Characterization of conduction system activation in the postinfarct ventricle using ripple mapping.

BACKGROUND: Three-dimensional (3D) mapping of the ventricular conduction system is challenging. OBJECTIVE: The purpose of this study was to use ripple mapping to distinguish conduction system activation to that of adjacent myocardium in order to characterize the conduction system in the postinfarct left ventricle (LV). METHODS: High-density mapping (PentaRay, CARTO) was performed during normal rhythm in patients undergoing ventricular tachycardia ablation. Ripple maps were viewed from the end of the P wave to QRS onset in 1-ms increments. Clusters of >3 ripple bars were interrogated for the presence of Purkinje potentials, which were tagged on the 3D geometry. Repeating this process allowed conduction system delineation. RESULTS: Maps were reviewed in 24 patients (mean 3112 ± 613 points). There were 150.9 ± 24.5 Purkinje potentials per map, at the left posterior fascicle (LPF) in 22 patients (92%) and at the left anterior fascicle (LAF) in 15 patients (63%). The LAF was shorter (41.4 vs 68.8 mm; P = .0005) and activated for a shorter duration (40.6 vs 64.9 ms; P = .002) than the LPF. Fourteen of 24 patients had left bundle branch block (LBBB), with 11 of 14 (78%) having Purkinje potential-associated breakout. There were fewer breakouts from the conduction system during LBBB (1.8 vs 3.4; 1.6 ± 0.6; P = .039) and an inverse correlation between breakout sites and QRS duration (P = .0035). CONCLUSION: We applied ripple mapping to present a detailed electroanatomic characterization of the conduction system in the postinfarct LV. Patients with broader QRS had fewer LV breakout sites from the conduction system. However, there was 3D mapping evidence of LV breakout from an intact conduction system in the majority of patients with LBBB.

SparkleMap-based left atrial flutter mapping and ablation.

Ablation of atypical left atrial flutters (LAF) is very challenging due to the complexity of the underlying atrial substrate and diverse arrhythmia mechanisms. The interpretation of the arrhythmia mechanism is usually difficult, even using advanced three-dimensional (3D) mapping systems. SparkleMap is a novel mapping algorithm that displays each electrogram as a green dot that lights up at the point corresponding to the local activation time, superimposed either on the substrate or the local activation time 3D-maps. It is not affected by the setting of the "window of interest" and there is no need for user post-processing. We present the case of patient with a persistent atypical LAF in whom we tested the concept of complex arrhythmia interpretation exclusively based on the analysis of the substrate and evaluation of SparkleMap-derived wavefront propagation. We describe the workflow for map collection and the systematic approach for arrhythmia interpretation that resulted in the identification of a dual loop perimitral mechanism with a common slow conducting isthmus inside a scar at the septum/anterior atrial wall. This new method of analysis enabled the use of a specifically targeted and precise approach for ablation, with restoration of sinus rhythm within five seconds of radiofrequency application. After 18 months of follow-up, the patient remains free from recurrences, without anti-arrhythmic medication. This case report exemplifies how helpful new mapping algorithms can be in the interpretation of the arrhythmia mechanism in patients with complex LAF. It also suggests an innovative workflow to integrate the SparkleMap into the mapping approach.

Outcome of ventricular tachycardia catheter ablation in ischemic heart disease patients using a high-density mapping substrate-based approach: A prospective cohort study.

INTRODUCTION AND OBJECTIVE: Radiofrequency catheter ablation (RCA) for ventricular tachycardia (VT) in patients with ischemic heart disease (IHD) is associated with a reduced risk of VT storm and implantable cardioverter defibrillator (ICD) shocks. We aim to report the outcome after a single RCA procedure for VT in patients with IHD using a high-density substrate-based approach. METHODS: We conducted a prospective, observational, single-center and single-arm study involving patients with IHD, referred for RCA procedure for VT using high-density mapping catheters. Substrate mapping was performed in all patients. Procedural endpoints were VT non-inducibility and local abnormal ventricular activities (LAVAs) elimination. The primary end point was survival free from appropriate ICD shocks and secondary end points included VT storm and all-cause mortality. RESULTS: Sixty-four consecutive patients were included (68±9 years, 95% male, mean ejection fraction 33±11%, 39% VT storms, and 69% appropriate ICD shocks). LAVAs were identified in all patients and VT inducibility was found in 83%. LAVA elimination and non-inducibility were achieved in 93.8% and 60%, respectively. After a mean follow-up of 25±18 months, 90% and 85% of patients are free from appropriate ICD shocks at one and two years, respectively. The proportion of patients experiencing VT storm decreased from 39% to 1.6%. Overall survival was 89% and 84% at one and two years, respectively. CONCLUSIONS: RCA of VT in IHD using a high-density mapping substrate-based approach resulted in a steady freedom of ICD shocks and VT storm.

Novel "late potential map" algorithm: Abnormal potentials and scar channels detection for ventricular tachycardia ablation.

BACKGROUND: Automated systems for substrate mapping in the context of ventricular tachycardia (VT) ablation may annotate far-field rather than near-field signals, rendering the resulting maps hard to interpret. Additionally, quantitative assessment of local conduction velocity (LCV) remains an unmet need in clinical practice. We evaluate whether a new late potential map (LPM) algorithm can provide an automatic and reliable annotation and localized bipolar voltage measurement of ventricular electrograms (EGMs) and if LCV analysis allows recognizing intrascar conduction corridors acting as VT isthmuses. METHODS: In 16 patients referred for scar-related VT ablation, 8 VT activation maps and 29 high-resolution substrate maps from different activation wavefronts were obtained. In offline analysis, the LPM algorithm was compared to manually annotated substrate maps. Locations of the VT isthmuses were compared with the corresponding substrate maps in regard to LCV. RESULTS: The LPM algorithm had an overall/local abnormal ventricular activity (LAVA) annotation accuracy of 94.5%/81.1%, which compares to 83.7%/23.9% for the previous wavefront algorithm. The resultant maps presented a spatial concordance of 88.1% in delineating regions displaying LAVA. LAVA median localized bipolar voltage was 0.22 mV, but voltage amplitude assessment had modest accuracy in distinguishing LAVA from other abnormal EGMs (area under the curve: 0.676; p < .001). LCV analysis in high-density substrate maps identified a median of two intrascar conduction corridors per patient (interquartile range: 2-3), including the one acting as VT isthmus in all cases. CONCLUSION: The new LPM algorithm and LCV analysis may enhance substrate characterization in scar-related VT.

Electroanatomic Characterization and Ablation of Scar-Related Isthmus Sites Supporting Perimitral Flutter.

OBJECTIVES: The authors reviewed 3-dimensional electroanatomic maps of perimitral flutter to identify scar-related isthmuses and determine their effectiveness as ablation sites. BACKGROUND: Perimitral flutter is usually treated by linear ablation between the left lower pulmonary vein and mitral annulus. Conduction block can be difficult to achieve, and recurrences are common. METHODS: Patients undergoing atrial tachycardia ablation using CARTO3 (Biosense Webster Inc., Irvine, California) were screened from 4 centers. Patients with confirmed perimitral flutter were reviewed for the presence of scar-related isthmuses by using CARTO3 with the ConfiDense and Ripple Mapping modules. RESULTS: Confirmed perimitral flutter was identified in 28 patients (age 65.2 ± 8.1 years), of whom 26 patients had prior atrial fibrillation ablation. Scar-related isthmus ablation was performed in 12 of 28 patients. Perimitral flutter was terminated in all following correct identification of a scar-related isthmus using ripple mapping. The mean scar voltage threshold was 0.11 ± 0.05 mV. The mean width of scar-related isthmuses was 8.9 ± 3.5 mm with a conduction speed of 31.8 ± 5.5 cm/s compared to that of normal left atrium of 71.2 ± 21.5 cm/s (p < 0.0001). Empirical, anatomic ablation was performed in 16 of 28, with termination in 10 of 16 (63%; p = 0.027). Significantly less ablation was required for critical isthmus ablation compared to empirical linear lesions (11.4 ± 5.3 min vs. 26.2 ± 17.1 min; p = 0.0004). All 16 cases of anatomic ablation were reviewed with ripple mapping, and 63% had scar-related isthmus. CONCLUSIONS: Perimitral flutter is usually easy to diagnose but can be difficult to ablate. Ripple mapping is highly effective at locating the critical isthmus maintaining the tachycardia and avoiding anatomic ablation lines. This approach has a higher termination rate with less radiofrequency ablation required.

Ripple-AT Study: A Multicenter and Randomized Study Comparing 3D Mapping Techniques During Atrial Tachycardia Ablations.

BACKGROUND: Ripple mapping (RM) is an alternative approach to activation mapping of atrial tachycardia (AT) that avoids electrogram annotation. We tested whether RM is superior to conventional annotation based local activation time (LAT) mapping for AT diagnosis in a randomized and multicenter study. METHODS: Patients with AT were randomized to either RM or LAT mapping using the CARTO3v4 CONFIDENSE system. Operators determined the diagnosis using the assigned 3D mapping arm alone, before being permitted a single confirmatory entrainment manuever if needed. A planned ablation lesion set was defined. The primary end point was AT termination with delivery of the planned ablation lesion set. The inability to terminate AT with this first lesion set, the use of more than one entrainment manuever, or the need to crossover to the other mapping arm was defined as failure to achieve the primary end point. RESULTS: One hundred five patients from 7 centers were recruited with 22 patients excluded due to premature AT termination, noninducibility or left atrial appendage thrombus. Eighty-three patients (pts; RM=42, LAT=41) completed mapping and ablation within the 2 groups of similar characteristics (RM versus LAT: prior ablation or cardiac surgery n=35 [83%] versus n=35 [85%], P=0.80). The primary end point occurred in 38/42 pts (90%) in the RM group and 29/41pts (71%) in the LAT group (P=0.045). This was achieved without any entrainment in 31/42 pts (74%) with RM and 18/41 pts (44%) with LAT (P=0.01). Of those patients who failed to achieve the primary end point, AT termination was achieved in 9/12 pts (75%) in the LAT group following crossover to RM with entrainment, but 0/4 pts (0%) in the RM group crossing over to LAT mapping with entrainment (P=0.04). CONCLUSIONS: RM is superior to LAT mapping on the CARTO3v4 CONFIDENSE system in guiding ablation to terminate AT with the first lesion set and with reduced entrainment to assist diagnosis. CLINICAL TRIALS REGISTRATION: https://www.clinicaltrials.gov. Unique identifier: NCT02451995.

Identification of a critical isthmus in complex macroreentrant atrial tachycardia using Ripple mapping in a patient with surgically repaired Ebstein's anomaly.

Ripple mapping is a novel, three-dimensional, electroanatomic mapping tool that displays each electrogram at its corresponding 3-dimensional coordinate as a dynamic moving bar, which changes in length according to the electrogram voltage-time relationship. We present the case of a 43-year-old male patient with surgically repaired Ebstein's anomaly who previously underwent two unsuccessful ablation procedures for right atrial flutter (cavotricuspid isthmus and intercaval lines). Ripple mapping was decisive, enabling the arrhythmia mechanism to be appropriately recognized, and a distinction to be made between critical areas of the circuit and delayed activated bystander regions.

Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation: follow-up results from a prospective observational study.

Aims: Cardiac Resynchronization Therapy (CRT) is associated with a particularly high non-response rate in patients with atrial fibrillation (AF). We aimed to assess the effectiveness of triple-site (Tri-V) pacing CRT in this population. Methods and results: Prospective observational study of patients with permanent AF who underwent CRT implantation with an additional right ventricle lead in the outflow tract septal wall. After implantation, programming mode (Tri-V or biventricular pacing) was selected based on cardiac output determination. Patients were classified as responders if NYHA class was reduced by at least one level and echocardiographic ejection fraction (EF) increased ≥ 10%, and as super-responders if in NYHA class I and EF ≥ 50%. Forty patients (93% male, mean age 72 ± 10 years) were included. Thirty-three were programmed in Tri-V. The following results pertain to this subgroup. At baseline, 58% were in NYHA class III and 36% NYHA class II. At 1 year follow-up, Minnesota QoL score was reduced (36 ± 23 vs. 8 ± 6; P = 0.001) and the 6MWT distance improved (384 ± 120 m to 462 ± 87 m, P = 0.003). Mean EF increased (26% ± 8 vs. 39 ± 10; P < 0.001 at 6 months and 41 ± 10; P < 0.001 at 12 months). Responder rate was 59% at 6 months and 79% at 12 months. Super-responder rate was 9% at 6 months and 16% at 12 months. One year survival free from heart failure hospitalization was 87.9%. Conclusion: Tri-V CRT yielded higher response and super-response rates than usually reported for CRT in patients with permanent AF using clinical and remodeling criteria.

Ripple mapping: Initial multicenter experience of an intuitive approach to overcoming the limitations of 3D activation mapping.

BACKGROUND: Ripple mapping (RM) displays electrograms as moving bars over a three-dimensional surface displaying bipolar voltage, and has shown in a single-center series to be effective for atrial tachycardia (AT) mapping without annotation of local activation time or window-of-interest assignment. We tested the reproducibility of these findings in operators naïve to RM, using it for the first time in postablation AT. METHODS: Maps were collected with multielectrode catheters and CARTO ConfiDENSE. A diagnosis of the tachycardia mechanism was made using RM and an assessment of operator confidence was made according to a three-grade scale (1 highest-3 lowest). RESULTS: The first 20 patients (64 ± 9 years, median two previous ablations) undergoing RM-guided AT ablation across five sites were studied. High-density maps (2,935 ± 1,328 points) in AT (CL = 296 ± 95 milliseconds) were collected. Macroreentrant ATs bordered by scar or anatomical obstacles were identified in n = 12 (60%), small reentrant ATs around scar in n = 3 (15%), and focal ATs from scar in n = 5 (25%). Diagnostic confidence with RM was grade 1 in n = 13 (65%), where operators felt confident to proceed to ablation without entrainment. Ablation offered the correct diagnosis n = 18 (90%). Retrospective review of the accompanying LAT maps demonstrated potential sources for error related to the window of interest selection, interpolation, and differentiating regions of scar during tachycardia on the voltage map. CONCLUSION: RM was easy to adopt by operators using it for the first time, and identified the correct target for ablation with high diagnostic confidence in most cases of complex AT.

Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation - Acute phase results from a prospective observational study.

INTRODUCTION AND AIM: Multi-site pacing is emerging as a new method for improving response to cardiac resynchronization therapy (CRT), but has been little studied, especially in patients with atrial fibrillation. We aimed to assess the effects of triple-site (Tri-V) vs. biventricular (Bi-V) pacing on hemodynamics and QRS duration. METHODS: This was a prospective observational study of patients with permanent atrial fibrillation and ejection fraction <40% undergoing CRT implantation (n=40). One right ventricular (RV) lead was implanted in the apex and another in the right ventricular outflow tract (RVOT) septal wall. A left ventricular (LV) lead was implanted in a conventional venous epicardial position. Cardiac output (using the FloTrac™ Vigileo™ system), mean QRS and ejection fraction were calculated. RESULTS: Mean cardiac output was 4.81±0.97 l/min with Tri-V, 4.68±0.94 l/min with RVOT septal and LV pacing, and 4.68±0.94 l/min with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV). Mean pre-implantation QRS was 170±25 ms, 123±18 ms with Tri-V, 141±25 ms with RVOT septal pacing and LV pacing and 145±19 with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV and pre-implantation). Mean ejection fraction was significantly higher with Tri-V (30±11%) vs. Bi-V pacing (28±12% with RVOT septal and LV pacing and 28±11 with RV apical and LV pacing) and pre-implantation (25±8%). CONCLUSION: Tri-V pacing produced higher cardiac output and shorter QRS duration than Bi-V pacing. This may have a significant impact on the future of CRT.

Epicardial ablation for prevention of ventricular fibrillation in a patient with Brugada syndrome.

We present the case of a 60-year-old woman with Brugada syndrome, permanent type 1 electrocardiographic pattern, who had previously received an implantable cardioverter-defibrillator. She suffered frequent syncopal episodes and multiple appropriate shocks (around five per month) due to polymorphic ventricular tachycardia/ventricular fibrillation, refractory to quinidine therapy. Combined epicardial and endocardial electroanatomical mapping was performed with a view to substrate ablation. An area of abnormal fractionated electrograms, lasting up to 370 ms and up to 216 ms after the end of the surface QRS, was identified in the epicardium in the lower anterior part of the right ventricular outflow tract. Extensive epicardial ablation of this area, which eliminated the fractionated electrograms, led to the disappearance of the Brugada electrocardiographic pattern six weeks after ablation. Despite discontinuation of quinidine, no further ventricular arrhythmias occurred during follow-up, which is still of short duration.

One-Shot Ablation For PV Isolation.

Atrial fibrillation ablation has evolved considerably over the last few years. In this article we review current and past catheter ablation techniques, with a special focus on new simplified systems that allow a faster and simpler procedure, so called "one-shot" atrial fibrillation ablation.