CARTO three-dimensional non-fluoroscopic electroanatomic mapping for catheter ablation of arrhythmias: a useful tool or an expensive toy for the electrophysiologist? (original) (raw)
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Kosuyolu Heart Journal, 2018
Introduction: Challenging and intractable macroreentrant atrial tachycardias mostly occur after cardiac surgeries, and the response of such arrhythmias to conventional treatments is poor. Also, arrhytmias with previous unsuccessful ablations are compulsive arrhytmias. This study represents our approach for the ablation of challenging atrial macroreentrant tachycardias. Patients and Methods: Five consecutive patients with atrial flutter and a previous history of cardiac surgery and/or radiofrequency ablation were enrolled to this study. The focal point of the clinical arrhythmia was defined in the CARTO ® and Columbus™ map and the critical isthmus was targeted for ablation. Radiofrequency ablation was performed until the arrhythmia stopped or until a change in cycle length or activation wave front was seen. Results: All the complex atrial macroreentrant tachycardias were arized from the right atrium. Overall, all the cases were successfully mapped and ablated. None of the patients had recurrence even after 6 months of follow-up. The mean (±SD) procedure time was 49.0 ± 22.4 min. Three-dimensional electroanatomic cardiac mapping technologies, including CARTO and Columbus™, are highly effective in revealing atrial arrhytmias and facilitating ablation of the scar-related potential circuits. Conclusion: This study highlights success and usefulness of three-dimensional electroanatomic cardiac mapping in complex atrial macroreentrant tachycardia ablations.
Magnetic Electroanatomical Mapping for Ablation of Focal Atrial Tachycardias
Pace-pacing and Clinical Electrophysiology, 1998
Uniform success for ablation of focal athaJ tachycardias has been difficult to achieve using standard catheter mapping and ablation techniques. In addition, our understanding of the complex relationship between atrial anatomy, electrophysiology. and surface ECG P wave morphology remains primitive. The magnetic electroanatomical mapping and display system (CARTO) offers an on-line display of electrical activation and/or signal amplitude related to the anatomical location of the recorded sites in the mapped chamber. A window of electrical interest is established based on signals timed from an electrical reference that usually represents a fixed electrogram recording from the coronary sinus or the atrial appendage. This window of electrical interest is established to include atrial activation prior to the onset of the P wave activity associated with the site of origin of a focal atrial tachycardia. Anatomical and electrical landmarks are defined with limited fluoroscopic imaging support and more detailed global chamber and more focal atrial mapping can be performed with minimal fluoroscopic guidance. A three-dimensional color map representing atrial activation or voltage amplitude at the magnetically defined anatomical sites is displayed with on-line data acquisition. This display can be manipulated to facilitate viewing from any angle. Altering the zoom control, triangle fill threshold, clipping plane, or color range can all enhance the display of a more focal area of interest. We documented the feasibility of using this single mapping catheter technique for localizing and ablating focal atrial tachycardias. In a consecutive series of 8 patients with 9 focal atrial tachycardias, the use of the single catheter CARTO mapping system was associated with ablation success in all but one patient who had a left atrial tachycardia localized to the medial aspect of the orifice of the left atrial appendage. Only low power energy deHvery was used in this patient because of the unavaHahiHty of temperature monitoring in the early version of the Navistar catheter, the location of the arrhythmia, and the history of arrhythmia control with flecainide. No attempt was made to Umit fluoroscopy time in our study population. Nevertheless, despite data acquisition from 120–320 anatomically distinct sites during global and more detaHed focal atrial mapping, total fluoroscopy exposure was typically < 30 minutes and was as little as 12 minutes. The detailed display capabilities of the CARTO system appear to offer the potential of enhancing our understanding of atrial anatomy, atrial activation, and their relationship to surface ECC P wave morphology during focal atrial tachycardias.
Electroanatomical Mapping Systems. An Epochal Change in Cardiac Electrophysiology
In the last two decades new mathematical and computational models and systems have been applied to the clinical cardiology, which continue to be developed particularly to quantify and simplify anatomy, physio-pathological mechanisms and treatment of many patients with cardiac arrhythmias. The Authors report our large experience on electroanatomical mapping systems and techniques that are currently used to quantify and analyze both anatomy and electrophysiology of the heart. In the last 15 years the Authors have performed more than 15,000 invasive catheter ablation procedures using different non-fluoroscopic three-dimensional (3D) elec-troanatomical mapping and ablation systems (CARTO, Ensite) to safely and accurately treat many patients with different cardiac arrhythmias particularly those with atrial fibrillation with a median age of 60 years (IQR, 55-64). The Authors have also developed and proposed for the first time a new robotic magnetic system to map and ablate cardiac arrhythmias without use of fluoroscopy (Stereotaxis) in >500 patients. Very recently, epicardial mapping and ablation by electroanatomical systems have been successfully performed to treat Brugada syndrome at risk of sudden death in a series of patients with a median age of 39 years (IQR, 30-42). Our experience indicates that electroanatomic mapping systems integrate several important func-tionalities. (1) Non-fluoroscopic localization of electrophysiological catheters in three-dimensional space; (2) Analysis and 3D display of cardiac activation sequences computed from local or calculated electrograms, and 3D display of electrogram voltage; (3) Integration of 'electroanatomic' data with non-invasive images of the heart, such as computed tomography or magnetic resonance images. The widespread use of such 3D systems is associated with higher success rates, shorter fluoroscopy and procedure times, and accurate visualization of complex cardiac and extra-cardiac anatomical structures needing to be protected during the procedure.
Journal of Cardiovascular Electrophysiology, 2000
Three-dimensional electroanatomic (CARTO) activation mapping of the cavotricuspid isthmus can be helpful to guide atrial flutter ablation, hut to date has not heen investigated in comparison to conventional strategies. The aim of the present study was to assess the efficacy of the CARTO navigation system, e.specially with respect to the fluoroscopy time required for successful atrial flutter ablation. Methods and Results: Eighty patients with recurrent common-type atrial flutter were randomly assigned to temperature-controlled radiofrequency (RF) catheter ablation, either guided by conventional criteria (group I) or additionally oriented on electroanatomic mapping (group 2). In all patients, similar multipolar catheters were inserted into the coronary sinus and placed at the tricuspid annulus. respectively. In group 2, positioning ofthe mapping electrode and delivery of RF pulses within the cavotricuspid isthmus was mainly oriented on the CARTO map to achieve the most linear and continuous RF lesions. Abolition of intra-atrial conduction verified by conventional criteria (group 1) and electroanatomic mapping (group 2) could be verified in all patients. Tbe overall number of RF pulses (group I: 16.7 ± 6.5; group 2: 13.2 ± 5.3) and mean procedure duration (group 1: 172.5 ± 47.4 min; group 2: 169.3 ± 47.3 min) were not different between the two groups, but mean Huoroscopy time was significantly shorter wben tbe CARTO tecbnology was used (group 1: 29.2 ± 9.4 min; group 2: 7.7 ± 2.8 min; F = 0.0001). Recurrence of atrial flutter was observed in 3 (9%) patients in each group after a mean follow-up of 8.5 ± 2.8 months. Conclusion: Atrial flutter can be abolished effectively using the conventional technique as well as oriented on electroanatomic mapping. However, overall X-ray exposure can he significantly reduced by the CARTO-guided approacb without prolongation of procedure duration.
Non-invasive transmural 3-dimensional mapping of atrial fibrillation for catheter ablation
le.ac.uk
In recent years, a non-contact multi-electrode array catheter (St Jude Medical, Ensite Array) has been developed to assist with the mapping of intracardiac electrical signals. This innovation allows re-creation of a 3-dimensional (3D) geometry of the heart chamber(s) whereby recorded electrical activity can be projected onto the geometry of the endocardial surface of the heart as simultaneous virtual electrograms. The balloon mounted catheter with electrodes arranged in an array fashion is placed within the blood pool of the cavity of interest and the electrograms from the endocardial surface of the chamber are collected (without contact with the myocardium) using inverse solution mathematics in an "inside-out" fashion. Up to 3000 points of electrical data can be collected in a single heartbeat.
Europace, 2011
Atrial tachycardia (AT) is a common complication after repair of congenital heart disease (CHD). This two-centre prospective study evaluated the ability of three-dimensional electroanatomic mapping (EAM) to guide ablation of ATs in this particular population with a minimally invasive simplified approach. Methods and results Thirty-one consecutive patients (mean age 26 + 17 years) with AT after repair of CHD were treated with a very limited number of intracavitary catheters and a specific setting of the Window of Interest (WoI) for the ablation of post-surgical ATs. A single-intracavitary catheter approach was performed in 22 patients, whereas an overall use of two intracavitary catheters in the other nine patients. Thirty-one patients exhibited 41 ATs. Seventy-six per cent of these were macro-reentrant ATs (MRATs), and 24% were focal ATs (FAT). The mid-diastolic isthmus (MDI) was located in the right atrial free wall (RAFW) in 82.8% of MRATs. Also in FATs, the RAFW was the most common site (77.8%) of the ectopic focus. Fifty-eight per cent of MRATs showed a double-loop reentry, with both loops sharing the same MDI in all cases. In 87% of cases, the abolition of the MRAT was obtained by applying radiofrequency energy to the MDI. Ninety per cent of FATs were successfully ablated. Mean conduction velocity and voltage amplitude had significantly lower values in successfully treated than in unsuccessfully treated MRATs. Conclusion Three-dimensional EAM, performed with a minimally invasive simplified approach and by using a specific parameter setting of the WoI, showed to be very effective to guide ablation of ATs in CHD patients.
Catheter Ablation of Subepicardial Ventricular Tachycardia Using Electroanatomic Mapping
Herz, 2003
In patients with left ventricular tachycardia (VT) and failed endocardial ablation, a subepicardial substrate may be considered. Patients and Methods: Seven patients with drug-refractory VT of right bundle branch block morphology were investigated to identify the arrhythmogenic substrate using three-dimensional (3-D) electroanatomic endocardial and epicardial mapping. Results: In three patients with repetitive monomorphic VT, endocardial and epicardial mapping during tachycardia showed a focal pattern with an earliest activation preceding the onset of the QRS complex by 20 and 28 ms in the lateral aspect of the epicardial outflow tract in two patients and by 24 ms near the posterolateral mitral annulus in one patient; in two patients with sustained VT, endocardial mapping during tachycardia displayed a focal pattern with a wide breakthrough, and epicardial mapping showed a macroreentrant VT with an isthmus located in the left anterior wall in one patient and in the Katheterablation von subepikardialen ventrikulären Tachykardien mit Hilfe von elektroanatomischem Mapping fully reablated in one patient and treated with oral amiodarone in the other. Conclusion: Subepicardial left focal and macroreentrant VT may present as focal origin on endocardial mapping and can only be abolished by radiofrequency (RF) applications in the epicardial space.
A Nonfluoroscopic Catheter-Based Mapping Technique to Ablate Focal Ventricular Tachycardia
Pacing and Clinical Electrophysiology, 1998
NADEMANEE, K., ET AL.: A Nonfluoroscopic Catheter-Based Mapping Technique to Ahlate Focal Ventricular Tachycardia. The recent introduction of a nonfluoroscopic ehc:troanatoinica! cardiac mapping system (CAHTO) is an exciting development in catheter ablation treatment of cardiac anhythmias. The system uses ultralow magnetic fields to locate a sensor positioned near tbe tip of a regular mapping and ablation catheter. The catheter location and electrograms are recorded and reconstructed in real-time and presented as a three-dimensional geonietrical mapped color coded witb tbe electropbysiological information. Tbe CARTO represents an important tool to guide tbe ablation of patients who bave focal taebycardia (e.g.. rigbt ventricular outflow tract [RVOTl taebycardia and idiopatbic left ventricular [ILV] taebycardia). Tbis study describes bow tbe CARTO system is useful in mapping and ablating tbese arrbytbmias. Two case illustrations, one patient witb RVOT taebycardia and anotber witb ILV taebycardia, are described in tbis article. Tbe tachycardia was mapped and ablated using tbe new electromagnetic catbeter tecbnology creating an electroanatomical map of tbe arrhyibmia focus for eacb tachycardia witbout fluoroscopy; botb tacbycardias were successfully ablated, terminated, and rendered nonindueible. The CARTO system is useful in mapping and guiding tbe ablation of focal taebycardia and merits furtber study.
Europace, 2006
Aims For ablation of ventricular tachycardia (VT) in patients after myocardial infarction, a threedimensional mapping system is often used. We report on our overall success rate of VT ablation using CARTO in 47 patients, with a subgroup analysis comparing VT mapping with the results of mapping that had to be performed during sinus rhythm or pacing (substrate mapping). Methods and results A CARTO map was performed and VT ablation attempted using two strategies: Patients in the VT-mapping group had incessant VT (four patients) or inducible stable VT (18 patients) such that the circuit of the clinical VT could be reconstructed using CARTO. During VT, the critical area of slow conduction was identified using diastolic potentials and conventional concealed entrainment pacing. In contrast, patients in the substrate-mapping group had initially inducible VT. However, a complete VT map was not possible because of catheter-induced mechanical block (six patients) or because haemodynamics deteriorated during the ongoing VT (19 patients). Therefore, pathological myocardium was identified by fragmented, late-and/or low-amplitude (,1.5 mV) bipolar potentials during sinus rhythm or pacing, and the ablation site was primarily determined by pace mapping inside or at the border of this pathological myocardium. Acute ablation success in all patients with regard to noninducibility of the clinical VT or any slower VT was 79% after a single ablation procedure, but increased to 95% after a mean of 1.2 ablation procedures. However, chronic success was 75%, when it was defined as freedom from any ventricular tachyarrhythmia (VT or VF) during a follow-up of 25 + 13 months. In the subgroup analysis, patients in the VT-mapping group were not significantly different from patients in the substrate-mapping group with regard to age (65+7 vs. 65+9 years), ejection fraction (30+7 vs. 30 + 8%), VT cycle length (448 + 81 vs. 429 + 82 ms), number of radiofrequency applications (17+9 vs. 14+6 applications), use of an irrigated tip catheter (23 vs. 32%), and ablation results. Conclusion When using a CARTO-guided approach for VT ablation in patients with coronary artery disease, the freedom from any ventricular arrhythmia is high (75%), but leaves the patient at a 23% risk of developing fast VT/VF during follow-up. Mapping during sinus rhythm or pacing is as successful as mapping during VT.