How to Distinguish Focal Atrial Tachycardia from Small Circuits and Reentry
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1 How to Distinguish Focal Atrial Tachycardia from Small Circuits and Reentry Pierre Jaïs; Bordeaux, France IHU LIRYC ANR-10-IAHU-04 Equipex MUSIC imaging platform ANR-11-EQPX-0030 Eutraf HEALTH-F HRS May 2014
2 Conflict of interest Consulting fees/honoraria (modest): Biosense Webster Bard Philips ST Jude Medical Stock holder Cardio Insight
3 Surgery for congenital Heart Disease is arrhythmogenic: incomplete linear atrial lesions!! ASD, VSD: Atrial incisions Mustard, Senning: Atrial incisions (Switch arterial? Canulations!) Fallot: canulations Fontan: Atrial incisions Any Heart surgery with atrial incisions
4 Surgery for ASD and Atrial Arrhythmias Vernant (1980) 9% (200 pts) Bink-Boelkens (1983) 18% (204 pts) Gatzoulis (1999) 213 pts 19% before, 13% after (AF or Flutter) Berger (1999) 211 pts 10% before and after! (AF or flutter) Mantovan, Europace 2003 (5:133) 9% before and 12% after
5 Nakagawa et al, Circulation. 2001;103: Fontan, Mustard and Senning are more complex substrate to map and ablate
6 SMALL RA REENTRY FOLLOWING TRICUSPID SURGERY Dominant loop Passive activation TRIC IVC TRIC IVC RAO LAO
7 Triedman (Circ 2001)
8 Ablation for Persistent/Permanent AF using a combination of strategies 1. PVI 2. Defragmentation 3. Linear lesions 84% AF termination 13% SR 71% AT JCE 2005
9 Atrial Flutter After AF Ablation - Incidence < 5% after PVI (Oral Circ 01, Pace 03, Gerstenfeld Circ 04) 18% after CPVA (Karch Circ 05) 10 to 20% persistent AF Ablation (Oral, Circ 07; Matsuo HR 07) Up to 50% acutely after stepwise approach for long standing AF (Haissaguerre JCE 05, Jais JCE 09)
10 Atrial Flutter After AF Ablation - Mechanisms Dipen Shah, JCE pts 15 AT after AF ablation 11 localized Reentry 4 macro Reentry
11 Narrow, Slow-Conducting Isthmus Dependent Left Atrial Reentry Developing After Ablation for Atrial Fibrillation: ECG Characterization and Shah et al, JCE ; Figure 1. Examples of narrow isthmus dependent left atrial tachycardia (LAT) ECGs with isoelectric intervals on all 12 leads.
12 Small reentry: Circuit limited to 1 (or 2 adjacent) LA segments: PVs, Ant, post, sept, lateral (+ LAA) EP criteria for reentry
13 PPI-TCL > 100 ms is color coded in purple Esato et al, HR 2009;6:
14 Patel et al, Circ EP. 2008;1: % macroreentry 22% focal
15 A B C D E I II III F
16 Focal Atrial Tachycardia vs Dynamic behavior: Frequent initiations Reentrant Variable cycle length Activation spread from the earliest site (origin) to the rest of the cavity (passive activation)
17 Macroreentrant tachycardia Centrifugal tachycardia Localized reentry Focal
18 Mohamed et al, JCE 2007
19 Repeating entrainment checking for consistency 1 st PPI mapping; ATCL250ms, PPI +0ms
20 2 nd PPI mapping; ATCL250ms, PPI +70ms This results suggest focal AT
21 Three Deductive Steps STEP 1 CL Irregularity > 15% Yes No STEP 2 Diagnose or exclude macroreentry Activation and PPI compatible with: Perimitral Roof dependant Peritricuspid Yes No Linear ablation STEP 3 Locate centrifugal arrhythmia Activation and PPI Focal ablation
22 Macroreentrant tachycardia Centrifugal tachycardia Localized reentry Focal 1. Circuit involving 3 or more segments 2. > 75% of the CL is mapped along the circuit 3. Good PPI in 2 opposite segments 1. Centrifugal activation 2. > 75% of CL is recorded 3. PPI increases with increasing distance from the source 4. Good PPI in only one segment 1. Centrifugal activation 2. < 75% of CL is recorded 3. PPI increases with increasing distance from the source 4. Good PPI in only one segment
23 100 ms 124 ms 240 ms
24 A PPI Septal: TCL+ 136 ms B PPI lateral: TCL+ 16 ms
25
26 124 ms 158 ms
27 PPI Anteroseptal LA: TCL + 40 ms ms ms + 80 ms + 80 ms + 40 ms
28 PPI: + 12 ms PPI: + 20 ms 14 ms before CS ref 82 ms before CS ref
29 A Low post High post B Low ant High ant
30
31 Activation mapping only may be misleading!!! Focus superior to a complete Mitral isthmus line RF D RF D CS CS RAA RF D CS RF D CS
32 Entrainment mapping only may be misleading!!!
33 Atrial Tach After AF Ablation Are they always man made? Jaïs et al, JCE pts 14 anterior LA AT after AF ablation localized Reentry
34 Boston AF Live Case: AT2 was successfully ablated at ant LA, the 3rd most active region according to phase mapping Ant LA:12 Persistent AF 3-4mths No CEE No structural heart disease LAA CL 145 Termination site
35 128 pts: 97% mapped and ablated conventionally 238 ATs were identified in 128 pts: 1.8±1.2 per pt Macro-reentry: 109 Peri Mitral Cavo tricuspid isthmus Peri R veins 13% Non macro reentrant: 129 (54%) focal AT, n=34; Localized Reentry, n=95 Mean diagnostic time per tachycardia: 10±5 min SVC: 1% RA 4% Septum 16% Anterior LA 12% PV 9% Posterior LA 1% CS 7% LAA 9%
36 Results Focal (F) Localized R Macro reentry (MR) P Focal / localized P Localized / MR P F / MR n = Cycle Length 341 ± ± ± 67 < 0,001 NS < 0,001 Cycle length Irregularity (%) Diagnostic time (min) Duration EGM Ablation site (min) 9,6 ± 9,4 5 ± 3,8 3.8 ± 3.2 < 0,001 0,02 < 0, ± ± 5 7 ± 6 0,005 0,001 0, ± ± 74 < 0,001 NA NA PPI TCL (ms) 10 ± 8 8 ± 13 6 ± 9 NS NS NS
37 Conclusion Combining Activation and Entrainment mapping is best The diagnosis can be made without mapping 3D system Localized reentries are always associated with very slow conduction and fractionated electrograms Good PPI in 2 opposite segments is always associated with macroreentry
38 Preferential distribution of localized reentry circuits SVC: 3 Anterior LA 24 PV 15 RA 3 LAA 23 Septum 12 Posterior LA 1 CS 14
39 Conclusion Macroreentries are frequently observed after persistent AF ablation Centrifugal tachycardia involve focal and localized reentries, a newly described mechanism, possibly more frequent in the context of CAFE ablation? 3D mapping systems are effective but there are practical and cost effective alternatives
40 Fiala et al, PACE 08 N=59 N=35 N= 100 Success Failure
41 Atrial Flutter After AF Ablation - Mechanisms Dipen Shah, JCE pts 15 AT after AF ablation 11 localized Reentry 4 macro Reentry
42 Atrial Flutter After AF Ablation - Mechanisms Esato/Hindricks, HR pts 29 AT after AF ablation- carto- NavX 9 localized Reentry 20 macro Reentry
43 Atrial Flutter After AF Ablation - Mechanisms Zheng/Kadish, JCE pts 146 AT after AF ablation in 200 pts 4 Focal- CL 225 ms 142 macro Reentry CL 205 ms
44 Atrial Flutter After AF Ablation - Mechanisms Satomi/Kuck, HR pts/at after PVI in 850 pts 8 localized Reentry CL 297 ms
45 A: mapping with the multipolar catheter B: mapping with the RF catheter RF dist RF prox
46 Left atrial tachycardia are frequently observed during AF ablation, particularly in persistent AF 3 D mapping is time consuming and impractical especially after many hours of AF ablation and situations of multiple atrial tachycardia We developed a diagnostic approach based on conventional mapping strategies
47 Localized reentry : Spiral is covering all the ATCL
48 LA Dynamic Isochrone Sequence During AT
49 Atrial Flutter After AF Ablation - Mechanisms Jaïs et al, JCE pts 14 anterior LA AT after AF ablation localized Reentry
50 LA activation during peri mitral flutter RPV LPV LPV RPV
51 Gerstenfeld et al, (Heart Rhythm 2007;4: )
52 P wave morphology to localize the origin of the tachycardia: Except after surgery For congenital HD! Kalman et al, (J Am Coll Cardiol 1998;31:451 9)
53
54
55 Electroanatomic Mapping of Entrained and Exit Zones in Patients With Repaired Congenital Heart Disease and Intra-Atrial Reentrant Tachycardia Triedman et al, Circ 2001;103:
56
57
58 Patient Population 128 patients, 238/246 atrial tachycardia successfuly mapped (97%) 109 male; Years 25/128 20% paroxysmal AF; 80% persistent/permanent SHD in 30% Dilated: 18 (14%) Hypertrophic: 9 (7%) Ischemic: 5 (4%) Valvular: 5 (4%)
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