A Practical Criterion for the Rapid Detection of Single‐Loop and Double‐Loop Reentry Tachycardias

Linton, Nick; Wilton, Stephen B.; Scherr, Douglas S.; Derval, Nicolas; Sacher, Frédéric; Wright, Matthew; Hocini, Mélèze; O’Neill, Mark; Haı̈ssaguerre, Michel; Jaı̈s, Pierre

doi:10.1111/jce.12076

Cited by 11 publications

(8 citation statements)

References 24 publications

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“…One is the prolonged conduction time that is longer than the TCL due to a long conduction pathway and/or slow conduction. The other is the dual‐loop reentry [12]. The excitation wavefront induced by the overdrive stimulation entered one circuit after going around the other, so the penetration to the other reentry circuit became the second beat after the stimulus.…”

Section: Discussionmentioning

confidence: 99%

Usefulness of entrainment mapping using the activation sequence of the last captured excitation in complex dual‐loop atrial tachycardia

Fujiki

Yoshioka

Sakabe

2014

Journal of Arrhythmia

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Section: Discussionmentioning

confidence: 99%

Usefulness of entrainment mapping using the activation sequence of the last captured excitation in complex dual‐loop atrial tachycardia

Fujiki

Yoshioka

Sakabe

2014

Journal of Arrhythmia

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“…In this issue of JCE, Linton et al . provide an exhaustive and detailed analysis of intracardiac EGM behavior during overdrive pacing of reentrant AT . They propose a novel formula based on pacing from 2 atrial sites, and criteria based on 3 possible results of the formula to differentiate reentrant from focal tachycardia, as well as single from double loop reentry.…”

Section: Editorial Commentmentioning

confidence: 99%

“…In this issue of JCE, Linton et al provide an exhaustive and detailed analysis of intracardiac EGM behavior during overdrive pacing of reentrant AT. 9 They propose a novel formula based on pacing from 2 atrial sites, and criteria based on 3 possible results of the formula to differentiate reentrant from focal tachycardia, as well as single from double loop reentry. The analysis requires identification at each mapping site of the first beat of tachycardia (FBT) after pacing, which is the first EGM that does not fall at the paced cycle length after the last pacing stimulus.…”

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confidence: 99%

Feeling a Little Loopy?

Michaud

Stevenson

2013

Cardiovasc electrophysiol

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Editorial CommentTransient entrainment was first demonstrated by Waldo and others in common right atrial flutter and scar-related ventricular tachycardia nearly 30 years ago, and has been shown to occur in all forms of reentry.1 Transient entrainment of a reentry circuit refers to the ability of a paced wavefront to penetrate an excitable gap and constantly, in the case of a stimulus train, reset the circuit to the pacing rate in an orthodromic direction. If the pacing rate is faster than the tachycardia cycle length (TCL) but not fast enough to impinge on the tail of tissue refractoriness, tachycardia continues after cessation of pacing. Also, after entering the exciteable gap, the paced wavefront traveling in the antidromic direction in the circuit collides with the tachycardia wavefront from the previous beat. Each site in the cardiac chamber can be viewed as activated either from a wavefront that traveled orthodromically through the circuit and was activated in the same manner during pacing as during tachycardia, which we will refer to as orthodromic activation, or by a wavefront traveling in a different direction, either in the circuit, or outside of the circuit, which will be referred to as antidromic activation. 2Fusion in the electrocardiogram (ECG) or at the electrogram (EGM) level is created by the combination of orthodromic and antidromic activation of the chamber. After a brief period of pacing at a fixed rate, the region of collision between the orthodromic and paced wavefronts becomes stable and fusion becomes constant on the ECG, except for the last entrained beat after pacing stops, which no longer exhibits fusion (criterion #1).1 At faster pacing rates there is greater propagation of antidromic wavefronts relative to orthodromic wavefronts and the ECG morphology demonstrates progressive fusion as the activation sequence becomes closer to that observed with pacing in sinus rhythm and less like the tachycardia morphology (criterion #2).1 If one continues to pace at faster rates, eventually the head of the conduction wavefront will meet the tail of tissue refractoriness and the tachycardia circuit will be interrupted. Sites distal to the conduction block will fail to be activated by the blocked orthodromic wavefront. The subsequent paced antidromic wavefront is no longer constrained by collision with orthodromic wavefronts and activates these distal sites antidromically, usually evident as a change in EGM morphology and a shorter stimulus to EGM interval than occurred during orthodromic activation (criterion 3). Progressive fusion can also be demonstrated from analysis of orthodromic and antidromic activation in intracardiac EGMs rather than in the surface ECG (criterion 4). 3Unlike reentry, focal mechanisms of tachycardia fail to demonstrate fusion, because conduction occurs centrifugally from a point source, like a ripple from a "pebble in the pond." After a brief period of stabilization, the paced wavefront completely suppresses conduction from the focal source and ECG or intracardiac EGM morphol...

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“…16 Lastly, although this technique can diagnose macroreentry readily, it does not distinguish whether multiple loops are present, and additional pacing maneuvers and mapping as described by Linton et al should be considered if that mechanism is suspected. 17 If the upstream and downstream electrodes are on opposite sides of a line of block, a long S-A u may occur in the absence of constant fusion. If this condition is suspected, a PPI−TCL value should be sought from both electrodes to exclude this unusual possibility and would be expected to be markedly different at the 2 sites, with a very long PPI on the side of block farther from the AT circuit/focus.…”

Section: Potential Pitfalls and Study Limitationsmentioning

confidence: 99%

“…Upstream recording electrodes immediately adjacent to the pacing site (eg, Figure 1A, RA 15,16) may be captured antidromically even at a slow pacing rate; furthermore, stimulus artifact may distort the electrogram. As a result, if there is a short SA interval at the nearest upstream recording electrode, progressively further recording electrodes should be examined (eg, Figure 1A, RA 16,17). No instances of antidromic penetration of sites >2 cm distant from the pacing site were seen in macroreentrant AT when the PCL was within 30 milliseconds of the TCL and the PPI−TCL was <40 milliseconds.…”

Section: Potential Pitfalls and Study Limitationsmentioning

confidence: 99%

Overdrive Pacing From Downstream Sites on Multielectrode Catheters to Rapidly Detect Fusion and to Diagnose Macroreentrant Atrial Arrhythmias

Barbhaiya

Kumar

et al. 2014

Circulation

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Background-Entrainment criteria for macroreentrant arrhythmias are based on detecting fusion between tachycardia and paced wavefronts, but this is often difficult for atrial tachycardias (AT) after ablation of atrial fibrillation. Methods and Results-With the use of a multipolar catheter, pacing was performed from electrodes within the coronary sinus showing activation later than adjacent electrodes (downstream overdrive pacing) during 66 ATs in 62 patients: 20 cavotricuspid isthmus-dependent ATs, 20 perimitral ATs, 13 focal ATs with sequential coronary sinus activation, and 13 other macroreentrant left atrial ATs. The paced cycle length was 10 to 30 milliseconds below the tachycardia cycle length (TCL), and activation at the neighboring upstream electrodes was assessed. Downstream overdrive pacing at 48 sites close to a macroreentrant circuit (PPI−TCL <40 milliseconds, where PPI is postpacing interval) produced constant fusion demonstrated by a long stimulus to upstream atrial electrogram interval (S-A u ) >75% TCL and was consistent with orthodromic activation of the upstream site despite its close proximity to the pacing site. In contrast, downstream overdrive pacing at 18 sites during focal AT or remote from the macroreentrant AT circuit (PPI−TCL >40 milliseconds) always demonstrated a comparatively short S-A u <25% of TCL (12±4% versus 89±4% of TCL; P<0.001), consistent with direct activation. Conclusions-Selection of a downstream activation site for overdrive pacing can facilitate rapid recognition of macroreentry and proximity to the reentry circuit using a single multielectrode catheter by recognizing a PPI-TCL <40 milliseconds and S-A u >75% of TCL. Recognition of intracardiac constant fusion with this method is a novel criterion for transient entrainment.

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A Practical Criterion for the Rapid Detection of Single‐Loop and Double‐Loop Reentry Tachycardias

Abstract: The proposed criterion can diagnose single- and double-loop reentry atrial tachycardia using intracardiac recordings from any pair of well separated positions. The criterion does not require precise electrode placement or extensive activation mapping.

Cited by 11 publications

References 24 publications

Usefulness of entrainment mapping using the activation sequence of the last captured excitation in complex dual‐loop atrial tachycardia

Usefulness of entrainment mapping using the activation sequence of the last captured excitation in complex dual‐loop atrial tachycardia

Feeling a Little Loopy?

Overdrive Pacing From Downstream Sites on Multielectrode Catheters to Rapidly Detect Fusion and to Diagnose Macroreentrant Atrial Arrhythmias

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