - Pablo Ramos
- Department of Cardiology and Cardiac Surgery, Arrhythmia UnitClínica Universidad de Navarra, IdiSNA, Navarra Institute for Health ResearchPamplonaSpain
| | - Ignacio García‐Bolao
- Department of Cardiology and Cardiac Surgery, Arrhythmia UnitClínica Universidad de Navarra, IdiSNA, Navarra Institute for Health ResearchPamplonaSpain
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Balaram N, Jose J, Gafoor AV, Balachandran S. Classification of electrical status epilepticus in sleep based on EEG patterns and spatiotemporal mapping of spikes. Epileptic Disord 2022; 24:1060-72. [PMID: 36125364 DOI: 10.1684/epd.2022.1486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective We firstly aimed to describe and classify EEG patterns in electrical status epilepticus in sleep (ESES), and secondly subclassify EEG patterns based on analysis of spikes using spatio-temporal mapping and electrical source analysis. Methods Overnight EEGs (minimum: eight hours) of 30 children, aged 2-12 years, with ESES (spike-wave index: at least 50%) were selected. Average reference montage was used for dipole analysis and mapping. The location and orientation of the dipoles were determined by mapping positive and negative poles and applying the rules of mapping. The onset and propagation of the spikes and the latency between the two hemispheres (for bisynchronous spikes) were determined (based on source analysis using BESA research 7.1). Results (1) ESES was classified as “generalised” (80%) and focal (20%) patterns; (2) the bisynchronous subtype in the “generalised” pattern was due to apparently synchronous bilateral activation of spikes (with lead-in of 20-60 ms from one hemisphere) with a tangential/oblique dipole (source analysis localised these spikes to around the peri-rolandic cortex); (3) the classic description of ESES spikes as “diffuse” spikes with bifrontal maxima is a misinterpretation using the 10-20 EEG system .Using voltage mapping and source analysis, cortical activation in the rolandic cortex was identified which imparts diffuse frontal negativity and parieto-occipital positivity; (4) ESES spikes showed intraspike and interspike dipole instability and the orientation of dipoles changed due to local spike propagation around the source and into the depth of the sulcus (which we refer to herein as “dancing dipoles”); and (5) focal ESES were classified as parietal, occipital and temporo-occipital patterns;a frontal ESES pattern was not seen. Significance Based on detailed mapping and source analysis of ESES, we have successfully reinterpreted various misconceptions in the literature. We have simplified the interpretation of complicated EEG patterns by extracting the primary and propagated sources which aid the classification of ESES. As the dipole is always stable in self-limited childhood epilepsy with centrotemporal spikes, we believe that the phenomenon of an intrinsically unstable dipole is a reliable qualitative EEG marker of ESES.
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Kiankhooy A. Talk like a duck, walk like a duck: A cardiac surgeon's understanding of complex imaging in the management of atrial fibrillation. J Card Surg 2022; 37:4178-4185. [PMID: 36273431 DOI: 10.1111/jocs.17045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 01/06/2023]
Abstract
The treatment of atrial fibrillation continues to evolve. The Heart Team Hybrid Ablation Approach is the latest iteration of Electrophysiology and Arrythmia surgeon collaboration that is focused on the treatment of complex (persistent and long-standing persistent) atrial fibrillation patients. Critical to this team approach is the ability to converse regarding atrial anatomy, atrial substrate and transmurality of ablation lesions. The cornerstone of these dialogs is advanced imaging techniques including; transesophageal echocardiography, enhanced magnetic resonance imaging, endocardial voltage mapping, and epicardial electrogram mapping. We herein review these techniques and their clinic implications.
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Affiliation(s)
- Armin Kiankhooy
- Department of Cardiothoracic Surgery, Adventist Health-Saint Helena, Saint Helena, California, USA
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11
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Saito J, Yamashita K, Numajiri T, Gibo Y, Usumoto S, Narui S, Fujioka T, Asukai Y, Igawa W, Ono M, Ebara S, Okabe T, Isomura N, Ochiai M. Grid-mapping catheters versus PentaRay catheters for left atrial mapping on ensite precision mapping system. J Cardiovasc Electrophysiol 2022; 33:1405-1411. [PMID: 35441420 DOI: 10.1111/jce.15498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Areas displaying reduced bipolar voltage are defined as low-voltage areas (LVAs). Moreover, left atrial (LA) LVAs after pulmonary vein isolation (PVI) have been reported as a predictor of recurrent atrial fibrillation (AF). In this study, we compared grid mapping catheter (GMC) with PentaRay catheter (PC) for LA voltage mapping on Ensite Precision mapping system. METHODS Twenty-six consecutive patients with LVAs and border zone within the LA were enrolled. After achieving PVI, voltage mapping under high right atrial pacing for 600 ms was performed twice using each catheter type (GMC first, PC next). Furthermore, LVA was defined as a region with a bipolar voltage of <0.50, and border zone was defined as a region with a bipolar voltage of <1.0, or <1.5 mV. RESULTS Compared with PC, using GMC, voltage mapping contained more mapping points (20 242 [15 859, 26 013] vs. 5589 [4088, 7649]; p < .0001), and more mapping points per minute(1428 [1275, 1803] vs. 558 [372, 783]; p < .0001). In addition, LVA and border zone size using GMC was significantly less than that reported using PC: <1.0 mV (5.9 cm2 [2.9, 20.2] vs. 13.9 cm2 [6.3, 24.1], p = .018) and <1.5 mV voltage cutoff (10.6 cm2 [6.6, 27.2] vs. 21.6 cm2 [12.6, 35.0], p = .005). CONCLUSION Bipolar voltage amplitude estimated by GMC was significantly larger than that estimated by PC on Ensite Precision mapping system. GMC may be able to find highly selective identification of LVAs with lower prevalence and smaller LVA and border zone size.
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Affiliation(s)
- Jumpei Saito
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Kennosuke Yamashita
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Japan.,Cardiac Arrhythmia Center, Sendai Kousei Hospital, Sendai, Japan
| | - Takaki Numajiri
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Yuma Gibo
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Soichiro Usumoto
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Syuro Narui
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Tatsuki Fujioka
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Yu Asukai
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Wataru Igawa
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Morio Ono
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Seitaro Ebara
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Toshitaka Okabe
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Naoei Isomura
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
| | - Masahiko Ochiai
- Division of Cadiology, Northern Yokohama Hospital, Showa University, Yokohama, Japan
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Hwang J, Park HS, Han S, Lee CH, Kim IC, Cho YK, Yoon HJ, Chung JW, Kim H, Nam CW, Hur SH, Kim JY, Kim YS, Jang WS. Ablation of persistent atrial fibrillation based on high density voltage mapping and complex fractionated atrial electrograms: A randomized controlled trial. Medicine (Baltimore) 2021; 100:e26702. [PMID: 34397805 PMCID: PMC8341227 DOI: 10.1097/md.0000000000026702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/07/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) catheter ablation. However, a PVI alone has been considered insufficient for persistent AF. This study aimed to evaluate the efficacy of persistent AF ablation targeting complex fractionated atrial electrogram (CFAE) areas within low voltage zones identified by high-resolution mapping in addition to the PVI. METHODS We randomized 50 patients (mean age 58.4 ± 9.5 years old, 86.0% males) with persistent AF to a PVI + CFAE group and PVI only group in a 1:1 ratio. CFAE and voltage mapping was performed simultaneously using a Pentaray Catheter with the CARTO3 CONFIDENSE module (Biosense Webster, CA, USA). The PVI + CFAE group, in addition to the PVI, underwent ablation targeting low voltage areas (<0.5 mV during AF) containing CFAEs. RESULTS The mean persistent AF duration was 24.0 ± 23.1 months and mean left atrial dimension 4.9 ± 0.5 cm. In the PVI + CFAE group, AF converted to atrial tachycardia (AT) or sinus rhythm in 15 patients (60%) during the procedure. The PVI + CFAE group had a higher 1-year AF free survival (84.0% PVI + CFAE vs 44.0 PVI only, P = .006) without antiarrhythmic drugs. However, there was no difference in the AF/AT free survival (60.0% PVI + CFAE vs 40.0% PVI only, P = .329). CONCLUSION Persistent AF ablation targeting CFAE areas within low voltage zones using high-density voltage mapping had a higher AF free survival than a PVI only. Although recurrence with AT was frequent in the PVI+CFAE group, the sinus rhythm maintenance rate after redo procedures was 76%.
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Affiliation(s)
- Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Cheol Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Yun-Kyeong Cho
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyuck-Jun Yoon
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jin wook Chung
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Chang-Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seung-Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jin Young Kim
- Department of Radiology, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular surgery, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular surgery, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
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13
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Sunaga A, Masuda M, Inoue K, Tanaka N, Watanabe T, Furukawa Y, Egami Y, Hirata A, Makino N, Minamiguchi H, Oka T, Minamisaka T, Takeda T, Yamada T, Kitamura T, Kida H, Oeun B, Sato T, Sotomi Y, Dohi T, Okada K, Suna S, Mizuno H, Nakatani D, Hikoso S, Sakata Y. The efficacy and safety of left atrial low-voltage area guided ablation for recurrence prevention compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation trial: Design and rationale. Clin Cardiol 2021; 44:1249-1255. [PMID: 34291484 PMCID: PMC8428000 DOI: 10.1002/clc.23677] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 01/27/2023] Open
Abstract
Recurrence rates of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are higher in patients with a left atrial low‐voltage area (LVA) than those without. However, the efficacy of LVA guided ablation is still unknown. The purpose of this study—the Efficacy and Safety of Left Atrial Low‐voltage Area Guided Ablation for Recurrence Prevention Compared to Pulmonary Vein Isolation Alone in Patients with Persistent Atrial Fibrillation trial (SUPPRESS‐AF trial)—is to elucidate whether LVA guided ablation in addition to PVI is superior to PVI alone in patients with persistent AF. The Osaka Cardiovascular Conference will conduct a multicenter, randomized, open‐label trial aiming to examine whether LVA guided ablation in addition to PVI is superior to PVI alone in patients with persistent AF and LVAs. The primary outcome is the recurrence of AF documented by scheduled or symptom‐driven electrocardiography (ECG) during the 1 year follow‐up period after the index ablation. The key secondary endpoints include all‐cause death, symptomatic stroke, bleeding events, and other complications related to the procedure. A total of 340 patients with an LVA will be enrolled and followed up to 1 year. The SUPPRESS‐AF trial is a randomized controlled trial designed to assess whether LVA guided ablation in addition to PVI is superior to PVI alone for patients with persistent AF and LVAs detected while undergoing their first catheter ablation.
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Affiliation(s)
- Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masaharu Masuda
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Koichi Inoue
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, Osaka, Japan.,Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, Osaka, Japan
| | - Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yoshio Furukawa
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Japan
| | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Nobuhiko Makino
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Hitoshi Minamiguchi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan.,Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Takafumi Oka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan.,Cardiovascular Center, Sakurabashi-Watanabe Hospital, Osaka, Japan
| | - Tomoko Minamisaka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Toshihiro Takeda
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomomi Yamada
- Department of Medical Innovation, Osaka University Hospital, Suita, Japan
| | - Tetsuhisa Kitamura
- Department of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shinichiro Suna
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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14
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Hayashida S, Nagashima K, Kurokawa S, Arai M, Watanabe R, Wakamatsu Y, Otsuka N, Yagyu S, Iso K, Okumura Y. Formation of low-voltage zones on the anterior left atrial wall due to mechanical compression by the ascending aorta. J Cardiovasc Electrophysiol 2021; 32:2275-2284. [PMID: 33969564 DOI: 10.1111/jce.15076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/09/2021] [Accepted: 04/27/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although low-voltage zones (LVZs) in the left atrium (LA) are considered arrhythmogenic substrates in some patients with atrial fibrillation (AF), the pathophysiologic factors responsible for LVZ formations remain unclear. OBJECTIVE To elucidate the anatomical relationship between the LA and ascending aorta responsible for anterior LA wall remodeling. METHODS We assessed the relationship between existence of LVZs on the anterior LA wall and the three-dimensional computed tomography image measurements in 102 patients who underwent AF ablation. RESULTS Twenty-nine patients (28%) had LVZs grearer than 1.0 cm2 on the LA wall in the LA-ascending aorta contact area (LVZ group); no LVZs were seen in the other 73 patients (no-LVZ group). The LVZ group (vs. no-LVZ group) had a smaller aorta-LA angle (21.0 ± 7.7° vs. 24.9 ± 7.1°, p = .015), greater aorta-left-ventricle (LV) angle (131.3 ± 8.8° vs. 126.0 ± 7.9°; p = .005), greater diameter of the noncoronary cusp (NCC; 20.4 ± 2.2 vs. 19.3 ± 2.5 mm; p = .036), thinner LA wall-thickness adjacent to the NCC (2.3 ± 0.7 vs. 2.8 ± 0.8 mm; p = .006), and greater cardiothoracic ratio (percentage of the area in the thoracic area, 40.1 ± 7.1% vs. 35.4 ± 5.7%, p < .001). The aorta-LA angle correlated positively with the patients' body mass index (BMI), and the aorta-LV angle correlated negatively with the body weight and BMI. CONCLUSION Deviation of the ascending aorta's course and distention of the NCC appear to be related to the development of LA anterior wall LVZs in the LA-ascending aorta contact area. Mechanical pressure exerted by extracardiac structures on the LA along with the limited thoracic space may contribute to the development of LVZs associated with AF.
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Affiliation(s)
- Satoshi Hayashida
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of Cardiology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Naoto Otsuka
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Seina Yagyu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuki Iso
- Department of Cardiology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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15
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Garg L, Pothineni NVK, Daw JM, Hyman MC, Arkles J, Tschabrunn CM, Santangeli P, Marchlinski FE. Impact of Left Atrial Bipolar Electrogram Voltage on First Pass Pulmonary Vein Isolation During Radiofrequency Catheter Ablation. Front Physiol 2021; 11:594654. [PMID: 33384608 PMCID: PMC7769759 DOI: 10.3389/fphys.2020.594654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background First pass pulmonary vein isolation (PVI) is associated with durable isolation and reduced recurrence of atrial fibrillation (AF). Objective We sought to investigate the relationship between left atrial electrogram voltage using multielectrode fast automated mapping (ME-FAM) and first pass isolation with radiofrequency ablation. Methods We included consecutive patients (pts) undergoing first time ablation for paroxysmal AF (pAF), and compared the voltage characteristics between patients with and without first pass isolation. Left atrium (LA) adjacent to PVs was divided into 6 regions, and mean voltages obtained with ME-FAM (Pentaray, Biosense Webster) in each region and compared. LA electrograms with marked low voltage (<0.5 mV) were identified and the voltage characteristics at the site of difficult isolation was compared to the voltage in adjacent region. Results Twenty consecutive patients (10 with first pass and 10 without) with a mean age of 63.3 ± 6.2 years, 65% males, were studied. Difficult isolation occurred on the right PVs in eight pts and left PVs in three pts. The mean voltage in pts without first pass isolation was lower in all 6 regions; posterior wall (1.93 ± 1.46 versus 2.99 ± 2.19; p < 0.001), roof (1.83 ± 2.29 versus 2.47 ± 1.99; p < 0.001), LA-LPV posterior (1.85 ± 3.09 versus 2.99 ± 2.19, p < 0.001), LA-LPV ridge (1.42 ± 1.04 versus 1.91 ± 1.61; p < 0.001), LA-RPV posterior (1.51 ± 1.11 versus 2.30 ± 1.77, p < 0.001) and LA-RPV septum (1.55 ± 1.23 versus 2.31 ± 1.40, p < 0.001). Patients without first pass isolation also had a larger percentage of signal with an amplitude of <0.5 mV for each of the six regions (12.8% versus 7.5%). In addition, the mean voltage at the site of difficult isolation was lower at 8 out of 11 sites compared to mean voltage for remaining electrograms in that region. Conclusion In patients undergoing PVI for paroxysmal AF, failure in first pass isolation was associated with lower global LA voltage, more marked low amplitude signal (<0.5 mV) and lower local signal voltage at the site with difficult isolation. The results suggest that a greater degree of global and segmental fibrosis may play a role in ease of PV isolation with radiofrequency energy.
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Affiliation(s)
- Lohit Garg
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Naga Venkata K Pothineni
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - J Michael Daw
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew C Hyman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey Arkles
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Cory M Tschabrunn
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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16
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Kiedrowicz RM, Wielusiński M, Wojtarowicz A, Kaźmierczak J. Atrial fibrillation risk scores to evaluate left atrial substrate based on voltage analysis in long-standing persistent type of arrhythmia. Kardiol Pol 2021; 79:525-530. [PMID: 34125925 DOI: 10.33963/kp.15902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pre-ablation identification of left atrial (LA) low voltage areas (LVA) among long-standing persistent atrial fibrillation (LSPAF) population remains challenging. AIMS The aim of the study was to analyze the potential of selected scores originally developed to assess arrhythmia recurrences, thromboembolic complications, or progression from paroxysmal to persistent AF to predict the presence of LA-LVA in LSPAF patients. METHODS One hundred and fifty-two patients underwent pulmonary vein isolation followed by high-density-high-resolution LA voltage mapping. AF risk scores, such as APPLE, ATLAS, CAAP-AF, DR-FLASH, CHA2DS2-VASc, and HATCH were retrospectively calculated. A receiver operating characteristic curve analysis was performed to evaluate the ability of the scores to predict LVA. RESULTS Low voltage areas were detected in 52% of the patients. 28% of the patients with LVA presented severe global LVA burden, whereas 56% of the patients showed a disseminated pattern of remodeling. CAAP-AF ≥7, DR-FLASH ≥4, and CHA2DS2-VASc ≥3 predicted the presence of LVA, whereas ATLAS ≤7 indicated the absence of LVA. ATLAS ≤8, CAAP-AF ≤9, DR-FLASH ≤4, and CHA2DS2-VASc ≤3 predicted the absence of severe LVA. APPLE ≤3 and CHA2DS2-VASc ≤2 predicted the absence of a LVA disseminated pattern. Among predictive scores, ATLAS (AUC, 0.633, 95% CI, 0.543-0.723, P = 0.004), DR-FLASH (AUC, 0.696; 95% CI, 0.594-0.81; P <0.001), and CHA2DS2-VASc (AUC, 0.644; 95% CI 0.518-0.77; P = 0.025) were the best predictors for the absence of LVA, severe LVA and a disseminated pattern of LVA, respectively. CONCLUSIONS Atrial fibrillation risk stratification with specific scoring systems can unmask the presence of LA-LVA in the LSPAF population.
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Glashan CA, Beukers HKC, Tofig BJ, Tao Q, Blom S, Mertens B, Kristiansen SB, Zeppenfeld K. Mini-, Micro-, and Conventional Electrodes: An in Vivo Electrophysiology and Ex Vivo Histology Head-to-Head Comparison. JACC Clin Electrophysiol 2020; 7:197-205. [PMID: 33602400 DOI: 10.1016/j.jacep.2020.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to assess the relative effect of catheter, tissue, and catheter-tissue parameters, on the ability to determine the amount of viable myocardium in vivo. BACKGROUND Although multiple variables impact bipolar voltages (BVs), electrode size, interelectrode spacing, and directional dependency are of particular interest with the development of catheters incorporating mini and microelectrodes. METHODS Nine swine with early reperfusion myocardial infarctions were mapped using the QDot catheter and then remapped using a Pentaray catheter. All QDot points were matched with Pentaray points within 5 mm. The swine were sacrificed, and mapping data projected onto the heart. Transmural biopsies corresponding to mapping points were obtained, allowing a comparison of electrograms recorded by mini, micro-, and conventional electrodes with histology. RESULTS The conventional BV of 2,322 QDot points was 1.9 ± 1.3 mV. The largest of the 3 microelectrode BVs (BVµMax) average 4.8 ± 3.1 mV. The difference between the largest (BVμMax) and smallest (BVμMin) at a given location was 53.7 ± 18.1%. The relationships between both BVμMax and BVμMin and between the conventional BV and BVμMax were positively related but with a significant spread in data, which was more pronounced for the latter. Pentaray points positively related to the BVμMax with poor fit. On histology, increasing viable myocardium increased voltage, but both the slope coefficient and fit were best for BVμMax. CONCLUSIONS Using histology, we could demonstrate that BVμMax is superior to identify viable myocardium compared with BVC and BV using the Pentaray catheter. The ability to simultaneously record 3 BVμs with different orientations, for the same beat, with controllable contact and selecting BVμMax for local BV may partially compensate for wave front direction.
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Affiliation(s)
- Claire A Glashan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans K C Beukers
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bawer J Tofig
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Qian Tao
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Sira Blom
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart Mertens
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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18
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Matsuda Y, Masuda M, Asai M, Iida O, Okamoto S, Ishihara T, Nanto K, Kanda T, Tsujimura T, Hata Y, Uematsu H, Mano T. A new clinical risk score for predicting the prevalence of low-voltage areas in patients undergoing atrial fibrillation ablation. J Cardiovasc Electrophysiol 2020; 31:3150-3158. [PMID: 32966648 DOI: 10.1111/jce.14761] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/07/2020] [Accepted: 09/20/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Although the presence of left atrial low-voltage areas (LVAs) is strongly associated with the recurrence of atrial fibrillation (AF) after ablation, few methods are available to classify the prevalence of LVAs. The purpose of this study was to establish a risk score for predicting the prevalence of LVAs in patients undergoing ablation for AF. METHODS We enrolled 1004 consecutive patients who underwent initial ablation for AF (age, 68 ± 10 years old; female, 346 (34%); persistent AF, 513 (51%)). LVAs were deemed present when the voltage map after pulmonary vein isolation demonstrated low-voltage areas with a peak-to-peak bipolar voltage of <0.5 mV covering ≥5 cm2 of the left atrium. RESULTS LVAs were present in 206 (21%) patients. The SPEED score was obtained as the total number of independent predictors as identified on multivariate analysis, namely female sex (odds ratio [OR], 3.4 [95% confidence interval {CI} 2.2-5.2], p < .01), persistent AF (OR, 1.8 [95% CI, 1.1-3.0], p = .02), age ≥ 70 years (OR, 2.3 [95% CI, 1.5-3.4], p < .01), elevated brain natriuretic peptide ≥100 pg/ml or N-terminal probrain natriuretic peptide ≥400 pg/ml (OR, 1.7 [95% CI, 1.02-2.8], p = .04), and diabetes mellitus (OR, 1.8 [95% CI, 1.1-2.8], p = .02). LVAs were more frequent in patients with a higher SPEED score, and prevalence increased with each additional SPEED score point (OR, 2.4 [95% CI, 2.0-2.8], p < .01). CONCLUSION The SPEED score accurately predicts the prevalence of LVAs in patients undergoing ablation for AF.
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Affiliation(s)
- Yasuhiro Matsuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Mitsutoshi Asai
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takayuki Ishihara
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takashi Kanda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takuya Tsujimura
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Yosuke Hata
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Hiroyuki Uematsu
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
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19
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Muser D, Santangeli P. Ventricular Arrhythmias in Myocarditis: Prognostic Role of Electroanatomic Voltage Mapping. JACC Clin Electrophysiol 2020; 6:583-585. [PMID: 32439045 DOI: 10.1016/j.jacep.2020.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Daniele Muser
- Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania,USA.
| | - Pasquale Santangeli
- Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania,USA
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Kiedrowicz RM, Wielusinski M, Wojtarowicz A, Kazmierczak J. Predictors of the voltage derived left atrial fibrosis in patients with long-standing persistent atrial fibrillation. Cardiol J 2020; 29:660-669. [PMID: 32419127 PMCID: PMC9273256 DOI: 10.5603/cj.a2020.0069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 11/25/2022] Open
Abstract
Background Left atrial (LA) arrhythmogenic substrate beyond the pulmonary veins (PV) seems to play a crucial role in the maintenance of atrial fibrillation (AF). The aim of this study was to evaluate the association of selected parameters with the presence and extent of voltage-defined LA fibrosis in patients with long-standing persistent AF (LSPAF) undergoing catheter ablation. Methods One hundred and sixteen consecutive patients underwent high density-high resolution voltage mapping of the LA with a multielectrode catheter following PV isolation and restoration of sinus rhythm with cardioversion. A non-invasive dataset, such as clinical variables, two- and three-dimensional echocardiography determined LA size and function and fibrillatory-wave amplitude on a standard surface electrocardiogram were obtained during AF before ablation. Results Low-voltage areas (LVA; 15 cm2 [IQR 8–31]) were detected in 56% of patients. Twenty nine percent of them presented mild, 43% moderate and 28% severe global LVA burden. In univariate analysis, age ≥ 57 years old, female sex, body surface area ≤ 1.76 m2, valvular heart disease, moderate mitral regurgitation, chronic coronary syndrome, hypothyroidism, CHA2DS2-VASc score ≥ 3 and ≥ 4 predicted the presence of LVA. In multivariate analysis only female sex, valvular heart disease and CHA2DS2-VASc ≥ 4 remained statistically significant. AF duration, LA size and function and fibrillatory-waves amplitude were neither associated with the prediction of the LVA, nor severe LVA burden. Conclusions A LSPAF diagnosis does not indicate the presence of voltage defined fibrosis in many cases. Simple non-invasive screening of the LSPAF population could predict LVA prevalence.
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Affiliation(s)
| | - Maciej Wielusinski
- Department of Cardiology, Pomeranian Medical University, Szczecin, Poland
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Nakatani Y, Sakamoto T, Yamaguchi Y, Tsujino Y, Kataoka N, Nishida K, Mizumaki K, Kinugawa K. Correlation between the left atrial low-voltage area and the cardiac function improvement after catheter ablation for paroxysmal atrial fibrillation. J Arrhythm 2019; 35:725-732. [PMID: 31624511 PMCID: PMC6787158 DOI: 10.1002/joa3.12221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/01/2019] [Accepted: 06/24/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The impact of the left atrial low-voltage area (LVA) on the cardiac function improvement following ablation for atrial fibrillation (AF) is unclear. METHODS In 49 patients with paroxysmal AF who underwent ablation, the left ventricular stroke volume index (SVI) was repeatedly measured using an impedance cardiography until 6 months after ablation. We defined the cardiac function improvement as a 20% increase in the SVI. The LVA (the area with the voltage amplitude of <0.5 mV) was assessed before ablation. RESULTS The reduced baseline SVI (<33 mL/m2) was observed in 18 (37%) patients. The SVI increased following ablation (from 36 ± 5 to 39 ± 6 mL/m2, P < .001). We observed the cardiac function improvement in 14 (29%) patients. The LVA was smaller in patients with the improved cardiac function than in those without (8.3% ± 5.2% vs 14.0% ± 8.5%, P = .026). The multivariate analysis revealed that only the LVA was independently associated with the cardiac function improvement (odds ratio, 0.878; 95% confidence interval: 0.778-0.991, P = .036). Furthermore, LVAs of the anterior (7.9% ± 7.6% vs 18.2% ± 15.5%, P = .022), septal (12.0 ± 7.3% vs 20.7% ± 13.8%, P = .031), and roof walls (6.9% ± 6.0% vs 16.9% ± 15.2%, P = .022) were smaller in patients with the improved cardiac function than in those without. CONCLUSIONS The LVA was related to the cardiac function improvement following ablation in patients with paroxysmal AF.
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Affiliation(s)
- Yosuke Nakatani
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Tamotsu Sakamoto
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | - Yasushi Tsujino
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Naoya Kataoka
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | | | - Koichiro Kinugawa
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
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Letsas KP, Efremidis M, Asvestas D, Vlachos K, Georgopoulos S, Tse G, Liu T, Bazoukis G, Sideris A, Baranchuk A, Ehrlich JR, Brugada P. Right Ventricular Outflow Tract Electroanatomical Abnormalities Predict Ventricular Fibrillation Inducibility in Brugada Syndrome. Circ Arrhythm Electrophysiol 2019; 11:e005928. [PMID: 29437762 DOI: 10.1161/circep.117.005928] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/12/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Konstantinos P Letsas
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.).
| | - Michael Efremidis
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Dimitrios Asvestas
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Konstantinos Vlachos
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Stamatis Georgopoulos
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Gary Tse
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Tong Liu
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - George Bazoukis
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Antonios Sideris
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Adrian Baranchuk
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Joachim R Ehrlich
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
| | - Pedro Brugada
- From the Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece (K.P.L., M.E., D.A., K.V., S.G., G.B., A.S.); Department of Medicine and Therapeutics and Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, SAR, P.R. China (G.T.); Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, P.R. China (T.L.); Division of Cardiology, Queen's University, Kingston General Hospital, Ontario, Canada (A.B.); Electrophysiology Section, St. Josefs-Hospital, Wiesbaden, Germany (J.R.E.); and Heart Rhythm Management Centre, UZ Brussel-VUB, Belgium (P.B.)
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23
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López-Yunta M, León DG, Alfonso-Almazán JM, Marina-Breysse M, Quintanilla JG, Sánchez-González J, Galán-Arriola C, Cañadas-Godoy V, Enríquez-Vázquez D, Torres C, Ibáñez B, Pérez-Villacastín J, Pérez-Castellano N, Jalife J, Vázquez M, Aguado-Sierra J, Filgueiras-Rama D. Implications of bipolar voltage mapping and magnetic resonance imaging resolution in biventricular scar characterization after myocardial infarction. Europace 2019; 21:163-174. [PMID: 30239689 PMCID: PMC6321957 DOI: 10.1093/europace/euy192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/06/2018] [Indexed: 11/14/2022] Open
Abstract
AIMS We aimed to study the differences in biventricular scar characterization using bipolar voltage mapping compared with state-of-the-art in vivo delayed gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) imaging and ex vivo T1 mapping. METHODS AND RESULTS Ten pigs with established myocardial infarction (MI) underwent in vivo scar characterization using LGE-CMR imaging and high-density voltage mapping of both ventricles using a 3.5-mm tip catheter. Ex vivo post-contrast T1 mapping provided a high-resolution reference. Voltage maps were registered onto the left and right ventricular (LV and RV) endocardium, and epicardium of CMR-based geometries to compare voltage-derived scars with surface-projected 3D scars. Voltage-derived scar tissue of the LV endocardium and the epicardium resembled surface projections of 3D in vivo and ex vivo CMR-derived scars using 1-mm of surface projection distance. The thinner wall of the RV was especially sensitive to lower resolution in vivo LGE-CMR images, in which differences between normalized low bipolar voltage areas and CMR-derived scar areas did not decrease below a median of 8.84% [interquartile range (IQR) (3.58, 12.70%)]. Overall, voltage-derived scars and surface scar projections from in vivo LGE-CMR sequences showed larger normalized scar areas than high-resolution ex vivo images [12.87% (4.59, 27.15%), 18.51% (11.25, 24.61%), and 9.30% (3.84, 19.59%), respectively], despite having used optimized surface projection distances. Importantly, 43.02% (36.54, 48.72%) of voltage-derived scar areas from the LV endocardium were classified as non-enhanced healthy myocardium using ex vivo CMR imaging. CONCLUSION In vivo LGE-CMR sequences and high-density voltage mapping using a conventional linear catheter fail to provide accurate characterization of post-MI scar, limiting the specificity of voltage-based strategies and imaging-guided procedures.
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Affiliation(s)
- Mariña López-Yunta
- Department of Computer Applications in Science and Engineering, Barcelona Supercomputing Center (BSC), Jordi Girona, 29, Barcelona, Spain
| | - Daniel G León
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
| | - José Manuel Alfonso-Almazán
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
| | - Manuel Marina-Breysse
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Agencia Española de Protección de la Salud en el Deporte (AEPSAD), Madrid, Spain
| | - Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
| | | | - Carlos Galán-Arriola
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
| | - Victoria Cañadas-Godoy
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
| | - Daniel Enríquez-Vázquez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, Madrid, Spain
| | - Carlos Torres
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, Madrid, Spain
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
- IIS-University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Julián Pérez-Villacastín
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
- Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Nicasio Pérez-Castellano
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
| | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
- Department of Internal Medicine, Center for Arrhythmia Research, Cardiovascular Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Mariano Vázquez
- Department of Computer Applications in Science and Engineering, Barcelona Supercomputing Center (BSC), Jordi Girona, 29, Barcelona, Spain
| | - Jazmín Aguado-Sierra
- Department of Computer Applications in Science and Engineering, Barcelona Supercomputing Center (BSC), Jordi Girona, 29, Barcelona, Spain
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 2, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Monforte de Lemos 3-5, Madrid, Spain
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Casado Arroyo R, Chatzikyriakou S. Characterization of Accessory Pathways Using an Orientation-Independent Catheter. JACC Clin Electrophysiol 2018; 4:1379-81. [PMID: 30336888 DOI: 10.1016/j.jacep.2018.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 05/31/2018] [Indexed: 11/20/2022]
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Shen W, Zhai L, Yang G, Liu H, Chen H, Ju W, Gu K, Li M, Zhang F, Chen M. Efficacy of sole pulmonary vein isolation in patients with nonparoxysmal atrial fibrillation without significant left atrium scar. Pacing Clin Electrophysiol 2018; 41:1356-1361. [PMID: 30055003 DOI: 10.1111/pace.13462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 07/01/2018] [Accepted: 07/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Catheter ablation strategies for nonparoxysmal atrial fibrillation (NPAF) are in varied forms. The mechanisms that circumferential pulmonary vein isolation (CPVI) alone could achieve success in some of the patients with NPAF are not well studied. This study sought to assess the clinical outcome of only CPVI approach in NPAF patients without significant left atrium scar. METHODS AND RESULTS A total of 241 consecutive patients with NPAF undergoing an initial ablation procedure were studied. After CPVI, cavotricuspid isthmus ablation and direct current cardioversion, high-density atrial voltage mapping was performed during sinus rhythm. Transitional-voltage zone (TZ) was defined as 0.4-1.3 mV, and low-voltage zone (LVZ) as <0.4 mV. No LVZs were identified in 101 patients (41.9%), and only CPVI was performed. Among the patients without LVZs, single-procedure freedom from atrial fibrillation (AF)/atrial tachycardia was achieved in 73 patients (72%), while 28 patients (28%) had AF recurrence with mean follow-up of 29 ± 14 months. TZ index (TZi) was deduced by calculating the ratio of all TZ points over the total number of points and was found to be a univariate predictor of recurrence after a single procedure (P = 0.047). CONCLUSIONS The CPVI alone strategy for patients with NPAF can be performed in highly selective patients without LVZs. TZi may reflect healthy extent of left atrium, which has trend toward the association with AF recurrence.
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Affiliation(s)
- Wenzhi Shen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lishang Zhai
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hailei Liu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Gu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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26
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Liang JJ, D'Souza BA, Betensky BP, Zado ES, Desjardins B, Santangeli P, Chik WW, Frankel DS, Callans DJ, Supple GE, Hutchinson MD, Dixit S, Schaller RD, Garcia FC, Lin D, Riley MP, Marchlinski FE. Importance of the Interventricular Septum as Part of the Ventricular Tachycardia Substrate in Nonischemic Cardiomyopathy. JACC Clin Electrophysiol 2018; 4:1155-1162. [PMID: 30236388 DOI: 10.1016/j.jacep.2018.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/16/2018] [Accepted: 04/19/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to characterize septal substrate in patients with nonischemic left ventricular cardiomyopathy (NILVCM) undergoing ventricular tachycardia (VT) ablation. BACKGROUND The interventricular septum is an important site of VT substrate in NILVCM. METHODS The authors studied 95 patients with NILVCM and VT. Electroanatomic mapping using standard bipolar (<1.5 mV) and unipolar (<8.3 mV) low-voltage criteria identified septal scar location and size. Analysis of unipolar voltage was performed and scars quantified using graded unipolar cutoffs from 4 to 8.3 mV were correlated with delayed gadolinium-enhanced cardiac magnetic resonance (DE-CMR), performed in 57 patients. RESULTS Detailed LV endocardial mapping (mean 262 ± 138 points) showed septal bipolar and unipolar voltage abnormalities (VAs) in 44 (46%) and 79 (83%) patients, most commonly with basal anteroseptal involvement. Of the 59 patients in whom the septum was targeted, bipolar and unipolar septal VAs were seen in 36 (61%) and 54 (92%). Of the 35 with CMR-defined septal scar, bipolar and unipolar septal VAs were seen in 18 (51%) and 31 (89%). In 12 patients without CMR septal scar, 6 (50%) had isolated unipolar septal VAs on electroanatomic mapping, a subset of whom the septum was targeted for ablation (44%). In the graded unipolar analysis, the optimal cutoff associated with magnetic resonance imaging septal scar was 4.8 mV (sensitivity 75%, specificity 70%; area under the curve: 0.75; 95% confidence interval: 0.60 to 0.90). CONCLUSIONS Septal substrate by unipolar or bipolar voltage mapping in patients with NILVCM and VT is common. A unipolar voltage cutoff of 4.8 mV provides the best correlation with DE-CMR. A subset of patients with septal VT had normal DE-CMR or endocardial bipolar voltage with abnormal unipolar voltage.
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Affiliation(s)
- Jackson J Liang
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin A D'Souza
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian P Betensky
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica S Zado
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benoit Desjardins
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William W Chik
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mathew D Hutchinson
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Riley
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Kumareswaran R, Marchlinski FE. Practical Guide to Ablation for Epicardial Ventricular Tachycardia: When to Get Access, How to Deal with Anticoagulation and How to Prevent Complications. Arrhythm Electrophysiol Rev 2018; 7:159-164. [PMID: 30416728 DOI: 10.15420/aer.2018.10.2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Epicardial ablation is needed to eliminate ventricular tachycardia (VT) in some patients with nonischaemic cardiomyopathy. The 12-lead electrocardiogram of VT, pre-procedural imaging and endocardial unipolar voltage maps can predict a high likelihood of epicardial substrate and VT. A septal VT substrate may preclude the need for epicardial access and mapping and can be identified with imaging, pacing and voltage mapping. Pericardial access is usually obtained prior to systemic anticoagulation or after reversal of systemic anticoagulation. A unique set of complications can be encountered with epicardial access, mapping and ablation, which include haemopericardium, phrenic nerve injury, damage to major coronary arteries and pericarditis. Anticipating, preventing and, if necessary, managing these complications are paramount for patient safety. Best practices are reviewed.
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Affiliation(s)
- Ramanan Kumareswaran
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia Pennsylvania, USA
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Van Aartsen A, Law IH, Maldonado JR, Von Bergen NH. Propagation Mapping Wave Collision Correlates to the Site of Successful Ablation During Voltage Mapping in Atrioventricular Nodal Reentry Tachycardia. J Innov Card Rhythm Manag 2017; 8:2836-2842. [PMID: 32494469 PMCID: PMC7252827 DOI: 10.19102/icrm.2017.080905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/02/2017] [Indexed: 11/06/2022] Open
Abstract
Voltage mapping has been used previously for slow-pathway localization for atrioventricular nodal reentrant tachycardia (AVNRT) ablation. However, propagation mapping may be a technique to further improve the localization of the slow pathway. This retrospective study aimed to evaluate the relationship of the propagation map to both the voltage mapping and successful site of ablation in patients who underwent ablation for AVNRT. All patients ≤20 years of age who underwent voltage mapping for AVNRT were included in this study. Patients were excluded if they had congenital heart disease or inadequate voltage point density within the triangle of Koch (TK). During the study, a propagation map was evaluated from the prior voltage map, marking a "wave collision" at the site of atrial wave convergence. Patient and procedural information, the location of the wave collision, the site of successful ablation, and the appearance of the voltage map were evaluated. Ultimately, 39 patients aged from four years of age to 20 years of age were evaluated. Success was achieved in 100% of patients, with a recurrence rate of 2.8% and no long-term complications observed. The average procedure time was 127 min. Follow-up length averaged seven months post operation. Low-voltage areas, and a wave collision, were present in all patients. This wave collision was typically located within the TK. The median number of ablations required for successful outcome was two. The successful ablation lesion was typically located over a low-voltage area within 4 mm of the wave collision within the TK. In conclusion, we found in this retrospective evaluation that propagation mapping resulted in a wave collision within the TK, and that the successful ablation site in the majority of patients was near a low-voltage area within 4 mm, typically superiorly, to the wave collision within the TK.
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Affiliation(s)
- Amy Van Aartsen
- Division of Cardiology, Department of Pediatrics, The University of Wisconsin-Madison, Madison, WI
| | - Ian H Law
- Division of Cardiology, Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Jennifer R Maldonado
- Division of Cardiology, Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Nicholas H Von Bergen
- Division of Cardiology, Department of Pediatrics, The University of Wisconsin-Madison, Madison, WI
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Vlachos K, Efremidis M, Letsas KP, Bazoukis G, Martin R, Kalafateli M, Lioni L, Georgopoulos S, Saplaouras A, Efremidis T, Liu T, Valkanas K, Karamichalakis N, Asvestas D, Sideris A. Low-voltage areas detected by high-density electroanatomical mapping predict recurrence after ablation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2017; 28:1393-1402. [PMID: 28884923 DOI: 10.1111/jce.13321] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/30/2017] [Accepted: 08/14/2017] [Indexed: 01/21/2023]
Abstract
INTRODUCTION We aimed to evaluate the extent of atrial fibrosis in paroxysmal atrial fibrillation (AF) and the correlation with ablation outcomes after pulmonary vein antral isolation (PVΑI) using a mapping system with high-resolution and high-spatial sampling. METHODS AND RESULTS We prospectively enrolled 80 consecutive patients (45 males, median age 60.26 years) with symptomatic paroxysmal AF who were scheduled for PVAI. Prior to PVAI, high-density bipolar voltage mapping (median number of 2,485 points) was carried out during sinus rhythm in all patients. Criteria for an adequate left atrium (LA) shell were > 2,000 points. Each acquired point was classified according to the peak-to-peak bipolar voltage electrogram based on two criteria (criterion A: healthy > 0.8 mV, border zone: 0.4-0.8 mV and scarred: < 0.4 mV, criterion Β: healthy: > 0.5 mV, border zone: 0.25-0.5 mV and scarred: < 0.25 mV). The extent of low-voltage area < 0.4 mV significantly predicted atrial tachyarrhythmia recurrence after the blanking period (P = 0.002). In univariate analysis, the presence of LA voltage areas < 0.4 mV more than 10% of the total surface area was the only significant predictor of arrhythmia recurrence. The analysis based on window B cutoff values failed to demonstrate any predictors of arrhythmia recurrence. CONCLUSION These data demonstrate that the existence of LA voltage areas < 0.4 mV more than 10% of the total LA surface area predicts arrhythmia recurrence following PVAI for paroxysmal AF.
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Affiliation(s)
- Konstantinos Vlachos
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Michael Efremidis
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Konstantinos P Letsas
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | | | - Maria Kalafateli
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Louiza Lioni
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Stamatis Georgopoulos
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Athanasios Saplaouras
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Theodore Efremidis
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Kosmas Valkanas
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Nikolaos Karamichalakis
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Dimitrios Asvestas
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Antonios Sideris
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, "Evangelismos" General Hospital of Athens, Athens, Greece
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Tyler SEB. Nature's Electric Potential: A Systematic Review of the Role of Bioelectricity in Wound Healing and Regenerative Processes in Animals, Humans, and Plants. Front Physiol 2017; 8:627. [PMID: 28928669 PMCID: PMC5591378 DOI: 10.3389/fphys.2017.00627] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 08/11/2017] [Indexed: 12/24/2022] Open
Abstract
Natural endogenous voltage gradients not only predict and correlate with growth and development but also drive wound healing and regeneration processes. This review summarizes the existing literature for the nature, sources, and transmission of information-bearing bioelectric signals involved in controlling wound healing and regeneration in animals, humans, and plants. It emerges that some bioelectric characteristics occur ubiquitously in a range of animal and plant species. However, the limits of similarities are probed to give a realistic assessment of future areas to be explored. Major gaps remain in our knowledge of the mechanistic basis for these processes, on which regenerative therapies ultimately depend. In relation to this, it is concluded that the mapping of voltage patterns and the processes generating them is a promising future research focus, to probe three aspects: the role of wound/regeneration currents in relation to morphology; the role of endogenous flux changes in driving wound healing and regeneration; and the mapping of patterns in organisms of extreme longevity, in contrast with the aberrant voltage patterns underlying impaired healing, to inform interventions aimed at restoring them.
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Magtibay K, Massé S, Asta J, Kusha M, Lai PFH, Azam MA, Porta-Sanchez A, Haldar S, Malebranche D, Labos C, Deno DC, Nanthakumar K. Physiological Assessment of Ventricular Myocardial Voltage Using Omnipolar Electrograms. J Am Heart Assoc 2017; 6:e006447. [PMID: 28862942 PMCID: PMC5586472 DOI: 10.1161/jaha.117.006447] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/21/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Characterization of myocardial health by bipolar electrograms are critical for ventricular tachycardia therapy. Dependence of bipolar electrograms on electrode orientation may reduce reliability of voltage assessment along the plane of arrhythmic myocardial substrate. Hence, we sought to evaluate voltage assessment from orientation-independent omnipolar electrograms. METHODS AND RESULTS We mapped the ventricular epicardium of 5 isolated hearts from each species-healthy rabbits, healthy pigs, and diseased humans-under paced conditions. We derived bipolar electrograms and voltage peak-to-peak (Vpps) along 2 bipolar electrode orientations (horizontal and vertical). We derived omnipolar electrograms and Vpps using omnipolar electrogram methodology. Voltage maps were created for both bipoles and omnipole. Electrode orientation affects the bipolar voltage map with an average absolute difference between horizontal and vertical of 0.25±0.18 mV in humans. Vpps provide larger absolute values than horizontal and vertical bipolar Vpps by 1.6 and 1.4 mV, respectively, in humans. Bipolar electrograms with the largest Vpps from either along horizontal or vertical orientation are highly correlated with omnipolar electrograms and with Vpps values (0.97±0.08 and 0.94±0.08, respectively). Vpps values are more consistent than bipoles, in both beat-by-beat (CoV, 0.28±0.19 versus 0.08±0.13 in human hearts) and rhythm changes (0.55±0.21 versus 0.40±0.20 in porcine hearts). CONCLUSIONS Omnipoles provide physiologically relevant and consistent voltages that are along the maximal bipolar direction on the plane of the myocardium.
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Affiliation(s)
- Karl Magtibay
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stéphane Massé
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - John Asta
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Marjan Kusha
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Patrick F H Lai
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mohammed Ali Azam
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Andreu Porta-Sanchez
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Shouvik Haldar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Daniel Malebranche
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | | | - Kumaraswamy Nanthakumar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Wang Z, Zhang H, Peng H, Shen X, Sun Z, Zhao C, Dong R, Gao H, Wu Y. Voltage combined with pace mapping is simple and effective for ablation of noninducible premature ventricular contractions originating from the right ventricular outflow tract. Clin Cardiol 2017; 39:733-738. [PMID: 28026917 DOI: 10.1002/clc.22598] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 08/23/2016] [Accepted: 08/31/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT) can resist conventional mapping strategies. Studies regarding optimal mapping and ablation methods for patients with noninducible RVOT-PVCs are limited. We retrospectively evaluated the efficacy and safety of a novel mapping strategy for these cases: voltage mapping combined with pace mapping. HYPOTHESIS METHODS: We retrospectively included symptomatic patients (n = 148; 76 males; age, 44.5 ± 1.4 years) with drug-refractory PVCs originating from the RVOT, who underwent radiofrequency catheter ablation (RFCA), and stratified them as Group 1 and Group 2. Group 1 patients had noninducible RVOT-PVCs, determined after programmed stimulation, burst pacing, and isoproterenol infusion (n = 21; 12 males; age, 39.5 ± 10.8 years). Group 2 patients had inducible PVCs. Group 1 patients were subjected to voltage mapping combined with pace mapping; Group 2 underwent conventional mapping. In all patients prior to RFCA, detailed 3-dimensional electroanatomic voltage maps of the RVOT were obtained during sinus rhythm using the CARTO system. RESULTS Patients from both groups had similar success and complication rates associated with the RFCA. In Group 2, 89% (113/127) experienced the earliest and the successful ablation points in the voltage transitional zone. During the follow-up (36 ± 8 months), patients from both groups suffered similar rates of PVC relapse (2/21 and 7/127, respectively; P = 0.826). CONCLUSIONS Voltage mapping combined with pace mapping is effective and safe for patients with noninducible RVOT-PVCs determined by conventional methods.
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Affiliation(s)
- Zefeng Wang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Heping Zhang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hui Peng
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xuhua Shen
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhijun Sun
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Can Zhao
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruiqing Dong
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Huikuan Gao
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yongquan Wu
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Weber LA, May JW, Needleman M. Preoperative right ventricle voltage mapping in Ebstein's anomaly: can we make the late arrhythmogenic mortality following the cone procedure zero? Cardiol Young 2017; 27:373-4. [PMID: 28081726 DOI: 10.1017/S1047951116001918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A young woman with Epstein's anomaly had a large endocardial scar in the atrialised ventricular myocardium. In patients with significant preoperative ventricular scarring, more information is needed to help appropriately manage the risk of ventricular arrhythmias and sudden death.
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Qiao Y, Wu L, Hou B, Sun W, Zheng L, Ding L, Chen G, Zhang S, Yao Y. Functional mitral regurgitation: predictor for atrial substrate remodeling and poor ablation outcome in paroxysmal atrial fibrillation. Medicine (Baltimore) 2016; 95:e4333. [PMID: 27472715 PMCID: PMC5265852 DOI: 10.1097/md.0000000000004333] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Functional mitral regurgitation (FMR) is not uncommon in atrial fibrillation (AF) patients. We sought to investigate the association between FMR and atrial substrate remodeling as well as the ablation outcome in paroxysmal AF (PAF) patients.We retrospectively analyzed a prospectively enrolled cohort of 132 patients (age 55.1 ± 9.6 years, 75.8% male) with symptomatic PAF who underwent initial ablation in our institute. Functional mitral regurgitation was defined as regurgitation jet area to left atrium (LA) area ratio ≥ 0.1 without any primary valvular disease. Voltage mapping of LA was performed under sinus rhythm. Low voltage zones (LVZs) were semi-quantitatively estimated and presented as low voltage index. Follow-up for AF recurrence ≥ 12 months was performed.In total, 40 patients (29.6%) were detected with FMR, who were older than the non-FMR patients (P = 0.007) and had larger LA diameters (P = 0.02). Left atrium LVZs were observed in 64.9% of patients with FMR versus 22.1% patients without FMR (P < 0.001). Functional mitral regurgitation independently predicted the presence of LVZs (OR 7.286; 95% CI 3.023-17.562; P < 0.001). During a mean follow-up of 22.9 ± 6.5 months, 38 patients (28.8%) experienced AF recurrence. The recurrence rate was 60.0% and 19.5% in FMR and non-FMR cohort, respectively (log rank P < 0.001). Multivariate analysis showed that FMR was an independent predictor for AF recurrence (HR 2.291; 95% CI 1.062-4.942; P = 0.03).Functional mitral regurgitation was strongly associated with atrial substrate remodeling. Furthermore, patients with FMR have substantial risk for AF recurrence post ablation.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yan Yao
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Correspondence: Yan Yao, Fuwai Hospital and Cardiovascular Institute, 167 Beilishi Road, Xicheng, Beijing 100037, China (e-mail: )
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Blauer JJE, Swenson D, Higuchi K, Plank G, Ranjan R, Marrouche N, Macleod RS. Sensitivity and specificity of substrate mapping: an in silico framework for the evaluation of electroanatomical substrate mapping strategies. J Cardiovasc Electrophysiol 2014; 25:774-80. [PMID: 24762029 DOI: 10.1111/jce.12444] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 04/02/2014] [Accepted: 04/21/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Voltage mapping is an important tool for characterizing proarrhythmic electrophysiological substrate, yet it is subject to geometric factors that influence bipolar amplitudes and thus compromise performance. The aim of this study was to characterize the impact of catheter orientation on the ability of bipolar amplitudes to accurately discriminate between healthy and diseased tissues. METHODS AND RESULTS We constructed a 3-dimensional, in silico, bidomain model of cardiac tissue containing transmural lesions of varying diameter. A planar excitation wave was stimulated and electrograms were sampled with a realistic catheter model at multiple positions and orientations. We carried out validation studies in animal experiments of acute ablation lesions mapped with a clinical mapping system. Bipolar electrograms sampled at higher inclination angles of the catheter with respect to the tissue demonstrated improvements in both sensitivity and specificity of lesion detection. Removing low-voltage electrograms with concurrent activation of both electrodes, suggesting false attenuation of the bipolar electrogram due to alignment with the excitation wavefront, had little effect on the accuracy of voltage mapping. CONCLUSIONS Our results demonstrate possible mechanisms for the impact of catheter orientation on voltage mapping accuracy. Moreover, results from our simulations suggest that mapping accuracy may be improved by selectively controlling the inclination of the catheter to record at higher angles with respect to the tissue.
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Affiliation(s)
- Joshua J E Blauer
- CARMA Center, University of Utah, Salt Lake City, Utah, USA; Department of Bioengineering, University of Utah, Salt Lake City, Utah, USA
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