Implication of 3D Mapping in EP

KCGMH 陳勉成 主任

Cardiac Arrhythmias

Indications for Radiofrequency Catheter Ablation

• Wolff-Parkinson-White Syndrome (WPW)• Atrioventricular Nodal Reentrant Tachycardia (AVNRT)• Atrial Flutter• Atrial Fibrillation (AF)• Ventricular Tachycardia (VT)• Atrial Tachycardia (AT)• Others

Sequence of the Flow in a Typical EP and Ablation Procedure

• Preparation of the Patient• Insertion of sheaths and Electrode catheters• Basic EPS study to get the basic data • Induction of the Arrhythmia• Diagnosis of the Arrhythmia• Ablation of the Arrhythmia (if indicated)• Confirmation of Therapy Success

Tachycardia are classified as focal or macro reentrant tachycardia

Focal tachycardia exhibit activation spreading from a single focus either radically, circularly or centrifugally without an electrical activation spanning the tachycardia cycle length (right atrial activation is considerably shorter than the tachycardia cycle length–about 14%)

Classification of Tachycardia

(Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)

Macro reentrant tachycardia typical atrial flutterlower loop reentry, double loop reentry, left atrial macro reentranttachycardia, scar-related AT, reverse typical atrial flutter and right atrial free wall macro reentry

The various patterns are: Single loop (like typical atrial flutter) Figure of eight (made up of two loops) Reentry through narrow channels adjacent to scar,

anatomic barriers (i.e. tricuspid annulus)

Classification of Tachycardia

(Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)

Arrhythmia Mechanisms

• Automaticity• Triggered Activity• Reentry

Everything should be made as simple as possible,

but not simpler.by Albert Einstein

Map Concept

Surface Temperature Animated Propagation Map

Color-coded Isochrones

AnatomicRepresentation

ActivationTimes

“Roving” catheters enable Endocardial isochronal maps

Advantage - percutaneous

procedure

Disadvantage - takes a long time; requires a

stable rhythm

1993 - Isochronal maps

...Electro-anatomic mapping is born

meet 3-D graphics...

meet 3-D graphics...

1995 – Epicardial “plaque” electrodes

move endocardial...• Location of catheter

electrodes, which enables– geometry creation– boundary-element

calculations– navigation

• Detection of cardiac electrical activity

• Combined, these functions enable non-contact mapping

...Graydon Beatty conceives the Array, non-contact mapping, establishes Endocardial Solutions, Inc.

15

≅

16

≅

QuickTime™ and aH.264 decompressor

are needed to see this picture.

24

EnGuide location relative to E1 and E2

How Created the Geometry of Non Contact Map

Identify Anatomy….

One Beat to Analysis Virtual

Unipolar Signal Analysis

Ablation Site and Confirm the Tracing Virtual

If you are an operator,

tell me, where you want to target ?

Successful to Complete line

Double Potentials• Double potentials are indicative of a line of block • Lines of block are either fixed or functional

– Atriotomy sites and the Eustachian ridge are examples of fixed lines of block

– Evidence exists that block in region of Cristal terminals during atrial flutter is a form of functional conduction block

Is True or False DSM ?

2003 - Isochronal maps

Contact Mapping is born

meet 3-D graphics...meet 3-D graphics...

Contact Mapping

Surface-based5.6 kHz (Classic) /8.138KHz. (Velocity) current signalsemitted from 3 pairs of surface electrodesEach catheter electrode located 93 times per secondSimultaneously view up to 12 catheters and 64 electrodesAll chamber navigation

Bipolar Signal and Multiple Catheters

Real Time Navigation• Minimize fluoro with NavX

Create Geometry by any Roving Catheters

LSPV

LIPV

RSPV

RMPV

RIPVLA

CS

RA

IVC

Respiration Compensation

Validation of Computed Tomography Image Integration into the EnSite NavX Mapping System to Perform Catheter Ablation of

Atrial Fibrillation

Journal of Cardiovascular ElectrophysiologyVolume 19, Issue 8, pages 821-827, 26 MAR 2008 DOI: 10.1111/j.1540-8167.2008.01127.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1540-8167.2008.01127.x/full#f1

Journal of Cardiovascular ElectrophysiologyVolume 19, Issue 8, pages 821-827, 26 MAR 2008 DOI: 10.1111/j.1540-8167.2008.01127.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1540-8167.2008.01127.x/full#f1

Validation of Computed Tomography Image Integration into the EnSite NavX Mapping System to Perform Catheter Ablation of

Atrial Fibrillation

No fluoroscopic Three Dimensional Mapping for Arrhythmia Ablation : Tool or Toy ?

Methods We compared the results of 88 arrhythmia ablations (79 patients) using CARTO with 100 ablations (94 patients) using the conventional technique. The ablations were separated into four groups: AV nodal reentrant tachycardia (AVNRT) Atrial tachycardia/flutter ventricular tachycardia (VT) bypass tract tachycardia.

J Cardiovasc Electrohysio, Vol. 11, pp.239-243,March 2000

No fluoroscopic Three Dimensional Mapping for Arrhythmia Ablation : Tool or Toy ?

ResultThe ablation outcomes were excellent and comparable in all four types of the arrhythmias between the two techniques.

Fluoroscopy time was shorter using the CARTO technique: 10 ± 7 versus 27 ± 15 minutes for AVNRT (P <0.01), 18 ± 17 versus 44 ± 23 minutes for atrial tachycardia and flutter (P < 0.01)15 ± 12 versus 34 ± 31 minutes for VT (P < 0.05)21 ± 14 versus 53 ± 32 minutes for by pass tract tachycardia (P < 0.01).

Conclusion The electro anatomic three-dimensional mapping technique reduced fluoroscopy time

J Cardiovasc Electrohysio, Vol. 11, pp.239-243,March 2000

3D for you is …………..?

What do you see ?

Where is the face in this picture?

Do not worry about your difficulties in Mathematics. I can assure you mine are

still greater. by Albert Einstein

THANK YOU FOR YOUR

ATTENATION