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

Background: Atrioventricular nodal reentrant tachycardia (AVNRT) is treatable by catheter ablation. Advances in mapping-system technology permit fluoroless workflow during ablations. As national practice trends toward fluoroless approaches, easily obtained, reproducible methods of slow-pathway identification, and ablation become increasingly important. We present a novel method of slow-pathway identification and initial ablation results from this method. Methods and Results:We examined AVNRT ablations performed at our institution over a 12-month period. In these cases, the site of the slow pathway was predicted by latest activation in the inferior triangle of Koch during sinus rhythm. Ablation was performed in this region. Proximity of the predicted site to the successful ablation location, complication rates, and patient outcomes were recorded. Junctional rhythm was seen in 40/41 ablations (98%) at the predicted site (mean, 1.3 lesions and median, 1 lesion per case). One lesion was defined as 5 mm of ablation. The initial ablation was successful in 39/41 cases (95%); in two cases, greater or equal to 2 echo beats were detected after the initial ablation, necessitating further lesion expansion. In 8/41 cases (20%), greater than one lesion was placed during initial ablation before attempted reinduction. Complications included one transient heart block and one transient PR prolongation. During follow-up (median, day 51), one patient had lower-extremity deep-vein thrombosis and pulmonary embolus, and one had a lower-extremity superficial venous thrombosis. There was one tachycardia recurrence, which prompted a redo ablation. Conclusions: Mapping-system detection of late-activation, low-amplitude voltage during sinus rhythm provides an objective, and fluoroless means of identifying the slow pathway in typical AVNRT. K E Y W O R D S arrhythmias, atrioventricular nodal reentrant, AVNRT, cardiac, fluoroless ablation, supraventricular, tachycardia How to cite this article: Hale ZD, Greet BD, Burkland DA, et al. Slow-pathway visualization by using voltage-time relationship: A novel technique for identification and fluoroless ablation of atrioventricular nodal reentrant tachycardia.

Section: Discussionmentioning

confidence: 99%

Slow‐pathway visualization by using voltage‐time relationship: A novel technique for identification and fluoroless ablation of atrioventricular nodal reentrant tachycardia

Hale

Greet

Burkland

et al. 2020

“…Eventually, current mapping algorithms may pose additional challenges during such complex cases and in many scenarios could be misleading. In fact, the diagnostic accuracy remains suboptimal, ranging from 20% to 60% in previous studies 5,8,9 …”

Section: Discussionmentioning

confidence: 98%

The utility of a novel mapping algorithm utilizing vectors and global pattern of propagation for scar‐related atrial tachycardias

Kuroda

Wazni

Saliba

et al. 2021

Background Activation maps of scar‐related atrial tachycardias (AT) can be challenging to interpret due to difficulty in inaccurate annotation of electrograms, and an arbitrarily predefined mapping window. A novel mapping software integrating vector data and applying an algorithmic solution taking into consideration global activation pattern has been recently described (Coherent™, Biosense Webster “Investigational”). Objective We aimed to assess the investigational algorithm to determine the mechanism of AT compared with the standard algorithm. Methods This study included patients who underwent ablation of scar‐related AT using the Carto 3 and the standard activation algorithm. The mapping data were analyzed retrospectively using the investigational algorithm, and the mechanisms were evaluated by two independent electrophysiologists. Results A total of 77 scar‐related AT activation maps were analyzed (89.6% left atrium, median tachycardia cycle length of 273 ms). Of those, 67 cases with a confirmed mechanism of arrhythmia were used to compare the activation software. The actual mechanism of the arrhythmia was more likely to be identified with the investigational algorithm (67.2% vs. 44.8%, p = .009). In five patients with dual‐loop circuits, 3/5 (60%) were correctly identified by the investigational algorithm compared to 0/5 (0%) with the standard software. The reduced atrial voltage was prone to lead to less capable identification of mechanism (p for trend: .05). The investigational algorithm showed higher inter‐reviewer agreement (Cohen's kappa .62 vs. .47). Conclusions In patients with scar‐related ATs, activation mapping algorithms integrating vector data and “best‐fit” propagation solution may help in identifying the mechanism and the successful site of termination.

“…In our study, two ATs were repeatedly terminated during CAM and were mapped successfully using ODPM; (b) variable AT CL. One of the characteristics of localized tachycardia, either AT or ventricular tachycardia, is variability in CL . One of the factors influencing CL is the surrounding tissue.…”

Section: Discussionmentioning

confidence: 99%

“…One of the characteristics of localized tachycardia, either AT or ventricular tachycardia, is variability in CL. 16 One of the factors influencing CL is the surrounding tissue. An increased scar burden will likely vary the routes of AT exit to the rest of the atrium.…”

Section: Advantages Of Odpm Over Cammentioning

confidence: 99%

Overdrive pacing mapping: An alternative approach used in scar associated localized atrial tachycardia

Jiang

Yang

Liu

et al. 2019

Background Mapping and ablation of localized reentry atrial tachycardia (AT) can be challenging, especially in those with varying cycle length (CL). Objective We attempted to use the traditional maneuver of overdrive pacing to facilitate AT mapping. Methods Data were collected from 12 patients with localized ATs. All patients had prior cardiac surgery or prior atrial fibrillation ablation. Overdrive pacing mapping (ODPM) was performed to find independent local activity (ILA) and compared with conventional activation mapping (CAM) during ongoing AT to determine its accuracy and efficacy. Patients with macro‐reentry AT around the tricuspid or mitral annulus were excluded. Results Twelve patients with 14 localized ATs were included. All 14 ATs including 4 (29%) with varying CL successfully completed ODPM and had the ILA, although two ATs terminated during ODP and required repeated mapping. Radiofrequency ablation focused on critical sites with ILA was successful in all 12 patients. Using CAM, however, 6 of 14 ATs (43%) mapping attempts were aborted due to AT termination (2 ATs) or varying CL (4 ATs), and only 5 of 8 (63%) located “critical sites” were ultimately confirmed by entrainment and ablation results. After 25 ± 9 months of follow‐up, no patient had AT recurrence. Conclusion Our preliminary results demonstrated that ODPM is superior to CAM in ATs that were poorly sustained or with varying CL and is a useful supplement to CAM.