Visualizing Localized Reentry With Ultra-High Density Mapping in Iatrogenic Atrial Tachycardia Beware Pseudo-Reentry
File(s)
Author(s)
Type
Journal Article
Abstract
Background—The activation pattern of localized reentry (LR) in atrial tachycardia remains incompletely understood. We used the ultra–high density Rhythmia mapping system to study activation patterns in LR.
Methods and Results—LR was suggested by small rotatory activations (carousels) containing the full spectrum of the color-coded map. Twenty-three left-sided atrial tachycardias were mapped in 15 patients (age: 64±11 years). 16 253±9192 points were displayed per map, collected over 26±14 minutes. A total of 50 carousels were identified (median 2; quartiles 1–3 per map), although this represented LR in only n=7 out of 50 (14%): here, rotation occurred around a small area of scar (<0.03 mV; 12±6 mm diameter). In LR, electrograms along the carousel encompassed the full tachycardia cycle length, and surrounding activation moved away from the carousel in all directions. Ablating fractionated electrograms (117±18 ms; 44±13% of tachycardia cycle length) within the carousel interrupted the tachycardia in every LR case. All remaining carousels were pseudo-reentrant (n=43/50 [86%]) occurring in areas of wavefront collision (n=21; median 0.5; quartiles 0–2 per map) or as artifact because of annotation of noise or interpolation in areas of incomplete mapping (n=22; median 1, quartiles 0–2 per map). Pseudo-reentrant carousels were incorrectly ablated in 5 cases having been misinterpreted as LR.
Conclusions—The activation pattern of LR is of small stable rotational activations (carousels), and this drove 30% (7/23) of our postablation atrial tachycardias. However, this appearance is most often pseudo-reentrant and must be differentiated by interpretation of electrograms in the candidate circuit and activation in the wider surrounding region.
Methods and Results—LR was suggested by small rotatory activations (carousels) containing the full spectrum of the color-coded map. Twenty-three left-sided atrial tachycardias were mapped in 15 patients (age: 64±11 years). 16 253±9192 points were displayed per map, collected over 26±14 minutes. A total of 50 carousels were identified (median 2; quartiles 1–3 per map), although this represented LR in only n=7 out of 50 (14%): here, rotation occurred around a small area of scar (<0.03 mV; 12±6 mm diameter). In LR, electrograms along the carousel encompassed the full tachycardia cycle length, and surrounding activation moved away from the carousel in all directions. Ablating fractionated electrograms (117±18 ms; 44±13% of tachycardia cycle length) within the carousel interrupted the tachycardia in every LR case. All remaining carousels were pseudo-reentrant (n=43/50 [86%]) occurring in areas of wavefront collision (n=21; median 0.5; quartiles 0–2 per map) or as artifact because of annotation of noise or interpolation in areas of incomplete mapping (n=22; median 1, quartiles 0–2 per map). Pseudo-reentrant carousels were incorrectly ablated in 5 cases having been misinterpreted as LR.
Conclusions—The activation pattern of LR is of small stable rotational activations (carousels), and this drove 30% (7/23) of our postablation atrial tachycardias. However, this appearance is most often pseudo-reentrant and must be differentiated by interpretation of electrograms in the candidate circuit and activation in the wider surrounding region.
Date Issued
2017-03-29
Date Acceptance
2017-03-01
Citation
CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY, 2017, 10 (4)
ISSN
1941-3149
Publisher
LIPPINCOTT WILLIAMS & WILKINS
Journal / Book Title
CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY
Volume
10
Issue
4
Copyright Statement
© 2017 American Heart Association, Inc. This is a non-final version of an article published in final form in Circulation: Arrhythmia and Electrophysiology: https://dx.doi.org/10.1161/CIRCEP.116.004724
Identifier
http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000399571700005&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=1ba7043ffcc86c417c072aa74d649202
Subjects
Science & Technology
Life Sciences & Biomedicine
Cardiac & Cardiovascular Systems
Cardiovascular System & Cardiology
atrial fibrillation
cardiac electrophysiology
fibrosis
tachycardia, supraventricular
VENTRICULAR-TACHYCARDIA
CATHETER ABLATION
FIBRILLATION ABLATION
FOCAL IMPULSE
PERSISTENT
MECHANISMS
CIRCUITS
ARRHYTHMIAS
INSIGHTS
SCAR
Aged
Atrial Fibrillation
Body Surface Potential Mapping
Catheter Ablation
Cohort Studies
Female
Follow-Up Studies
Humans
Iatrogenic Disease
Male
Middle Aged
Retrospective Studies
Risk Assessment
Severity of Illness Index
Tachycardia, Atrioventricular Nodal Reentry
Tachycardia, Supraventricular
Treatment Outcome
Cardiovascular System & Hematology
Publication Status
Published
Article Number
ARTN e004724