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Valeri Y, Bagliani G, Compagnucci P, Volpato G, Cipolletta L, Parisi Q, Misiani A, Fogante M, Molini S, Dello Russo A, Casella M. Pathophysiology of Typical Atrial Flutter. Card Electrophysiol Clin 2022; 14:401-409. [PMID: 36153122 DOI: 10.1016/j.ccep.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nowadays, the pathophysiology mechanism of initiation and maintenance of reentrant arrhythmias, including atrial flutter, is well characterized. However, the anatomic and functional elements of the macro reentrant arrhythmias are not always well defined. In this article, we illustrate the anatomic structures that delineate the typical atrial flutter circuit, both clockwise and counterclockwise, paying attention to the inferior vena cava-tricuspid isthmus (CTI) and crista terminalis crucial role. Finally, we describe the left atrial role during typical atrial flutter, electrophysiologically a by-stander but essential in the phenotypic electrocardiogram (ECG).
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Affiliation(s)
- Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy.
| | - Giuseppe Bagliani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Agostino Misiani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Marco Fogante
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Silvano Molini
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
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Yvorel C, Da Costa A, Lerebours C, Guichard JB, Viallon G, Romeyer C, Ferreira T, Benali K, Isaaz K. Comparison of clockwise and counterclockwise right atrial flutter using high-resolution mapping and automated velocity measurements. J Cardiovasc Electrophysiol 2021; 32:2127-2139. [PMID: 34041809 DOI: 10.1111/jce.15111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/28/2021] [Accepted: 05/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Only few studies have been performed that explore the electrophysiological differences between clockwise (CW) and counterclockwise (CCW) right atrial (RA) cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) using the high-resolution Rhythmia mapping system. OBJECTIVES We sought to compare CW and CCW CTI-dependent AFL in pure right AFL patients (pts) using the ultra-high-definition (ultra-HD) Rhythmia mapping system and we mathematically developed a cartography model based on automatic velocity RA measurements to identify electrophysiological AFL specificities. METHODS AND RESULTS Thirty-three pts were recruited. The mean age was 71 ± 13 years old. The sinus venosus (SV) block line was present in 32/33 of cases (97%) and no significant difference was found between CCW and CW CTI AFL (100% vs. 91%; p = .7). No line was localized in the region of the crista terminalis (CT). A superior gap was present in the posterior line in 14/31 (45.2%) but this was similarly present in CCW AFL, when compared to CW AFL (10/22 [45.5%] vs. 4/10 [40%]; p = .9). When present, the extension of the posterior line of block was observed in 18/31 pts (58%) without significant differences between CCW and CW CI AFL (12/22 [54.5%] vs. 6/10 [60%]; p = .9) The Eustachian ridge line of block was similarly present in both groups (82% [18/22] vs. 45.5% [5/11]; p = .2). The absence of the Eustachian ridge line of block led to significantly slowed velocity in this area (28 ± 10 cm/s; n = 8), and the velocities were similarly altered between both groups (26 ± 10 [4/22] vs. 29.8 ± 11 cm/s [4/11]; p = .6). We created mathematical, three-dimensional RA reconstruction-velocity model measurements. In each block localization, when the block line was absent, velocity was significantly slowed (≤20 cm/s). A systematic slowdown in conduction velocity was observed at the entrance and exit of the CTI in 100% of cases. This alteration to the conduction entrance was localized at the lateral side of the CTI for the CCW AFL and at the septal side of the CTI for CW AFL. The exit-conduction alteration was localized at the CTI septal side for the CCW AFL and at the CTI lateral side for the CW AFL. CONCLUSION The ultra-HD Rhythmia mapping system confirmed the absence of significant electrophysiological differences between CCW and CW AFL. The mechanistic posterior SV and Eustachian ridge block lines were confirmed in each arrhythmia. A systematic slowing down at the entrance and exit of the CTI was demonstrated in both CCW and CW AFL, but in reverse positions.
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Affiliation(s)
- Cedric Yvorel
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Antoine Da Costa
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Chloe Lerebours
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Jean B Guichard
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Gregory Viallon
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Cécile Romeyer
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Thomas Ferreira
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Karim Benali
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
| | - Karl Isaaz
- Division of Cardiology, Jean Monnet University, Saint-Etienne, France
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Luongo G, Schuler S, Luik A, Almeida TP, Soriano DC, Dossel O, Loewe A. Non-Invasive Characterization of Atrial Flutter Mechanisms Using Recurrence Quantification Analysis on the ECG: A Computational Study. IEEE Trans Biomed Eng 2021; 68:914-925. [PMID: 32746003 DOI: 10.1109/tbme.2020.2990655] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Atrial flutter (AFl) is a common arrhythmia that can be categorized according to different self-sustained electrophysiological mechanisms. The non-invasive discrimination of such mechanisms would greatly benefit ablative methods for AFl therapy as the driving mechanisms would be described prior to the invasive procedure, helping to guide ablation. In the present work, we sought to implement recurrence quantification analysis (RQA) on 12-lead ECG signals from a computational framework to discriminate different electrophysiological mechanisms sustaining AFl. METHODS 20 different AFl mechanisms were generated in 8 atrial models and were propagated into 8 torso models via forward solution, resulting in 1,256 sets of 12-lead ECG signals. Principal component analysis was applied on the 12-lead ECGs, and six RQA-based features were extracted from the most significant principal component scores in two different approaches: individual component RQA and spatial reduced RQA. RESULTS In both approaches, RQA-based features were significantly sensitive to the dynamic structures underlying different AFl mechanisms. Hit rate as high as 67.7% was achieved when discriminating the 20 AFl mechanisms. RQA-based features estimated for a clinical sample suggested high agreement with the results found in the computational framework. CONCLUSION RQA has been shown an effective method to distinguish different AFl electrophysiological mechanisms in a non-invasive computational framework. A clinical 12-lead ECG used as proof of concept showed the value of both the simulations and the methods. SIGNIFICANCE The non-invasive discrimination of AFl mechanisms helps to delineate the ablation strategy, reducing time and resources required to conduct invasive cardiac mapping and ablation procedures.
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Chen X, Sun L, Chen Q, Kojodjojo P, Chen H, Ju W, Zhu W, Zhu Y, Zhao P, Zhang F, Chen M. Contact‐ versus noncontact‐guided ablation of the right ventricular outflow tract arrhythmias: A propensity score matched analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:822-827. [PMID: 32363589 DOI: 10.1111/pace.13935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/18/2020] [Accepted: 04/28/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Xinguang Chen
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Ling Sun
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Qiushi Chen
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | | | - Hongwu Chen
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Weizhu Ju
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Wenwu Zhu
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Yeqian Zhu
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Pengcheng Zhao
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Fengxiang Zhang
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
- Qinghai Province Hospital
| | - Minglong Chen
- Section of Pacing and Electrophysiology, Division of Cardiology Jiangsu Province Hospital and the First Affiliated Hospital with Nanjing Medical University Nanjing China
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Grace A, Willems S, Meyer C, Verma A, Heck P, Zhu M, Shi X, Chou D, Dang L, Scharf C, Scharf G, Beatty G. High-resolution noncontact charge-density mapping of endocardial activation. JCI Insight 2019; 4:126422. [PMID: 30895945 DOI: 10.1172/jci.insight.126422] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spatial resolution in cardiac activation maps based on voltage measurement is limited by far-field interference. Precise characterization of electrical sources would resolve this limitation; however, practical charge-based cardiac mapping has not been achieved. METHODS A prototype algorithm, developed from first principles of electrostatic field theory, derives charge density (CD) as a spatial representation of the true sources of the cardiac field. The algorithm processes multiple, simultaneous, noncontact voltage measurements within the cardiac chamber to inversely derive the global distribution of CD sources across the endocardial surface. RESULTS Comparison of CD to an established computer-simulated model of atrial conduction demonstrated feasibility in terms of spatial, temporal, and morphologic metrics. Inverse reconstruction matched simulation with median spatial errors of 1.73 mm and 2.41 mm for CD and voltage, respectively. Median temporal error was less than 0.96 ms and morphologic correlation was greater than 0.90 for both CD and voltage. Activation patterns observed in human atrial flutter reproduced those established through contact maps, with a 4-fold improvement in resolution noted for CD over voltage. Global activation maps (charge density-based) are reported in atrial fibrillation with confirmed reduction of far-field interference. Arrhythmia cycle-length slowing and termination achieved through ablation of critical points demonstrated in the maps indicates both mechanistic and pathophysiological relevance. CONCLUSION Global maps of cardiac activation based on CD enable classification of conduction patterns and localized nonpulmonary vein therapeutic targets in atrial fibrillation. The measurement capabilities of the approach have roles spanning deep phenotyping to therapeutic application. TRIAL REGISTRATION ClinicalTrials.gov NCT01875614. FUNDING The National Institute for Health Research (NIHR) Translational Research Program at Royal Papworth Hospital and Acutus Medical.
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Affiliation(s)
- Andrew Grace
- Royal Papworth Hospital Foundation Trust, Cambridge University Health Partners, Cambridge, United Kingdom.,Department of Biochemistry, University of Cambridge, Cambridge, United Kingdom
| | - Stephan Willems
- University Heart Center, University Hospital, Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Meyer
- University Heart Center, University Hospital, Hamburg-Eppendorf, Hamburg, Germany
| | - Atul Verma
- Southlake Regional Health Center, Newmarket, University of Toronto, Ontario, Canada
| | - Patrick Heck
- Royal Papworth Hospital Foundation Trust, Cambridge University Health Partners, Cambridge, United Kingdom
| | - Min Zhu
- Acutus Medical Inc., Carlsbad, California, USA
| | - Xinwei Shi
- Acutus Medical Inc., Carlsbad, California, USA
| | | | - Lam Dang
- Cardiovascular Center, Klinik im Park, Zürich, Switzerland
| | | | - Günter Scharf
- Physics Institute, University of Zurich, Zurich, Switzerland
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Pathik B, Kalman JM. Perceiving the Imperceptible in Atrial Macro-Reentry: Ultrahigh Resolution Mapping to Characterize the Critical Isthmus. Circ Arrhythm Electrophysiol 2018; 10:CIRCEP.116.004850. [PMID: 28039283 DOI: 10.1161/circep.116.004850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bhupesh Pathik
- From the Department of Cardiology, Royal Melbourne Hospital & Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Australia
| | - Jonathan M Kalman
- From the Department of Cardiology, Royal Melbourne Hospital & Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Australia.
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De Sisti A, Andronache M, Damiano P, Eschalier R, Font M. Is proximal coronary sinus involved in the circuit in some cases of ECG "typical" atrial flutter? J Cardiovasc Electrophysiol 2018; 29:1508-1514. [PMID: 30080278 DOI: 10.1111/jce.13703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 07/19/2018] [Accepted: 07/24/2018] [Indexed: 11/29/2022]
Abstract
AIM It is commonly conceived that coronary sinus (CS) participates in atrial flutter (AFL) circuit but limited to the fibers surrounding its ostium. We evaluated the involvement of proximal CS in typical AFL. METHODS Twenty AFL patients underwent entrainment mapping using postpacing interval minus AFL cycle length (PPI-AFL CL) including CS where a decapolar catheter was positioned with proximal bipole 1 cm from the ostium. RESULTS We compared patients with proximal CS within the circuit (group 1, PPI-AFL CL ≤ 20 ms + concealed entrainment) and those without (group 2, PPI-AFL CL > 20 ms). Group 1 patients were older, 77.5 ± 4 vs 71 ± 12 years (P < 0.05). No difference was found in AFL CL, PPI-AFL CL at cavotricuspid isthmus (CTI) entry, plateau, and septal site. Group 1 patients had shorter PPI-AFL CL at proximal CS (9 ± 3 vs 40 ± 15 ms; P < 0.001) and fragmented mesodiastolic CS atrial potentials (APs) (106 ± 27 vs 58.5 ± 22 ms; P < 0.001). A mid-septal unexcitable scar was found in five of eight group 1 patients vs one of 12 group 2 patients (P < 0.05). All were ablated at CTI. A patient had AFL recurrence and underwent a second attempt: PPI-AFL CL was 60 ms at CTI entry and less than or equal to 20 ms at septal CTI and proximal CS; AFL was terminated 1 cm inside CS, applying RF at a fragmented AP. CONCLUSION Proximal CS appears to be involved in a substantial subset of typical AFL patients, in whom advanced age, fragmented CS APs, and the presence of right atrial scar are prevalent. Proximal CS might be considered as an un-"innocent by-stander," but able, in rare cases, to generate a second AFL circuit.
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Affiliation(s)
- Antonio De Sisti
- Rhythmology Unit, Cardiology Department, Henry Mondor Hospital, Aurillac, France
| | - Marius Andronache
- Rhythmology Unit, Cardiology Department, University Hospital Center, Clermont-Ferrand, France
| | - Pamela Damiano
- Rhythmology Unit, Cardiology Department, Henry Mondor Hospital, Aurillac, France
| | - Roman Eschalier
- Rhythmology Unit, Cardiology Department, University Hospital Center, Clermont-Ferrand, France
| | - Manuel Font
- Rhythmology Unit, Cardiology Department, Henry Mondor Hospital, Aurillac, France
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Corrado C, Williams S, Karim R, Plank G, O'Neill M, Niederer S. A work flow to build and validate patient specific left atrium electrophysiology models from catheter measurements. Med Image Anal 2018; 47:153-163. [PMID: 29753180 PMCID: PMC5998385 DOI: 10.1016/j.media.2018.04.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 02/16/2018] [Accepted: 04/19/2018] [Indexed: 11/19/2022]
Abstract
Biophysical models of the atrium provide a physically constrained framework for describing the current state of an atrium and allow predictions of how that atrium will respond to therapy. We propose a work flow to simulate patient specific electrophysiological heterogeneity from clinical data and validate the resulting biophysical models. In 7 patients, we recorded the atrial anatomy with an electroanatomical mapping system (St Jude Velocity); we then applied an S1-S2 electrical stimulation protocol from the coronary sinus (CS) and the high right atrium (HRA) whilst recording the activation patterns using a PentaRay catheter with 10 bipolar electrodes at 12 ± 2 sites across the atrium. Using only the activation times measured with a PentaRay catheter and caused by a stimulus applied in the CS with a remote catheter we fitted the four parameters for a modified Mitchell-Schaeffer model and the tissue conductivity to the recorded local conduction velocity restitution curve and estimated local effective refractory period. Model parameters were then interpolated across each atrium. The fitted model recapitulated the S1-S2 activation times for CS pacing giving a correlation ranging between 0.81 and 0.98. The model was validated by comparing simulated activations times with the independently recorded HRA pacing S1-S2 activation times, giving a correlation ranging between 0.65 and 0.96. The resulting work flow provides the first validated cohort of models that capture clinically measured patient specific electrophysiological heterogeneity.
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Affiliation(s)
- Cesare Corrado
- Division of Imaging Sciences & Biomedical Engineering, King's College London, London SE17EH, United Kingdom.
| | - Steven Williams
- Division of Imaging Sciences & Biomedical Engineering, King's College London, London SE17EH, United Kingdom
| | - Rashed Karim
- Division of Imaging Sciences & Biomedical Engineering, King's College London, London SE17EH, United Kingdom
| | - Gernot Plank
- Department of Biophysics, Medical University of Graz, Neue Stiftingtalstraße 6/IV, 8010 Graz, Austria
| | - Mark O'Neill
- Division of Imaging Sciences & Biomedical Engineering, King's College London, London SE17EH, United Kingdom
| | - Steven Niederer
- Division of Imaging Sciences & Biomedical Engineering, King's College London, London SE17EH, United Kingdom
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Sau A, Sikkel MB, Luther V, Wright I, Guerrero F, Koa-Wing M, Lefroy D, Linton N, Qureshi N, Whinnett Z, Lim PB, Kanagaratnam P, Peters NS, Davies DW. The sawtooth EKG pattern of typical atrial flutter is not related to slow conduction velocity at the cavotricuspid isthmus. J Cardiovasc Electrophysiol 2017; 28:1445-1453. [DOI: 10.1111/jce.13323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/13/2017] [Accepted: 08/15/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Arunashis Sau
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Markus B. Sikkel
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Vishal Luther
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Ian Wright
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | | | - Michael Koa-Wing
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - David Lefroy
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Nicholas Linton
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Norman Qureshi
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Zachary Whinnett
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Phang Boon Lim
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Prapa Kanagaratnam
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Nicholas S. Peters
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - D. Wyn Davies
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
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Typical Flutter Rewritten. JACC Clin Electrophysiol 2017; 3:987-990. [DOI: 10.1016/j.jacep.2017.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 02/16/2017] [Indexed: 11/22/2022]
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New Insights Into an Old Arrhythmia. JACC Clin Electrophysiol 2017; 3:971-986. [DOI: 10.1016/j.jacep.2017.01.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/04/2017] [Accepted: 01/04/2017] [Indexed: 11/19/2022]
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12
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Lee G, McLellan AJ, Hunter RJ, Lovell MJ, Finlay M, Ullah W, Dhinoja MB, Sporton S, Earley MJ, Schilling RJ. Panoramic characterization of endocardial left atrial activation during human persistent AF: Insights from non-contact mapping. Int J Cardiol 2017; 228:406-411. [DOI: 10.1016/j.ijcard.2016.11.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/05/2016] [Indexed: 10/20/2022]
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Sabouri S, Matene E, Vinet A, Richer LP, Cardinal R, Armour JA, Pagé P, Kus T, Jacquemet V. Simultaneous epicardial and noncontact endocardial mapping of the canine right atrium: simulation and experiment. PLoS One 2014; 9:e91165. [PMID: 24598778 PMCID: PMC3945013 DOI: 10.1371/journal.pone.0091165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 02/10/2014] [Indexed: 11/19/2022] Open
Abstract
Epicardial high-density electrical mapping is a well-established experimental instrument to monitor in vivo the activity of the atria in response to modulations of the autonomic nervous system in sinus rhythm. In regions that are not accessible by epicardial mapping, noncontact endocardial mapping performed through a balloon catheter may provide a more comprehensive description of atrial activity. We developed a computer model of the canine right atrium to compare epicardial and noncontact endocardial mapping. The model was derived from an experiment in which electroanatomical reconstruction, epicardial mapping (103 electrodes), noncontact endocardial mapping (2048 virtual electrodes computed from a 64-channel balloon catheter), and direct-contact endocardial catheter recordings were simultaneously performed in a dog. The recording system was simulated in the computer model. For simulations and experiments (after atrio-ventricular node suppression), activation maps were computed during sinus rhythm. Repolarization was assessed by measuring the area under the atrial T wave (ATa), a marker of repolarization gradients. Results showed an epicardial-endocardial correlation coefficients of 0.80 and 0.63 (two dog experiments) and 0.96 (simulation) between activation times, and a correlation coefficients of 0.57 and 0.46 (two dog experiments) and 0.92 (simulation) between ATa values. Despite distance (balloon-atrial wall) and dimension reduction (64 electrodes), some information about atrial repolarization remained present in noncontact signals.
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Affiliation(s)
- Sepideh Sabouri
- Département de Physiologie, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Elhacene Matene
- Département de Physiologie, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Alain Vinet
- Département de Physiologie, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | | | - René Cardinal
- Département de Physiologie, Université de Montréal, Montréal, Québec, Canada
- Département de Pharmacologie, Université de Montréal, Montréal, Québec, Canada
| | - J. Andrew Armour
- Department of Pharmacology, East Tennessee State University, Johnson City, Tennessee, United States of America
| | - Pierre Pagé
- Centre de Recherche, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
- Département de Chirurgie, Université de Montréal, Montréal, Québec, Canada
| | - Teresa Kus
- Département de Physiologie, Université de Montréal, Montréal, Québec, Canada
- Département de Pharmacologie, Université de Montréal, Montréal, Québec, Canada
| | - Vincent Jacquemet
- Département de Physiologie, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
- * E-mail:
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LATCU DECEBALG, SAOUDI NADIR. How Fast Does the Electrical Impulse Travel Within the Myocardium? The Need for a New Clinical Electrophysiology Tool: The Conduction Velocity Mapping. J Cardiovasc Electrophysiol 2014; 25:395-397. [DOI: 10.1111/jce.12350] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Salinet JL, Tuan JH, Sandilands AJ, Stafford PJ, Schlindwein FS, Ng GA. Distinctive patterns of dominant frequency trajectory behavior in drug-refractory persistent atrial fibrillation: preliminary characterization of spatiotemporal instability. J Cardiovasc Electrophysiol 2013; 25:371-379. [PMID: 24806529 DOI: 10.1111/jce.12331] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 11/03/2013] [Accepted: 11/12/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The role of substrates in the maintenance of persistent atrial fibrillation (persAF) remains poorly understood. The use of dominant frequency (DF) mapping to guide catheter ablation has been proposed as a potential strategy, but the characteristics of high DF sites have not been extensively studied. This study aimed to assess the DF spatiotemporal stability using high density noncontact mapping (NCM) in persAF. METHODS AND RESULTS Eight persAF patients were studied using NCM during AF. Ventricular far-field cancellation was performed followed by the calculation of DF using Fast Fourier Transform. Analysis of DF stability and spatiotemporal behavior were investigated including characteristics of the highest DF areas (HDFAs). A total of 16,384 virtual electrograms (VEGMs) and 232 sequential high density 3-dimensional DF maps were analyzed. The percentage of DF stable points decreased rapidly over time. Repetition or reappearance of DF values were noted in some instances, occurring within 10 seconds in most cases. Tracking the HDFAs' center of gravity revealed 3 types of propagation behavior, namely (i) local, (ii) cyclical, and (iii) chaotic activity, with the former 2 patterns accounting for most of the observed events. CONCLUSIONS DF of individual VEGMs was temporally unstable, although reappearance of DF values occurred at times. Hence, targeting sites of 'peak DF' from a single time frame is unlikely to be a reliable ablation strategy. There appears to be a predominance of local and cyclical activity of HDFAs hinting a potentially nonrandom temporally periodic behavior that provides further mechanistic insights into the maintenance of persAF.
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Affiliation(s)
- João L Salinet
- Department of Engineering, University of Leicester, Leicester, UK
| | - Jiun H Tuan
- University Hospitals of Leicester NHS Trust, Leicester, UK.,National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | | | | | - Fernando S Schlindwein
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - G André Ng
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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16
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Reentry mechanisms and ablation of ECG-typical atrial flutters involving the cavo-tricuspid isthmus and the proximal coronary sinus. Int J Cardiol 2013; 168:3728-35. [DOI: 10.1016/j.ijcard.2013.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 04/12/2013] [Accepted: 06/15/2013] [Indexed: 11/16/2022]
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17
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Zhang F, Yang B, Chen H, Ju W, Kojodjojo P, Cao K, Chen M. Noncontact mapping to guide ablation of right ventricular outflow tract arrhythmias. Heart Rhythm 2013; 10:1895-902. [PMID: 24055941 DOI: 10.1016/j.hrthm.2013.09.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is limited data on outcomes after noncontact mapping (NCM)-guided right ventricular outflow tract (RVOT) ventricular arrhythmia (VA) ablation. OBJECTIVES To assess outcomes of NCM-guided RVOT VA ablation in a large cohort with extended follow-up, to determine optimal ablation site, and to analyze limitations of conventional mapping techniques. METHODS In consecutive patients undergoing RVOT VA ablation, 2 sites of early activation--earliest activation (EA) and breakout (BO) sites--were identified on NCM maps. Pace mapping and activation mapping were performed at both sites. The area of depolarized myocardium during the first 10 ms of spontaneous VA and pacing was measured. The initial site of ablation was randomized to either EA or BO sites, with crossover to the alternate site if ablation was not successful. RESULTS In 136 patients, prematurity of local activation and pace maps were similar at EA and BO sites. More myocardium was depolarized 10 ms after pacing than during spontaneous VA (12.9 ± 7.8 cm(2) vs 5.3 ± 3.9 cm(2); P < .01). Clinical success was more likely achieved when initial ablation was directed toward the EA site (P < .05). A wider EA-BO separation was associated with acute procedural failure (P < .01). With a follow-up of 36.2 ± 17.5 months, the success rate after a single procedure without antiarrhythmic agents was 86.8%. CONCLUSIONS NCM-guided RVOT VA ablation is highly effective, and clinical success is best achieved by ablating the EA site. Broad regions of early activation are associated with worsened clinical outcomes. Spatial resolution of activation and pace mapping is limited by rapid electrical propagation in the RVOT.
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Affiliation(s)
- Fengxiang Zhang
- Section of Pacing and Electrophysiology, Division of Cardiology, First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
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18
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Kondo M, Fukuda K, Wakayama Y, Nakano M, Hasebe Y, Shimokawa H. Usefulness of the noncontact mapping system to elucidate the conduction property for the treatment of common atrial flutter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1464-71. [PMID: 23035956 DOI: 10.1111/pace.12001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The functional role of the cavotricuspid isthmus (CTI) for common atrial flutter (cAFL) remains to be elucidated. In the present study, we examined whether the EnSite system (St. Jude Medical, St. Paul, MN, USA), a noncontact mapping system, is useful to evaluate the conduction properties of CTI to minimize radiofrequency (RF) ablation applications for cAFL. METHODS We enrolled 22 consecutive patients with cAFL (64.1 ± 9.5 years old, M/F 21/1) treated with the EnSite system and examined the conduction properties during cAFL and during atrial pacing. In addition, the effectiveness of the system was evaluated in comparison with the conventional ablation group (67 ± 8.9 years old, n = 15, M/F 13/2). RESULT In 11 out of the 22 patients, CTI block line was achieved by fewer RF applications on a presumed single activation pathway which the EnSite system showed (point ablation [PA] group), and the remaining 11 patients needed additional linear ablation (additional ablation [AA] group). The number of RF applications in the PA group was significantly smaller than that in the conventional group. During the lower lateral right atrial pacing at a cycle length of 600 ms, the CV of the CTI in the PA group was smaller compared to that in the AA group (1.36 ± 0.61 vs 2.17 ± 0.66 m/s, P < 0.05), although the CV during cAFL (averaged cycle length 245 ± 34 ms) was not different in both groups. CONCLUSIONS These results indicate that targeting the presumed single line identified by EnSite could be an optional therapy for cAFL RF ablation, and diverse conduction properties in CTI are related to the success rate of this procedure. (PACE 2012;35:1464-1471).
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Affiliation(s)
- Masateru Kondo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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19
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YANG BING, JU WEIZHU, CHEN HONGWU, ZHANG FENGXIANG, CHEN KAI, GU KAI, CAO KEJIANG, CHEN MINGLONG. Comparison of the Location of Slow Conduction Velocity in Cavotricuspid-Dependent Atrial Flutter in Patients With and Without Prior Atriotomy: Different Arrhythmogenic Basis and Clinical Implications for Placement of Atriotomy. J Cardiovasc Electrophysiol 2012; 23:988-95. [DOI: 10.1111/j.1540-8167.2012.02348.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Jacquemet V, Kappenberger L, Henriquez CS. Modeling atrial arrhythmias: impact on clinical diagnosis and therapies. IEEE Rev Biomed Eng 2012; 1:94-114. [PMID: 22274901 DOI: 10.1109/rbme.2008.2008242] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial arrhythmias are the most frequent sustained rhythm disorders in humans and often lead to severe complications such as heart failure and stroke. Despite the important insights provided by animal models into the mechanisms of atrial arrhythmias, direct translation of experimental findings to new therapies in patients has not been straightforward. With the advances in computer technology, large-scale electroanatomical computer models of the atria that integrate information from the molecular to organ scale have reached a level of sophistication that they can be used to interpret the outcome of experimental and clinical studies and aid in the rational design of therapies. This paper reviews the state-of-the-art of computer models of the electrical dynamics of the atria and discusses the evolving role of simulation in assisting the clinical diagnosis and treatment of atrial arrhythmias.
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Affiliation(s)
- Vincent Jacquemet
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.
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21
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Dössel O, Krueger MW, Weber FM, Wilhelms M, Seemann G. Computational modeling of the human atrial anatomy and electrophysiology. Med Biol Eng Comput 2012; 50:773-99. [PMID: 22718317 DOI: 10.1007/s11517-012-0924-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 05/21/2012] [Indexed: 01/08/2023]
Abstract
This review article gives a comprehensive survey of the progress made in computational modeling of the human atria during the last 10 years. Modeling the anatomy has emerged from simple "peanut"-like structures to very detailed models including atrial wall and fiber direction. Electrophysiological models started with just two cellular models in 1998. Today, five models exist considering e.g. details of intracellular compartments and atrial heterogeneity. On the pathological side, modeling atrial remodeling and fibrotic tissue are the other important aspects. The bridge to data that are measured in the catheter laboratory and on the body surface (ECG) is under construction. Every measurement can be used either for model personalization or for validation. Potential clinical applications are briefly outlined and future research perspectives are suggested.
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Affiliation(s)
- Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany.
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22
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TAKAMI MITSURU, YOSHIDA AKIHIRO, FUKUZAWA KOJI, TAKEI ASUMI, KANDA GAKU, TAKAMI KAORU, KUMAGAI HIROYUKI, TANAKA SATOKO, ITOH MITSUAKI, IMAMURA KIMITAKE, FUJIWARA RYUDO, SUZUKI ATSUSHI, HIRATA KENICHI. Rate-Dependent and Site-Specific Conduction Block at the Posterior Right Atrium and Drug Effects Evaluated Using a Noncontact Mapping System in Patients with Typical Atrial Flutter. J Cardiovasc Electrophysiol 2012; 23:827-34. [DOI: 10.1111/j.1540-8167.2012.02313.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Utility of virtual unipolar electrogram morphologies to detect transverse conduction block and turnaround points of typical atrial flutter. J Interv Card Electrophysiol 2011; 32:111-9. [PMID: 21505798 PMCID: PMC3204041 DOI: 10.1007/s10840-011-9571-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Accepted: 03/21/2011] [Indexed: 11/17/2022]
Abstract
Background Noncontact mapping is useful for the diagnosis of various arrhythmias. Virtual unipolar electrogram morphologies (VUEM) of the conduction block and the turnaround points, however, are not well defined. We compared the VUEM characteristics of a transverse conduction block in the posterior right atrium (RA) with those of contact bipolar electrograms obtained during typical atrial flutter (AFL). Methods Contact bipolar electrograms were used to map the posterior RA during typical AFL in 16 patients. Twenty points of the VUEM recorded along the block line were analyzed and compared with contact bipolar electrograms. Results Seventeen AFLs were analyzed. Fifteen AFLs showed an incomplete transverse conduction block in the posterior RA by contact bipolar mapping. A double potential on the block line corresponded to the two components of the VUEM, in which the second component showed an Rs, RS, or rS pattern. At the turnaround point, a fused double potential of the contact bipolar electrograms corresponded to a change of the second component of the VUEM from an rS to a QS morphology. Two AFLs showed a complete block line in the posterior RA. The contact bipolar electrogram showed double potentials from the inferior vena cava to the superior vena cava, whereas the second component of the VUEM remained in an unchanged Rs, RS, or rS pattern. Conclusion VUEM analysis was a reliable method for identifying the posterior block line during AFL. This method may also be applicable for detecting block lines and turnaround points of circuits in other unmappable arrhythmias.
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DIXIT SANJAY, LAVI NIMROD, ROBINSON MELISSA, RILEY MICHAELP, CALLANS DAVIDJ, MARCHLINSKI FRANCISE, LIN DAVID. Noncontact Electroanatomic Mapping to Characterize Typical Atrial Flutter: Participation of Right Atrial Posterior Wall in the Reentrant Circuit. J Cardiovasc Electrophysiol 2010; 22:422-30. [DOI: 10.1111/j.1540-8167.2010.01917.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Chinchapatnam P, Rhode KS, Ginks M, Rinaldi CA, Lambiase P, Razavi R, Arridge S, Sermesant M. Model-based imaging of cardiac apparent conductivity and local conduction velocity for diagnosis and planning of therapy. IEEE TRANSACTIONS ON MEDICAL IMAGING 2008; 27:1631-42. [PMID: 18955178 DOI: 10.1109/tmi.2008.2004644] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
We present an adaptive algorithm which uses a fast electrophysiological (EP) model to estimate apparent electrical conductivity and local conduction velocity from noncontact mapping of the endocardial surface potential. Development of such functional imaging revealing hidden parameters of the heart can be instrumental for improved diagnosis and planning of therapy for cardiac arrhythmia and heart failure, for example during procedures such as radio-frequency ablation and cardiac resynchronisation therapy. The proposed model is validated on synthetic data and applied to clinical data derived using hybrid X-ray/magnetic resonance imaging. We demonstrate a qualitative match between the estimated conductivity parameter and pathology locations in the human left ventricle. We also present a proof of concept for an electrophysiological model which utilizes the estimated apparent conductivity parameter to simulate the effect of pacing different ventricular sites. This approach opens up possibilities to directly integrate modelling in the cardiac EP laboratory.
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Affiliation(s)
- Phani Chinchapatnam
- Centre for Medical Image Computing, University College London, Gower Street, WC1E 6BT London, U.K.
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26
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Sawa A, Shimizu A, Ueyama T, Yoshiga Y, Suzuki S, Sugi N, Oono M, Oomiya T, Matsuzaki M. Activation patterns and conduction velocity in posterolateral right atrium during typical atrial flutter using an electroanatomic mapping system. Circ J 2008; 72:384-91. [PMID: 18296833 DOI: 10.1253/circj.72.384] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND To investigate the activation patterns and conduction velocity (CV) in the posterolateral right atrial (RA) wall during typical counterclockwise atrial flutter (AFL) using an electroanatomic mapping system. METHODS AND RESULTS During typical AFL in 25 patients, the transverse conduction pattern and CV were classified and calculated. The line blocking transverse conduction was defined by the conduction pattern and double potentials recorded during mapping. There were 3 types (including 2 subtypes) of transverse conduction pattern based on the conduction blocks across the posterolateral RA in a line between the superior and inferior venae cava. Trans-cristal conduction activation in a horizontal direction was seen in all but 4 patients. The CV in the gap area was 0.59+/-0.21 m/s. CONCLUSIONS Three types of transverse conduction pattern were observed during trans-ctristal conduction and the trans-ctristal CV was relatively slower than that in other parts of the RA, except for the isthmus.
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Affiliation(s)
- Akira Sawa
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
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27
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Use of non-contact mapping in the treatment of right atrial tachycardias in patients with and without congenital heart disease. Europace 2008; 10:972-81. [DOI: 10.1093/europace/eun183] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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28
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Abrams DJ, Earley MJ, Sporton SC, Kistler PM, Gatzoulis MA, Mullen MJ, Till JA, Cullen S, Walker F, Lowe MD, Deanfield JE, Schilling RJ. Comparison of Noncontact and Electroanatomic Mapping to Identify Scar and Arrhythmia Late After the Fontan Procedure. Circulation 2007; 115:1738-46. [PMID: 17372177 DOI: 10.1161/circulationaha.106.633982] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The right atrium late after the Fontan procedure is characterized by multiple complex arrhythmia circuits. We performed simultaneous electroanatomic and noncontact mapping to assess the accuracy of both systems to identify scar and arrhythmia.
Methods and Results—
Mapping was performed in 26 patients aged 26.8±8.9 years, 18.7±4.4 years after Fontan surgery. The area and site of abnormal endocardium defined by electroanatomic mapping (bipolar contact electrogram <0.5 mV) were compared with those defined by noncontact mapping during sinus rhythm and by dynamic substrate mapping. Contact and reconstructed unipolar electrograms at a known distance from the multielectrode array, recorded by the noncontact system simultaneously at 452 endocardial sites, were compared for morphological cross correlation, timing difference, and amplitude. Mapping of arrhythmias was performed with both systems when possible. The median patient abnormal endocardium as defined by electroanatomic mapping covered 38.0% (range 16.7% to 97.8%) of the right atrial surface area, as opposed to 60.9% (range 21.3% to 98.5%) defined by noncontact mapping during sinus rhythm and 11.9% (range 0.4% to 67.3%) by dynamic substrate mapping. A significant decrease in electrogram cross correlation (
P
=0.003), timing (
P
=0.012), and amplitude (
P
=0.003) of reconstructed electrograms, but not of contact electrograms (
P
=0.742), was seen at endocardial sites >40 mm from the multielectrode array. Successful arrhythmia mapping by electroanatomic versus noncontact mapping was superior in 15 patients (58%), the same in 6 (23%), and inferior in 5 (19%;
P
=0.044).
Conclusions—
Electroanatomic mapping is the superior modality for arrhythmia mapping late after the Fontan procedure. Noncontact mapping is limited by a significant reduction in reconstructed electrogram correlation, timing, and amplitude >40 mm from the multielectrode array and cannot accurately define areas of scar and low-voltage endocardium.
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MESH Headings
- Adolescent
- Adult
- Aging
- Amiodarone/therapeutic use
- Arrhythmias, Cardiac/drug therapy
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/therapy
- Atrial Function, Right
- Cardiac Catheterization/instrumentation
- Cardiac Catheterization/methods
- Catheter Ablation
- Cicatrix/pathology
- Cicatrix/physiopathology
- Combined Modality Therapy
- Diagnosis, Computer-Assisted/instrumentation
- Diagnosis, Computer-Assisted/methods
- Drug Resistance
- Electrocardiography
- Electrodes
- Endocardium/pathology
- Endocardium/physiopathology
- Female
- Fontan Procedure/adverse effects
- Fontan Procedure/methods
- Heart Atria/pathology
- Heart Atria/physiopathology
- Heart Atria/surgery
- Humans
- Imaging, Three-Dimensional/instrumentation
- Imaging, Three-Dimensional/methods
- Male
- Models, Cardiovascular
- Organ Size
- Postoperative Period
- Pressure
- Pulmonary Circulation
- Pulmonary Veins/physiopathology
- Pulmonary Veins/surgery
- Tachycardia/drug therapy
- Tachycardia/etiology
- Tachycardia/physiopathology
- Tachycardia/therapy
- Vena Cava, Superior/physiopathology
- Vena Cava, Superior/surgery
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Affiliation(s)
- Dominic J Abrams
- Department of Cardiac Electrophysiology, St Bartholomew's Hospital, London, EC1A 7BE, United Kingdom
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29
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Yamabe H, Tanaka Y, Morihisa K, Uemura T, Kawano H, Nagayoshi Y, Kojima S, Ogawa H. Tachycardia circuit in typical atrial flutter: the role of a posterolateral line of block in the perpetuation of the tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:333-42. [PMID: 17367352 DOI: 10.1111/j.1540-8159.2007.00673.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The essential boundaries in typical atrial flutter (AF) are unknown. METHODS To examine the role of the tricuspid annulus (TA) and posterolateral line of block (LB) in maintaining AF, single extrastimuli were delivered during AF both around the LB and the TA in 29 patients. Single extrastimuli were delivered from the superior, middle, and inferior third of the anterior LB, superior, middle, and inferior third of the posterior LB, and the superior, lateral, inferior, and septal portions of the TA. The longest coupling interval (LCI) of single extrastimuli that reset AF and subsequent return cycle (RC) were analyzed. RESULTS The resetting response showed two patterns (groups 1 and 2). The differences between the AF cycle length (AFCL) and the LCI (AFCL-LCI) at the superior, lateral, inferior, and septal portions of the TA were the shortest, and were significantly shorter than those at the other sites (P < 0.0001) in group 1. However, the AFCL-LCI at the superior, middle, and inferior third of the anterior LB, and the superior, lateral, inferior, and septal portions of the TA were the shortest, and were significantly shorter than those at the other sites (P < 0.0001) in group 2. The difference between the RC and the AFCL exhibited the same two patterns, similar to the AFCL-LCI. In group 1, a single extrastimulus produced an artificial conduction across the LB, but AF was not reset. CONCLUSIONS Two types of reentry circuits exist in AF; one has its essential reentry circuit confined to the TA and thus the LB acts as a bystander, while the LB and the TA are essential boundaries in the other one.
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Affiliation(s)
- Hiroshige Yamabe
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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30
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Kojodjojo P, Kanagaratnam P, Markides V, Davies DW, Peters N. Age-related changes in human left and right atrial conduction. J Cardiovasc Electrophysiol 2006; 17:120-7. [PMID: 16533247 DOI: 10.1111/j.1540-8167.2005.00293.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Advancing age is an independent risk factor for atrial fibrillation (AF), which is considered to be initiated by ectopic triggers and maintained by an arrhythmogenic substrate. It is not known whether substrate changes produce this age-related increase in propensity toward AF. We addressed the hypothesis that advancing age is associated with changes in biatrial electrophysiology even in patients with no history of atrial arrhythmias. METHODS AND RESULTS Patients with left-sided accessory pathways and requiring routine electrophysiological studies were recruited. Electroanatomic mapping was performed in the left and right atria of 23 patients (age ranging from 17 to 75 years) with structurally normal hearts and no history of AF during sinus rhythm and pacing. Unlike previous studies, a trigonometric method was used to quantify wavefront propagation velocities (WPV) precisely in the direction of propagation. Refractoriness was measured at 2 cycle lengths, at three different atrial sites. Both right (r =-0.77, P < 0.0001) and left (r =-0.79, P < 0.001) atrial WPV demonstrated strongly inverse correlation with age. Furthermore, left and right WPVs were highly correlated (r = 0.66, P < 0.01), with velocities being 6.4 +/- 2.2 cm/sec higher in the right atria (P < 0.01). Refractoriness was significantly correlated with increasing age only at the septum (r = 0.53, P < 0.01). Left atrial wavelength was inversely correlated with increasing age (r =-0.56, P = 0.03). P wave duration was associated with age (r = 0.42, P = 0.04) and left atrial size (r = 0.44, P = 0.04) but not atrial WPV. CONCLUSION Aging human atria demonstrate progressive decline in WPV and increase in septal refractoriness. These age-related changes in biatrial electrophysiology are likely to be important factors in the age-related increase in AF prevalence.
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Affiliation(s)
- Pipin Kojodjojo
- St. Mary's Hospital, National Heart and Lung Institute of Imperial College of Medicine, London, UK
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31
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Sawa A, Shimizu A, Ueyama T, Yoshiga Y, Suzuki S, Sugi N, Matsuaki M. Conduction Velocity around the Tricuspid Valve Annulus during Typical Atrial Flutter by Electro-anatomic Mapping System. J Arrhythm 2006. [DOI: 10.1016/s1880-4276(06)80004-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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32
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Wieczorek M, Djajadisastra I, Hoeltgen R. Transversal crista terminalis conduction suggests ineffective bidirectional isthmus block. Herzschrittmacherther Elektrophysiol 2005; 16:274-7. [PMID: 16362734 DOI: 10.1007/s00399-005-0471-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2005] [Accepted: 06/10/2005] [Indexed: 11/27/2022]
Abstract
Catheter ablation of the posterior isthmus is an effective tool to cure typical atrial flutter. In some cases, however, bidirectional block cannot be obtained despite extensive RF applications. Anatomic obstacles or abnormalities are thought to be the most common reasons for failed or prolonged procedures. We present a case of recurrent typical atrial flutter that seemed to be refractory to all ablation attempts in the region of the posterior isthmus although no anatomic abnormalities could be detected. Despite extensive RF application, bidirectional conduction was unchanged. Using a novel noncontact mapping system (En-Site 3000) the existence of a fast conducting gap in the region of the inferior terminal crest was revealed. Rapid conduction over this gap to the opposite side of the isthmus led to the impression that bidirectional isthmus block was not established. As a result no further RF applications were necessary because isthmus block was complete at that time. This is the first time that transverse conduction across the terminal crest could be detected by this novel noncontact mapping system masquerading as unchanged bidirectional isthmus conduction.
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Affiliation(s)
- M Wieczorek
- Herzzentrum Duisburg, Medizinische Klinik III, Abteilung für Elektrophysiologie, Gerrickstrasse 21, 47137 Duisburg, Germany.
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Armour JA, Richer LP, Pagé P, Vinet A, Kus T, Vermeulen M, Nadeau R, Cardinal R. Origin and pharmacological response of atrial tachyarrhythmias induced by activation of mediastinal nerves in canines. Auton Neurosci 2005; 118:68-78. [PMID: 15795179 DOI: 10.1016/j.autneu.2005.01.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Revised: 01/05/2005] [Accepted: 01/11/2005] [Indexed: 01/09/2023]
Abstract
We sought to determine the sites of origin of atrial tachyarrhythmias induced by activating mediastinal nerves, as well as the response of such arrhythmias to autonomic modulation. Under general anaesthesia, atrioventricular block was induced after thoracotomy in 19 canines. Brief trains of 5 electrical stimuli were delivered to right-sided mediastinal nerves during the atrial refractory period. Unipolar electrograms were recorded from 191 right and left atrial epicardial sites under several conditions, i.e. (i) with intact nervous systems and following (ii) acute decentralization of the intrathoracic nervous system or administration of (iii) atropine, (iv) timolol, (v) hexamethonium. Concomitant right atrial endocardial mapping was performed in 7 of these dogs. Mediastinal nerve stimulation consistently initiated bradycardia followed by atrial tachyarrhythmias. In the initial tachyarrhythmia beats, early epicardial breakthroughs were identified in the right atrial free wall (28/50 episodes) or Bachmann bundle region (22/50), which corresponded to endocardial sites of origin associated with the right atrial subsidiary pacemaker complex, i.e. the crista terminalis and dorsal locations including the right atrial aspect of the interatrial septum. Neuronally induced responses were eliminated by atropine, modified by timolol and unaffected by acute neuronal decentralization. After hexamethonium, responses to extra-pericardial but not intra-pericardial nerve stimulation were eliminated. It is concluded that concomitant activation of cholinergic and adrenergic efferent intrinsic cardiac neurons induced by right-sided efferent neuronal stimulation initiates atrial tachyarrhythmias that originate from foci anatomically related to the right atrial pacemaker complex and tissues underlying major atrial ganglionated plexuses.
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Affiliation(s)
- J Andrew Armour
- Centre de recherche, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada H4J 1C5
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Narayan SM, Hassankhani A, Feld GK, Bhargava V. Separating non-isthmus- from isthmus-dependent atrial flutter using wavefront variability. J Am Coll Cardiol 2005; 45:1269-79. [PMID: 15837261 DOI: 10.1016/j.jacc.2004.12.070] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Revised: 12/06/2004] [Accepted: 12/07/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to separate isthmus-dependent atrial flutter (IDAFL) from non-isthmus-dependent atrial flutter (NIDAFL) from the electrocardiogram (ECG) based on functional differences. BACKGROUND The ECG analyses of F-wave shape suboptimally separate NIDAFL from IDAFL. The authors hypothesized that anatomic and functional differences may result in greater wavefront variability in NIDAFL than IDAFL, allowing their separation. The authors tested this hypothesis in patients undergoing ablation for atrial flutter using a novel ECG algorithm to detect subtle F-wave variability, validated by intracardiac measurements. METHODS In 62 patients (23 NIDAFL, 39 IDAFL) ECG atrial wavefronts were represented as correlations of an F-wave template to the ECG over time. Correlations in orthogonal ECG lead-pairs were plotted at each time point to yield loops reflecting temporal and spatial regularity in each plane. The ECG analyses were compared with intracardiac standard deviations of: 1) atrial electrograms (temporal variability), and 2) bi-atrial activation time differences (spatial variability). RESULTS Atrial ECG temporospatial loops were reproducible in IDAFL, but varied in NIDAFL (p < 0.01) suggesting greater variability that correctly classified IDAFL (39 of 39 cases) from NIDAFL (22 of 23 cases; p < 0.001). Intra-atrial mapping confirmed greater temporal variability for NIDAFL versus IDAFL, in lateral (p < 0.01) and septal (p = 0.03) right atrium, and proximal (p = 0.02) and distal (p < 0.01) coronary sinus. Spatial variability was greater in NIDAFL than IDAFL (p = 0.02). CONCLUSIONS Greater cycle-to-cycle atrial wavefront variability separates NIDAFL from IDAFL and is detectable from the ECG using temporospatial analyses. These results have implications for guiding ablation and support the concept that IDAFL and NIDAFL lie along a spectrum of intracardiac organization.
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Affiliation(s)
- Sanjiv M Narayan
- University of California and Veterans Administration Medical Centers, San Diego, California 92161, USA.
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Gonzalez MD, Erga KS, Rivera J, Contreras LJ, Mladinich CR, Schultz JD, Afonso VX. Rate-Dependent Block in the Sinus Venosa of the Swine Heart during Transverse Right Atrial Activation: Correlation Between Electrophysiologic and Anatomic Findings. J Cardiovasc Electrophysiol 2005; 16:193-200. [PMID: 15720459 DOI: 10.1046/j.1540-8167.2004.40483.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Rate-dependent block in the sinus venosa. INTRODUCTION Whether the crista terminalis or the sinus venosa result in rate-dependent block during transverse activation of the right atrial activation remains unknown. In the present study, right atrial activation at different cycle lengths was studied in the swine heart using high-resolution noncontact mapping (Endocardial Solutions). The location of the block was tagged and correlated with postmortem anatomical findings. METHODS AND RESULTS Eight pigs were studied using noncontact mapping to obtain right atrial geometry and detailed sequence of activation using noncontact endocardial mapping. During sinus rhythm, activation proceeded uninterrupted craniocaudally along the sinus venosa and crista terminalis with similar conduction velocities (1.08+/-0.17 and 1.17+/-0.14 m/sec, respectively). Proximal coronary sinus stimulation was used to create transverse activation of the posterior right atrial wall. A rate-dependent decrease in conduction velocity occurred in the sinus venosa region (0.93+/-0.21, 0.82+/-0.14, and 0.52+/-0.09 m/sec at 500, 400, and 300 ms, respectively; P<0.05). The line of block verified by isopotential mapping and double potentials was obtained at cycle lengths of 240+/-30 ms. This line of the block was tagged with radiofrequency current lesions. Postmortem, all lesions were located in the sinus venosa region, 9.8+/-4.1 mm from the posteromedial edge of the crista terminalis. This region showed abrupt changes in muscle fiber thickness and orientation as well as in collagen content. CONCLUSIONS The sinus venosa and not the crista terminalis results in a rate-dependent line of block during transverse right atrial activation. The morphologic characteristics of the sinus venosa appear to facilitate block in this region.
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Affiliation(s)
- Mario D Gonzalez
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida 32610-0277, USA.
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Tai CT, Liu TY, Lee PC, Lin YJ, Chang MS, Chen SA. Non-contact mapping to guide radiofrequency ablation of atypical right atrial flutter. J Am Coll Cardiol 2004; 44:1080-6. [PMID: 15337222 DOI: 10.1016/j.jacc.2004.05.057] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2004] [Revised: 05/13/2004] [Accepted: 05/18/2004] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study was aimed at evaluating the efficacy of non-contact mapping and ablation of non-incisional atypical right atrial (RA) flutters. BACKGROUND The majority of atypical RA flutters were reported in patients after surgical incision of the RA. METHODS The study group consisted of 15 patients (61 +/- 13 years, 8 males) with atypical atrial flutter (AFL). The RA activation during AFL was delineated using a non-contact mapping system (EnSite 3000 with Precision Software, Endocardial Solutions, St. Paul, Minnesota). The narrowest part of each reentrant circuit was targeted using radiofrequency energy. RESULTS In all 15 patients, non-contact mapping showed AFLs confined to the RA with RA activation time accounting for 100% of the cycle length (210 +/- 19 ms). During single-loop re-entry in seven patients, the activation wave front circulated around the central obstacle (CO) in the anterolateral wall with conduction through the channel between the CO and the crista terminalis (CT). During figure-of-eight re-entry in eight patients, simultaneous upper and lower loop re-entry through the conduction gap in the CT was found in four patients, and simultaneous upper loop and free-wall single-loop re-entry was observed in four patients. Radiofrequency ablation of the free-wall channel and/or CT gap was effective in eliminating these AFLs in 13 patients. During a follow-up of 16.8 +/- 3.8 months, two patients had recurrence of left AFL, and one had recurrence of atrial fibrillation. CONCLUSIONS Atypical RA flutters could arise from single-loop or double-loop figure-of-eight re-entry. Radiofrequency ablation of the free-wall channel and/or the CT gap was effective in eliminating these arrhythmias.
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Affiliation(s)
- Ching-Tai Tai
- Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine, Taipei Veterans General Hospital, Taiwan, Republic of China.
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Lai LP, Lin JL, Lin JM, Du CC, Tseng YZ, Huang SKS. Use of Double-Potential Barrier to Identify Functional Isthmus at the Cavotricuspid Isthmus for Facilitating Catheter Ablation of Isthmus-Dependent Atrial Flutter. J Cardiovasc Electrophysiol 2004; 15:396-401. [PMID: 15089986 DOI: 10.1046/j.1540-8167.2004.03424.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The aim of the study was to identify an alternative target for more effective radiofrequency catheter ablation (RFCA) of isthmus-dependent atrial flutter (AFL). METHODS AND RESULTS We hypothesized that a functional isthmus formed by preexisting double potential barrier at the cavotricuspid isthmus (CTI) could serve as a new target site for facilitating RFCA of AFL. Forty-three consecutive patients with recurrent isthmus-dependent AFL were studied using three-dimensional navigated magnetic mapping and ablation technique. Twenty patients (47%, group A) were shown to have a narrower functional channel at the CTI (functional isthmus). The remaining 23 patients did not have this feature (53%, group B). In group A, double potentials were clustered near the border of the inferior vena cava (IVC) of the CTI and served as a functional channel along the tricuspid annulus (TA). The interspike interval of double potentials was 87 +/- 26 ms near the IVC border and 45 +/- 17 ms (P < 0.0001) near the TA border of CTI. RFCA targeting at the functional isthmus in group A resulted in interruption of bidirectional transisthmus conduction with fewer radiofrequency pulses (6.7 +/- 4.7 in group A vs 21.1 +/- 17.1 pulses in group B, P < 0.001), shorter ablation line (11.6 +/- 4.0 mm vs 37.8 +/- 7.2 mm, P < 0.0001) with no arrhythmia recurrence. These functional isthmuses were found to be located at the lateral third of CTI in 12 patients, middle third in 7, and medial third in 1. This finding is different from that obtained by the conventional method in group B (lateral in 5, middle in 16, medial in 2, P < 0.038). CONCLUSION In our study, a functional, rather than anatomic, isthmus formed by preexisting double-potential barrier at the CTI was identified in 47% of patients with isthmus-dependent AFL. It is a useful guide to facilitate RFCA of isthmus-dependent AFL.
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Affiliation(s)
- Ling-Ping Lai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, 7 Chun-Shan S. Road, Taipei, Taiwan
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Tai CT, Huang JL, Lee PC, Ding YA, Chang MS, Chen SA. High-Resolution Mapping Around the Crista Terminalis During Typical Atrial Flutter:. New Insights into Mechanisms. J Cardiovasc Electrophysiol 2004; 15:406-14. [PMID: 15089988 DOI: 10.1046/j.1540-8167.2004.03535.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The aim of this study was to delineate activation patterns around the crista terminalis (CT) using high-resolution noncontact mapping. METHODS AND RESULTS Twenty-six patients with typical atrial flutter (20 counterclockwise and 6 clockwise) were enrolled in the study. A noncontact mapping system was used to map atrial flutter. There were three activation patterns around the line(s) of block. Type I (n = 6) showed activation around a single complete line of block located in the CT. Type II (n = 17) showed activation around a single incomplete line of block with a conduction gap in the CT. Type III (n = 3) showed activation around double lines of block, one located in the CT and the other located in the sinus venosa region. Simultaneous activation around the tricuspid annulus and through the CT gap could result in double loop reentry (n = 12). After successful ablation of the cavotricuspid isthmus (CTI) in 24 patients, upper loop reentry was still induced in 12 patients with double loop reentry. Subsequent ablation of the CT gap was performed successfully in these 12 patients, and no arrhythmia was inducible thereafter. During the follow-up period of 8.4 +/- 4.1 months, there was no recurrence of atrial flutter in any patient. CONCLUSION During typical atrial flutter, the CT might be an incomplete barrier. Simultaneous conduction through the CTI and CT gap could result in double loop reentry. Radiofrequency ablation of the CTI and CT gap was effective in eliminating this arrhythmia.
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Affiliation(s)
- Ching-Tai Tai
- Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine, Taipei Veterans General Hospital, 201 Sec. 2 Shih-Pai Road, Taipei, Taiwan, Republic of China.
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Lambiase PD, Rinaldi A, Hauck J, Mobb M, Elliott D, Mohammad S, Gill JS, Bucknall CA. Non-contact left ventricular endocardial mapping in cardiac resynchronisation therapy. BRITISH HEART JOURNAL 2004; 90:44-51. [PMID: 14676240 PMCID: PMC1768036 DOI: 10.1136/heart.90.1.44] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Up to 30% of patients with heart failure do not respond to cardiac resynchronisation therapy (CRT). This may reflect placement of the coronary sinus lead in regions of slow conduction despite optimal positioning on current criteria. OBJECTIVES To characterise the effect of CRT on left ventricular activation using non-contact mapping and to examine the electrophysiological factors influencing optimal left ventricular lead placement. METHODS and results: 10 patients implanted with biventricular pacemakers were studied. In six, the coronary sinus lead was found to be positioned in a region of slow conduction with an average conduction velocity of 0.4 m/s, v 1.8 m/s in normal regions (p < 0.02). Biventricular pacing with the left ventricle paced 32 ms before the right induced the optimal mean velocity time integral and timing for fusion of depolarisation wavefronts from the right and left ventricular pacing sites. Pacing outside regions of slow conduction decreased left ventricular activation time and increased cardiac output and dP/dt(max) significantly. CONCLUSIONS In patients undergoing CRT for heart failure, non-contact mapping can identify regions of slow conduction. Significant haemodynamic improvements can occur when the site of left ventricular pacing is outside these slow conduction areas. Failure of CRT to produce clinical benefits may reflect left ventricular lead placement in regions of slow conduction which can be overcome by pacing in more normally activating regions.
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Affiliation(s)
- P D Lambiase
- Department of Cardiology, St Thomas' Hospital, London, UK
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Chen J, Hoff PI, Erga KS, Rossvoll O, Ohm OJ. Global Right Atrial Mapping Delineates Double Posterior Lines of Block in Patients with Typical Atrial Flutter:. J Cardiovasc Electrophysiol 2003; 14:1041-8. [PMID: 14521656 DOI: 10.1046/j.1540-8167.2003.03068.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Double Posterior Lines of Block in Typical Atrial Flutter. INTRODUCTION The crista terminalis (CT) has been shown to be a barrier to transverse conduction during typical atrial flutter (AFL). However, some studies have demonstrated the presence of functional block in the sinus venosa region but not at the CT. The aim of this study was to define these regions of block in the right atrium using a three-dimensional noncontact mapping system. METHODS AND RESULTS In 39 AFL patients (33 men and six women, mean age 56 +/- 13 years), a noncontact multielectrode array was used to reconstruct electrograms in the right atrium. Isochronal and isopotential propagation mapping was performed during AFL and during pacing from the coronary sinus ostium and the low lateral wall (cycle length from 600 to 240 msec) in sinus rhythm after creation of isthmus block. A single line of block along the CT area was found in 18 patients (46%). Two lines of block were found in 21 patients (54%), with the first line located along the CT area. The second was located in the sinus venosa region in 20 patients (51%) and in the lateral wall in 1 patient (3%). In all patients, the block in the lower part of the CT was observed during AFL (60%) and during pacing at all cycle lengths (48%-62%). The length and proportion of block were inversely proportional to pacing cycle length. CONCLUSION Double lines of block were frequently observed in patients with AFL, and both lines may form the posterior boundaries of the AFL circuit. Block was fixed in the lower part of the CT and was functional in the upper part of the CT.
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Affiliation(s)
- Jian Chen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
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Luo J, Yuan S, Hertervig E, Kongstad O, Ljungström E, Holm M, Olsson SB. Electroanatomic mapping of right atrial activation in patients with and without paroxysmal atrial fibrillation. J Electrocardiol 2003; 36:237-42. [PMID: 12942486 DOI: 10.1016/s0022-0736(03)00031-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Inter-atrial conduction delay in patients with atrial fibrillation (AF) has been reported. However, the area of this conduction delay has not been well identified. The activation time and conduction velocity over the right atrial endocardium were evaluated during sinus rhythm using the CARTO mapping technique in 6 patients with paroxysmal AF (AF group) and 11 patients without history of AF (control group). No significant differences were observed between the 2 groups in the mean activation times and conduction velocities from the earliest activation site to the superior septum, His bundle area and coronary sinus ostium, or in the total activation times of the right atrium. There was no significant difference between the two groups in the local conduction velocity between 2 adjacent sites in the free wall, septum and bottom of the right atrium. This study suggests the previously reported conduction delay in the posteroseptal region in patients with paroxysmal AF might locate within the posterior inter-atrial septum.
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Affiliation(s)
- Jijian Luo
- Department of Cardiology, University Hospital, Lund University, Lund, Sweden
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Chen J, Hoff PI, Erga KS, Rossvoll O, Ohm OJ. Three-dimensional noncontact mapping defines two zones of slow conduction in the circuit of typical atrial flutter. Pacing Clin Electrophysiol 2003; 26:318-22. [PMID: 12687837 DOI: 10.1046/j.1460-9592.2003.00041.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The cavotricuspid isthmus (CTI) is a slow conduction area in the circuit of typical atrial flutter. However, conventional methods are limited by the inaccuracy of measurements of distance on the surface of the heart. The aim of the study was to define the conduction properties of the atrial flutter circuit along the tricuspid annulus by using a three-dimensional noncontact mapping system. In 34 atrial flutter patients (30 men, 4 women; mean age 54 +/- 14; 27 counter-clockwise, 4 clockwise, and 3 both), a noncontact multielectrode array was used to reconstruct electrograms in the right atrium. Isochronal and isopotential propagation mapping was performed during atrial flutter. The conduction velocity was calculated by dividing conduction time by surface distance. The right atrium along the tricuspid annulus was divided into five regions: lateral wall, superior right atrium, septum, septal CTI, and lateral CTI. Conduction velocities were 0.99 +/- 0.85, 1.67 +/- 1.21, 1.58 +/- 1.05, 0.82 +/- 0.72, and 1.68 +/- 1.00 m/s in counter-clockwise and 0.81 +/- 0.71, 2.61 +/- 1.90, 1.52 +/- 0.91, 0.91 +/- 0.80 and 1.91 +/- 0.83 m/s in clockwise, respectively. Conduction velocities were significantly slower in the septal CTI and lateral wall than in the lateral CTI, the septum, and the superior right atrium (P < 0.05). No significant difference was found between the septal CTI and the lateral wall. Conduction within the septal CTI was slower in patients treated with antiarrhythmic agents than in untreated patients (P < 0.05). The septal part of the CTI (but not the lateral CTI) and the lateral wall are slow conduction zones in the atrial flutter circuit, and both may, therefore, be mechanically important for the development of atrial flutter.
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Affiliation(s)
- Jian Chen
- Department of Heart Disease, Haukeland University Hospital, N-5021 Bergen, Norway.
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Birnbaum SE. Mechanisms of atrial reentry tachycardia after surgery for congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2002. [DOI: 10.1016/s1058-9813(01)00139-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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