Journal of Interventional Cardiac Electrophysiology

, Volume 49, Issue 3, pp 319–326 | Cite as

A novel 3D anatomic mapping approach using multipoint high-density voltage gradient mapping to quickly localize and terminate typical atrial flutter

  • William C. Choe
  • Sri Sundaram
  • J. Ryan Jordan
  • Nate Mullins
  • Charles Boorman
  • Austin Davies
  • Alex C. Tiftickjian
  • Sunil Nath
Article
  • 257 Downloads

Abstract

Purpose

The purposes of the study were to evaluate and characterize the cavotricuspid isthmus using multipoint high density voltage gradient mapping (HD-VGM) to see if this would improve on current ablation techniques compared to standard cavotricuspid isthmus ablation techniques.

Methods

Group 1, 25 patients who underwent ablation using standard methods of 3D mapping and ablation, was compared to group 2, 33 patients undergoing ablation using HD-VGM and ablation. Using this method, we are able to identify the maximum voltage areas within isthmus and target it for ablation. Total procedure times, ablation times and number of lesions, distance ablated, and fluoroscopy times were compared.

Results

Fifty-eight patients were included in this study. Compared to group 1, in group 2, HD-VGM decreased the total ablation time 18.2 ± 9.2 vs 8.3 ± 4.0 min (p < 0.0001), total ablation lesions 22.7 ± 18.8 vs 5.5 ± 4.2 (p < 0.0001), and the length of the ablation lesions was significantly shorter 47.0 mm ± 13 mm vs 32.6 mm ± 10.0 mm (p < 0.0001). While the average length of the CTI was similar, 47.0 mm ± 13 mm vs 46.1 mm ± 10.0 mm (p 0.87), in group 2, only 71% of the isthmus was ablated.

Conclusion

Multipoint high density voltage gradient mapping can help identify maximum voltage areas within the isthmus and when ablated can create bidirectional block with decreased ablation times and length of the lesion.

Keywords

Typical atrial flutter Radiofrequency ablation 3D anatomic mapping High density mapping Voltage gradient mapping Catheter ablation 

Abbreviations

AF

Atrial fibrillation

HD-VGM

High density activation sequence mapping with voltage gradient mapping

AFL

Typical atrial flutter

LA

Left atrium

RA

Right atrium

CS

Coronary sinus

LAT

Local activation timing

RAI

Roving activation interval

Low V ID

Low voltage identification

RF

Radiofrequency

References

  1. 1.
    Jolly WA, Ritchie WT: Auricular Flutter and Fibrillation Heart. 1910–1911 2 177.Google Scholar
  2. 2.
    Lewis T. Observations on a curious and Not Uncommon Form of Extreme Acceleration of the Auricle. “Auricular Flutter.”. Heart. 1912–1913;4:–171.Google Scholar
  3. 3.
    Blackford JM, Willius F. Auricular Flutter. Arch Int Med. 1918;21:p147–65.CrossRefGoogle Scholar
  4. 4.
    Olshansky B, Okumura K, Hess P, Waldo A. Demonstration of an area of slow conduction in human atrial flutter. J Am Coll Cardiol. 1990;16:1639–48.CrossRefPubMedGoogle Scholar
  5. 5.
    Gami AS, Edwards WD, Lachman N, FriedmanPA TD, Munger TM, Hammill SC, et al. Electrophysiological anatomy of typical atrial flutter: the posterior boundary and causes for difficulty with ablation. J Cardiovasc Electrophysiol. 2010;21:144–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Feld G, Fleck P, Chen PS, Boyce K, Bahnson T, Stein J, et al. Radiofrequency catheter ablation for the treatment of human type 1 atrial flutter. Identification of a critical zone in the reentrant circuit by endocardial mapping techniques. Circulation. 1992;86:1233–40.CrossRefPubMedGoogle Scholar
  7. 7.
    Cosio FG, Lopez-Gil M, Coicolea A, Arribas F, Barroso JL. Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol. 1993;71:705–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Poty H, Saoudi N, Nair M, Anselme F, Letac B. Radiofrequency catheter ablation of atrial flutter. Further insights into the various types of isthmus block: application to ablation during sinus rhythm. Circulation. 1996;94:3204–13.CrossRefPubMedGoogle Scholar
  9. 9.
    Anselme F, Savoure A, Cribier A, Saoudi N. Catheter ablation of typical atrial flutter. A randomized comparison of 2 methods for determining complete bidirectional isthmus block. Circulation. 2001;103:1434–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Ensite Velocity System Instructions for Use 2011 v.3.0.1 : p161.Google Scholar
  11. 11.
    Winkle RA, Moskovitz R, Mead RH, Engel G, Kong MH, Fleming W, et al. Ablation of atypical atrial flutter using ultra high density-activation sequence mapping. J Interv Card Electrophysiol. 2017;48:177–84.CrossRefPubMedGoogle Scholar
  12. 12.
    Sundaram S, Choe W, Mullins N, Boorman C, Nath S. Catheter ablation of atypical atrial flutter: a novel 3D anatomic approach to quickly localize and terminate atypical atrial flutter. Poster Presentation HRS May 2016. PO 003–110. Heart Rhythm, Vol.13, No.5 May Supplement 2016: S295.Google Scholar
  13. 13.
    Cosio F, Lopez-Gil M, Goicolea A, Arribas F. Electrophysiologic Studies in Atrial Flutter. Clin Cardiol. 15:667–73.Google Scholar
  14. 14.
    Olgin J, Kalman J, Fitzpatrick A, Lesh M. Role of right atrial endocardial structures as barriers to conduction during human type I atrial flutter. Activation and entrainment mapping guided by Intracardiac echocardiography. Circulation. 1995;92:1839–48.CrossRefPubMedGoogle Scholar
  15. 15.
    Klein GJ, Guiraudon GM, Sharma AD, Milstein S. Demonstration of macroreentry and feasibility of operative therapy in the common type of atrial flutter. Am J Cardiol. 1986;57:587–91.CrossRefPubMedGoogle Scholar
  16. 16.
    Saoudi N, Atallah G, Kirkorian G, Touboul P. Catheter ablation of the atrial myocardium in human type I atrial flutter. Circulation. 1990;81:762–71.CrossRefPubMedGoogle Scholar
  17. 17.
    Asirvatham SJ. Correlative anatomy and electrophysiology for the interventional electrophysiologist: right atrial flutter. J Cardiovasc Electrophysiol. 2009;20:113–22.CrossRefPubMedGoogle Scholar
  18. 18.
    Redfearn DP, Skanes AC, Gula LJ, Krahn AD, Yee R, Klein GJ. Cavotricuspid isthmus conduction is dependent on underlying anatomic bundle architecture: observations using a maximum voltage-guided ablation technique. J Cardiovasc Electrophysiol. 2006;17:823–38.CrossRefGoogle Scholar
  19. 19.
    Bailin SJ, Johnson WB, Jumrussirkul P, Sorentino D, West R. A new methodology for atrial flutter ablation by direct visualization of cavotricuspid conduction with voltage gradient mapping: a comparison to standard technique. Europace. 2013;15:1013–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Maruyama M, Kobayashi Y, Miyauchi Y, Iwasaki Y, Morita N, Miyamoto S, et al. Mapping-guided ablation of the cavotricuspid isthmus: a novel simplified approach to radiofrequency catheter ablation of isthmus-dependent atrial flutter. Heart Rhythm. 2006;3:665–73.CrossRefPubMedGoogle Scholar
  21. 21.
    Subbiah RN, Gula LJ, Krahn AD, Posan E, Yee R, Klein GJ, et al. Rapid ablation for atrial flutter by targeting maximum voltage-factors associated with short ablation times. J Cardiovasc Electrophysiol. 2007;18:612–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Gula LJ, Redfearn DP, Veenjuyzen GD, Krahn AD, Yee R, Klein GJ, et al. Reduction in atrial flutter ablation time by targeting maximum voltage: results of a prospective randomized clinical trial. J Cardiovasc Electrophysiol. 2009;20:1108–12.CrossRefPubMedGoogle Scholar
  23. 23.
    Lewalter T, Lickfett L, Weiss C, Mewis C, Spencker S, Jung W, et al. “largest amplitude ablation” is the optimal approach for typical atrial flutter ablation: a subanalysis from the AURUM 8 study. J Cardiovasc Electrophysiol. 2012;23:479–85.CrossRefPubMedGoogle Scholar
  24. 24.
    Mechulan A, Gula LJ, Klein GJ, Leong-Sit P, Obeyesekere M, Krahn AD, et al. Further evidence for the “muscle bundle” hypothesis of Cavotricuspid isthmus conduction: physiological proof, with clinical implications for ablation. J Cardiovasc Electrophysiol. 2013;24:47–52.CrossRefPubMedGoogle Scholar
  25. 25.
    Cabrera JA, Sanchez-Quintana D, Ho SY, Medina A, Wanguemert F, Gross E, et al. Angiographic anatomy of the inferior right atrial isthmus in patients with and without history of common atrial flutter. Circulation. 1999;99:3017–23.CrossRefPubMedGoogle Scholar
  26. 26.
    Boineau JP, Schuessler RB, Mooney CR, Miller CB, Wylds AC, Hudson RD, et al. Natural and evoked atrial flutter due to circus movement in dogs: role of abnormal pathways, slow conduction, nonuniform refractory period distribution and premature beats. Am J Cardiol. 1980;45:1167–81.CrossRefPubMedGoogle Scholar
  27. 27.
    Waki K, Saito Tsukasa S, Becker AE. Right atrial flutter isthmus revisited: normal anatomy favors nonuniform anisotropic conduction. J Cardiovasc Electrophysiol. 2000;11:90–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Cabrera JA, Sanchez-Quintana D, Ho SY, Medina A, Anderson RH. The architecture of the atrial musculature between the orifice of the inferior Caval vein and the tricuspid valve: the anatomy of the isthmus. J Cardiovasc Electrophysiol. 1998;9:1186–95.CrossRefPubMedGoogle Scholar
  29. 29.
    Scaglione M, Caponi D, Di Donna P, Riccardi R, Bocchiardo M, Azzaro G, et al. Typical atrial flutter ablation outcome: correlation with isthmus anatomy using intracardiac echo 3D reconstruction. Europace. 2004;6:407–17.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.South Denver Cardiology AssociatesLittletonUSA
  2. 2.St Jude MedicalSt PaulUSA
  3. 3.Porter Adventist HospitalDenverUSA
  4. 4.Colorado Springs CardiologistsColorado SpringsUSA

Personalised recommendations