Non-fluoroscopic catheter-based mapping systems in cardiac electrophysiology—from approved clinical indications to novel research usage (original) (raw)
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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.
Anadolu kardiyoloji dergisi : AKD = the Anatolian journal of cardiology, 2002
This review enlightens the application issues of the novel CARTO electroanatomic mapping system (Biosense Webster, Diamond Bar, CA, USA) in both research and clinical electrophysiology. It is a very useful tool in catheter ablation procedures in patients with sustained atrial tachycardias, macroreentrant atrial arrhythmias after surgical correction of congenital heart disease, and ventricular tachycardia in the setting of previous myocardial infarction or other structural heart disease. It can also be useful in other types of arrhythmias, including isthmus dependent atrial flutter and idiopathic ventricular tachycardia, by guiding the ablation procedure and limiting fluoroscopy. The major drawbacks for more widespread use of electroanatomic mapping at present time include the inability to map nonsustained arrhythmias and the associated high costs of the mapping system.
electroanatomical imaging of cardiac electrophysiology
O Ob bj je ec ct ti iv ve e: : More than two decades of research work have shown that magnetocardiographic mapping (MCG) is reliable for non-invasive three-dimensional electroanatomical imaging (3D-EAI) of arrhythmogenic substrates. Magnetocardiographic mapping is now become appealing to interventional electrophysiologists after recent evidence that MCG-based dynamic imaging of atrial arrhythmias could be useful to classify patients with atrial fibrillation (AF) before ablation and to plan the most appropriate therapeutic approach. This article will review some key-points of 3D-EAI and discuss what is still missing to favor clinical applicability of MCG-based 3D-EAI. M Me et th ho od ds s: : Magnetocardiographic mapping is performed with a 36-channel unshielded mapping system, based on DC-SQUID sensors coupled to second-order axial gradiometers (pick-up coil 19 mm and 55-70 mm baselines; sensitivity of 20 fT/√Hz in above 1 Hz), as part of the electrophysiologic investigation protocol, tailored to the diagnostic need of each arrhythmic patient. More than 500 arrhythmic patients have been investigated so far. R Re es su ul lt ts s: : The MCG-based 3D-EAI has proven useful to localize well-confined arrhythmogenic substrates, such as focal ventricular tachycardia or preexcitation, to understand some causes for ablation failure, to study atrial electrophysiology including spectral analysis and localization of dominant frequency components of AF. However, MCG is still missing software tools for automatic and/or interactive 3D imaging, and multimodal data fusion equivalent to those provided with systems for invasive 3D electroanatomical mapping. C Co on nc cl lu us si io on n: : Since there is an increasing trend to favor interventional treatment of arrhythmias, clinical application of MCG 3D-EAI is foreseen to improve preoperative selection of patients, to plan the appropriate interventional approach and to reduce ablation failure. (Anadolu Kardiyol Derg 2007: 7 Suppl 1; 23-8) K Ke ey y w wo or rd ds s: : magnetocardiography, body surface cardiac mapping, electroanatomical imaging, mathematical modeling, atrial fibrillation, catheter ablation ABSTRACT Riccardo Fenici, Donatella Brisinda
International Journal of Cardiovascular Imaging, 2006
O Ob bj je ec ct ti iv ve e: : More than two decades of research work have shown that magnetocardiographic mapping (MCG) is reliable for non-invasive three-dimensional electroanatomical imaging (3D-EAI) of arrhythmogenic substrates. Magnetocardiographic mapping is now become appealing to interventional electrophysiologists after recent evidence that MCG-based dynamic imaging of atrial arrhythmias could be useful to classify patients with atrial fibrillation (AF) before ablation and to plan the most appropriate therapeutic approach. This article will review some key-points of 3D-EAI and discuss what is still missing to favor clinical applicability of MCG-based 3D-EAI. M Me et th ho od ds s: : Magnetocardiographic mapping is performed with a 36-channel unshielded mapping system, based on DC-SQUID sensors coupled to second-order axial gradiometers (pick-up coil 19 mm and 55-70 mm baselines; sensitivity of 20 fT/√Hz in above 1 Hz), as part of the electrophysiologic investigation protocol, tailored to the diagnostic need of each arrhythmic patient. More than 500 arrhythmic patients have been investigated so far. R Re es su ul lt ts s: : The MCG-based 3D-EAI has proven useful to localize well-confined arrhythmogenic substrates, such as focal ventricular tachycardia or preexcitation, to understand some causes for ablation failure, to study atrial electrophysiology including spectral analysis and localization of dominant frequency components of AF. However, MCG is still missing software tools for automatic and/or interactive 3D imaging, and multimodal data fusion equivalent to those provided with systems for invasive 3D electroanatomical mapping. C Co on nc cl lu us si io on n: : Since there is an increasing trend to favor interventional treatment of arrhythmias, clinical application of MCG 3D-EAI is foreseen to improve preoperative selection of patients, to plan the appropriate interventional approach and to reduce ablation failure. (Anadolu Kardiyol Derg 2007: 7 Suppl 1; 23-8) K Ke ey y w wo or rd ds s: : magnetocardiography, body surface cardiac mapping, electroanatomical imaging, mathematical modeling, atrial fibrillation, catheter ablation ABSTRACT Riccardo Fenici, Donatella Brisinda
Heart Rhythm, 2009
BACKGROUND Mapping of regular cardiac arrhythmias is frequently performed using sequential point-by-point annotation of local activation relative to a fixed timing reference. Assigning a single activation for each electrogram is unreliable for fragmented, continuous, or double potentials. Furthermore, these informative electrogram characteristics are lost when only a single timing point is assigned to generate activation maps. OBJECTIVE The purpose of this study was to develop a novel method of electrogram visualization conveying both timing and morphology as well as location of each point within the chamber being studied. METHODS Data were used from six patients who had undergone electrophysiological study with the Carto electroanatomic mapping system. Software was written to construct a three-dimensional surface from the imported electrogram locations. Electrograms were time gated and displayed as dynamic bars that extend out from this surface, changing in length and color according to the local electrogram voltage-time relationship to create a ripple map of cardiac activation. RESULTS Ripple maps were successfully constructed for sinus rhythm (n ϭ 1), atrial tachycardia (n ϭ 3), and ventricular tachycardia (n ϭ 2), simultaneously demonstrating voltage and timing information for all six patients. They showed low-amplitude continuous activity in four of five tachycardias at the site of successful ablation, consistent with a reentrant mechanism. CONCLUSION Ripple mapping allows activation of the myocardium to be tracked visually without prior assignment of local activation times and without interpolation into unmapped regions. It assists the identification of tachycardia mechanism and optimal ablation site, without the need for an experienced computer-operating assistant.
Pace-pacing and Clinical Electrophysiology, 1998
The purpose of the study was to validate, in patients, the accuracy of magnetocardiography (MCG) for three-dimensional localization of an amagnetic catheter (AC) for multiple monophasic action potential (MAP) with a spatial resolution of 4 mm2. The AC was inserted in five patients after routine electrophysiological study. Four MAPs were simultaneously recorded to monitor the stability of endocardial contact of the AC during the MCG localization. MAP signals were band-pass filtered DC-500 Hz and digitized at 2 KHz. The position of the AC was also imaged by biplane fluoroscopy (XR), along with lead markers. MCG studies were performed with a multichannel SQUID system in the Helsinki BioMag shielded room. Current dipoles (5mm; 10mA), activated at the tip of the AC, were localized using the equivalent current dipole (ECD) model in patient-specific boundary element torso. The accuracy of the MCG localizations was evaluated by: (1) anatomic location of ECD in the MRI, (2) mismatch with XR. The AC was correctly localized in the right ventricle of all patients using MRI. The mean three-dimensional mismatch between XR and MCG localizations was 6 ± 2 mm (beat-to-beat analysis). The coefficient of variation of three-dimensional localization of the AC was 1.37% and the coefficient of reproducibility was 2.6 mm. In patients, in the absence of arrhythmias, average local variation coefficients of right ventricular MAP duration at 50% and 90% ofrepolarization, were 7.4% and 3.1%, respectively. This study demonstrates that with adequate signal-to-noise ratio, MCG three-dimensional localizations are accurate and reproducible enough to provide nonfluoroscopy dependant multimodal imaging for high resolution endocardial mapping of monophasic action potentials.
Cardiac mapping: utility or futility?
Indian pacing and electrophysiology journal, 2002
Cardiac mapping is a broad term that covers several modes of mapping such as body surface, 1 endocardial, 2 and epicardial 3 mapping. The recording and analysis of extracellular electrograms, reported as early as 1915, forms the basis for cardiac mapping. 4 More commonly, cardiac mapping is performed with catheters that are introduced percutaneously into the heart chambers and sequentially record the endocardial electrograms with the purpose of correlating local electrogram to cardiac anatomy. These electrophysiological catheters are navigated and localized with the use of fluoroscopy. Nevertheless, the use of fluoroscopy for these purposes may be problematic for a number of reasons, including: 1) the inability to accurately associate intracardiac electrograms with their precise location within the heart; 2) the endocardial surface is invisible using fluoroscopy and the target sites can only be approximated by their relationship with nearby structures such as ribs, blood vessels, and the position of other catheters; 3) due to the limitations of two-dimensional fluoroscopy, navigation is not exact, time consuming, and requires multiple views to estimate the three-dimensional location of the catheter; 4) inability to accurately return the catheter precisely to a previously mapped site; and 5) exposure of the patient and medical team to radiation. Newer mapping systems have revolutionized the clinical electrophysiology laboratory in recent years and have offered new insights into arrhythmia mechanisms. They are aimed at improving the resolution, three-dimensional spatial localization, and/or rapidity of acquisition of cardiac activation maps. These systems use novel approaches to accurately determine the threedimensional location of the mapping catheter and local electrograms are acquired using conventional, well-established methods. Recorded data of the catheter location and intracardiac electrogram at that location are used to reconstruct in real-time a representation of the threedimensional geometry of the chamber, color-coded with relevant electrophysiological information. However, these mapping systems are very expensive and not required for the commoner clinical arrhythmias like atrioventricular nodal reentry (AVNRT), accessory pathway mediated tachycardia (WPW syndrome and concealed pathways) and typical atrial flutter. The purpose of this article is to discuss the possible contribution of newer cardiac mapping system to treat various arrhythmias.
International Congress Series, 2007
Catheter ablation has significantly changed the diagnostic approach and the treatment of cardiac arrhythmias. Being the appropriate localization of the arrhythmogenic target a key-point for effective ablation, new technologies have been recently developed, for three-dimensional (3D) electroanatomical imaging during ablation procedures. However all of them are invasive and cannot be used for preoperative assessment and localization of arrhythmogenic substrates. Magnetocardiographic mapping (MCG) on the contrary is a feasible method, which provide 3D electroanatomical imaging of cardiac sources non-invasively, therefore it can be repeated on ambulatory patients, to define the characteristics of the arrhythmogenic substrate before intervention. MCG detection of electrophysiologic (EP) abnormalities and 3D electroanatomical imaging of arrhythmogenic substrates can be enhanced by simultaneous EP study with amagnetic trans-esophageal atrial pacing. Alternatively minimally invasive, single-catheter multiple monophasic action potential recordings (Multi-MAP) can be aimed at the arrhythmogenic targets identified by MCG. The MCG-guided Multi-MAP EP study is also useful for direct validation of MCG estimate of atrial and ventricular de-repolarization by comparison with simultaneous MAP recordings in sinus rhythm and under pacing. Future robotic navigation of an ablation catheter guided by 3D MCG coordinates of the arrhythmogenic target is foreseeable.
2011
Background-Scar heterogeneity identified with contrast-enhanced cardiac magnetic resonance (CE-CMR) has been related to its arrhythmogenic potential by using different algorithms. The purpose of the study was to identify the algorithm that best fits with the electroanatomic voltage maps (EAM) to guide ventricular tachycardia (VT) ablation. Methods and Results-Three-dimensional scar reconstructions from preprocedural CE-CMR study at 3T were obtained and compared with EAMs of 10 ischemic patients submitted for a VT ablation. Three-dimensional scar reconstructions were created for the core (3D-CORE) and border zone (3D-BZ), applying cutoff values of 50%, 60%, and 70% of the maximum pixel signal intensity to discriminate between core and BZ. The left ventricular cavity from CE-CMR (3D-LV) was merged with the EAM, and the 3D-CORE and 3D-BZ were compared with the corresponding EAM areas defined with standard cutoff voltage values. The best match was obtained when a cutoff value of 60% of the maximum pixel signal intensity was used, both for core (r 2 ϭ0.827; PϽ0.001) and BZ (r 2 ϭ0.511; Pϭ0.020), identifying 69% of conducting channels (CC) observed in the EAM. Matching improved when only the subendocardial half of the wall was segmented (CORE: r 2 ϭ0.808; PϽ0.001 and BZ: r 2 ϭ0.485; Pϭ0.025), identifying 81% of CC. When comparing the location of each bipolar voltage intracardiac electrogram with respect to the 3D CE-CMR-derived structures, a Cohen coefficient of 0.70 was obtained. Conclusions-Scar characterization by means of high resolution CE-CMR resembles that of EAM and can be integrated into the CARTO system to guide VT ablation. (Circ Arrhythm Electrophysiol. 2011;4:674-683.)
Global Electrophysiological Mapping of the Atrium: Computerized Three-Dimensional Mapping System
Pacing and Clinical Electrophysiology, 1997
RODEFELD, M.D., ET AL.: Global Electrophysiological Mapping of the Atrium: Computerized Three-Dimensional Mapping System. The atria are anatomically complex three-dimensional (3-D) structures. Impulse propagation is dynamic and complex during both normal conduction and arrhythmia, Atrial activation has traditionally been represented on two-dimensional surface maps, which have inherent inaccuracies and are difficult to interpret. Interactive computerized 3-D display facilitates interpretation of complex atrial activation sequence data obtained from form-fitting multipoint electrodes. Accordingly, the purpose of this article is to describe the application of 3-D form-fitting electrode molds to the 3-D mapping and display system developed in this laboratory for the study of complex cardiac arrhythmias. Computer generated 3-D surface models are created from a database of serial cross-sectional anatomical images. Points chosen on endocardia} and epicardial surfaces in each cross-sectional image are processed to create polygons defining myocardial wall boundaries. The polygons from adjacent serial images are then combined, to create a 3-D surface model. The discrete anatomical locations of unit electrodes on multipoint electrode templates are then assigned in the proper position on the surface model. Computer analysis of simultaneous activation data from each unit electrode is performed based on parameters set by the user. Activation data from each unit electrode site are displayed on the computer surface model in a color spectrum correlating with a user-defined time scale. Activation sequence maps can be visualized as static isochrone maps, interval maps, or as dynamic maps at variable speeds, from any 3-D perspective. Thus, an interactive computerized 3-D display system is described, which allows anatomically superior analysis and interpretation of complex atrial arrhythmias. (PACE 1997; 20[Pt, I]:2227 20[Pt, I]: -2236 computerized mapping, atrial, cardiac, three-dimensional