DR HIMAL RAJM SR CARDIOLOGY Contents History Electrophysiological mapping Mapping techniques Mapping sites History Josephson et al endocardial catheter mapping of VT Huang et al1985 radiofrequency catheter ablation ID: 1046918
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1. Electrophysiological study- mapping TECHNIQUESDR HIMAL RAJ.MSR CARDIOLOGY
2. Contents HistoryElectrophysiological mappingMapping techniquesMapping sites
3. History Josephson et al- endocardial catheter mapping of VTHuang et al,1985- radiofrequency catheter ablationSternick EB, Gerken LM, Vrandecic MO. Appraisal of ‘Mahaim’ automatic tachycardia. J Cardiovasc Electrophysiol 2002;13:244–9.
4. Electrophysiological mapping
5. Mappingto localize site of origin of abnormal beats orto identify tachycardia circuit in case of reentrant arrhythmiasMapping proceduresPace MappingActivation Sequence MappingVoltage mapping( Substrate / Fractionated electrogram )Entrainment MappingMiscellaneousKlein LS, Shih H-T, Hackett FK, Zipes DP, Miles WM. Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease. Circulation 1992; 85: 1666–74
6. Pace mappingto locate tachycardia sources by stimulating at different endocardial sites to reproduce clinical tachycardia characteristicsManipulation of mapping catheter to region of origin of tachycardiaPace at this site at same cycle length as tachycardiaGreater the concordance b/w tachycardia and morphology during pacing - closer exit siteKlein LS, Shih H-T, Hackett FK, Zipes DP, Miles WM. Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease. Circulation 1992; 85: 1666–74
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8. Look for 12/12 matchMore useful in ventricular tachycardia as QRS morphology easier to compareAllows to home in on region of interest - cannot pinpoint site for ablationDoes not require tachycardia to sustain over a longer time
9. Pace Map 12/12 MatchKlein LS, Shih H-T, Hackett FK, Zipes DP, Miles WM. Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease. Circulation 1992; 85: 1666–74
10. Activation sequence mappingRequired to pinpoint focus of tachycardiaDuring tachycardia - mapping catheter explores endocardium - to identify site where earliest electrogram relative to a fixed reference is recorded
11. Suitable siteLocal electrogram precedes any other activityOne from which any movement results in a later electrogramOne at which unipolar electrogram shows a sharp initial negative deflectionKlein LS, Shih H-T, Hackett FK, Zipes DP, Miles WM. Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease. Circulation 1992; 85: 1666–74
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14. To create activation map- points are color-codedwhite and red for earliest electrical activation areas orange, yellow, green, blue and purple for progressively delayed activation areasBetween these points-colors are interpolated and adjoining triangles are colored with these interpolated values
15. Propagation mapActivation sequence in mapped chamber can also be represented as propagation mapin which whole chamber is blue and electrical activation waves are seen in red, spreading throughout chamber as a loop(manually done in ENSITE)
16. Substrate( Voltage) MappingScarred Myocardium has Low Voltage0.5 mV or Less - Dense Scar0.5 – 1.5 mV - Borderline Zone> 1.5 mv - Normal areaMcClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H et al. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994;89:2655–66.
17. Voltage mappingAlso color-codedRed as lowest amplitude and orange, yellow, green, blue and purple indicating progressively higher amplitudesMyocardial scars are seen as low voltage - and their delineation may help in understanding location of arrhythmia
18. Entrainment mappingAllows confirmation of ReentryAllows localization of circuit and isthmus Entrainment is a continuous resetting of a reentrant circuit by a series of stimuliMcClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H et al. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994;89:2655–66.
19. Criteria for EntrainmentConstant fusion during overdrive pacing except for last paced beat which is entrained but not fusedProgressive fusion during overdrive pacingLocalized conduction block to a site for 1 paced beat associated with interruption of tachycardia, followed by activation of that site by next paced beat from a different direction and with a shorter conduction timeDuring pacing at 2 different rates during tachycardia- change in conduction time and EGM morphology at electrode recording site (equivalent of demonstrating progressive fusion - second criterion - with intracardiac electrogram recordings).McClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H et al. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994;89:2655–66
20. Entrainment results in a fusion complexPacing stopped-last one entrained but goes round circuit-morphology similar to original rhythm
21. If pacing CL progressively shortened circuit is invaded to a greater extent-fusion increases
22. A premature paced beat collides with head and tail-fails to propagate Next beat is purely paced and R is activated from a different direction
23. Manifest entrainment- demonstration of resetting with fusionConcealed entrainment- failure to demonstrate fusion but PPI equal to tachycardia cycle length-site protected isthmusPPI equal to TCL (within 20-30 ms)if pacing site within reentrant circuitPost pacing interval-interval b/w last pacing stimulus that entrained tachycardia and next recorded EGM at pacing site
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25. Manifest Entrainment with FusionPremature impulse invade tachycardia circuit.In antidromic direction it collides and extinguishes reentrant wavefront. In orthodromic direction it creates a new wavefront(resets).
26. Area of slow conduction : IsthmusConcealed FusionAntidromic wave front does not contribute much to morphology of tachycardia beat
27. Concealed FusionPost Pacing IntervalIf paced from the critical Isthmus PPI = TCL
28. Determining Pacing SiteHow to Determine if the Pacing Site is Within the CircuitPost Pacing IntervalQRS Configuration during EntrainmentS-QRS Interval During Entrainment with Concealed FusionStevenson Et al. Entrainment Techniques for Mapping Atrial and Ventricular Tachycardias. JCE 6(3) March 1995; 201-216
29. Post Pacing IntervalPace at rates slightly faster than TCL - measure local activation time from last paced beat to local EGM at pacing siteIndication of proximity of pacing site to reentry circuit - time from stimulus to next nonstimulated depolarizationPPI for ischemic VT should be within 30ms20ms in atrial flutter circuitsMcClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H et al. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994;89:2655–66.
30. Types of mapping site
31. Types of Mapping SitesRemote BystandersAdjacent BystandersOuter Loop SitesExit SiteCentral, Proximal, and Inner Loop SitesAlbert L. Waldo. Heart Rhythm (2004) 1, 94–106
32. Remote BystanderEntrains with QRS fusionPost Pacing Interval exceeds the Tachycardia Cycle lengthVishal Luther, Michael Koa-Wing. Ventricular Tachycardia Ablation in the Post Infarct Patient. http://bhrs.com/editorial-vt-ablation-in-the-post-infarct-patient
33. Adjacent BystanderPacing entrains tachycardia with concealed fusion.PPI does not approximate TCLS-QRS interval during entrainment does not match electrogram QRS interval during tachycardiaVishal Luther, Michael Koa-Wing. Ventricular Tachycardia Ablation in the Post Infarct Patient. http://bhrs.com/editorial-vt-ablation-in-the-post-infarct-patient
34. Outer Loop SitesPPI matches TCLPacing at these sites produce QRS fusionVishal Luther, Michael Koa-Wing. Ventricular Tachycardia Ablation in the Post Infarct Patient. http://bhrs.com/editorial-vt-ablation-in-the-post-infarct-patient
35. Exit SitePacing produces entrainment with concealed fusionPPI matches TCLS-QRS interval < 30% of TCLStevenson Et al. Entrainment Mapping. JACC 29 (6) May 2007: 1180-9
36. Central, Proximal, and Inner Loop SitesAs the pacing site is moved further from the exit to more proximal sites the S-QRS interval increases.If the S-QRS interval is>31-50% of the tachycardia cycle length they are designated as central sites51-70% of the tachycardia cycle length they are designated as proximal sites>70% of the tachycardia cycle length they are designated as Inner Loop sitesStevenson Et al. Entrainment Mapping. JACC 29 (6) May 2007: 1180-9
37. McClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H et al. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994;89:2655–66.
38. Advanced mapping systemsElectro anatomic mapping-CARTO systemMetal coil placed in a magnetic fieldCatheter contains a location sensor in tip3D map created by placing catheter in known anatomic positionsLocal electrogram at each point superimposed on anatomical map to give a color coded activation map
39. Non contact mapping-ENSITEMulti electrode array probe with 64 non contact electrodesEndocardial boundaries defined with conventional mapping catheter3D Endocardial potential map created from single cardiac cycleMcClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H et al. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994;89:2655–66.
40. Basket catheter Ensite array
41. Magnetic navigation systemAblation catheter guided and positioned by magnetic fields to a desired site within cardiac chamber
42. 3D anatomical mapping system
43. Newer techniques -- 3DCreating and displaying 3D image of heart chambers Displaying in multiple colors activation sequence of electrical signals of heart chambersVisualizing physical point of origin of arrhythmia accurately
44. ADVANTAGE OF 3DManaging complex arrhythmias, postoperative cases with altered anatomy and single beat non-sustained arrhythmias
45. ENSITECARTORMP
46. Site of placement of electrodes
47. Anatomical shellFollowing selection of anatomic reference - mapping catheter positioned in mapping chamber under fluoroscopic guidanceCatheter initially positioned at known anatomic points - serve as landmarks for electroanatomic map eg:to map right atrium, points such as SVC, IVC, His and CS os
48. Catheter tip advanced slowly along different walls Analysis of anatomic position of these points - generate real-time 3-D models on a monitor display Selected points connected by lines to form several adjoining triangles in a global model of chamber
49. RA anatomical chamber
50. LA anatomical mapping
51. LA anatomical mapping
52. Bi-atrial anatomical chamber
53. LV Anatomical shell
54. Biatrial anatomical chamber
55. LA mapping :-Earliest activation from the RSPV
56. LA mapping :- Earliest activation from the RSPV
57. RVOT VT activation
58. CARTOCombined electroanatomic means of mapping cardiac arrhythmias Patient is positioned over a tripod emitting three electromagnetic waves at unique frequencies Each beam is registered by one of three specifically tuned coils embedded in mapping catheter tip to specify location in 3D space
59. CARTOAn electrogram recorded at that site is thereby archived within that positional context Direction of catheter tip, along with its pitch, yaw, and roll altitude creates a orientation vectorLocal tissue activation at each successive recording site produces activation maps within framework of acquired surrogate geometry
60. CARTO principle magnetic mapping
61. Carto catheter position
62. Carto
63. CARTO view from all postions
64. RMP Mapping Systembased on ultrasound-distance ranging. Real-time Position ManagementThree catheters-fitted with microtransducers- positioned into right ventricle and coronary sinus- with a third catheter used as a roving ablation or mapping catheter
65. Newer ModalitiesNavXRHYTHMIAREMOTE NAVIGATION SYSTEMSREAL TIME IMAGING
66. M