Characterizing localized reentry with high-resolution mapping: Evidence for multiple slow conducting isthmuses within the circuit

Frontera, Antonio; Mahajan, Rajiv; Dallet, Corentin; Vlachos, Konstantinos; Kitamura, Τakeshi; Takigawa, Masateru; Cheniti, Ghassen; Martin, Claire; Duchâteau, Josselin; Lam, Anna; Bourier, Félix; Denis, Arnaud; Pambrun, Thomas; Hocini, Mélèze; Sacher, Frédéric; Derval, Nicolas; Haı̈ssaguerre, Michel; Dubois, Rémi; Jaı̈s, Pierre

doi:10.1016/j.hrthm.2018.11.027

Cited by 41 publications

(34 citation statements)

References 15 publications

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“…Localized reentry was defined when at least 85% of the tachycardia cycle length was encompassed within an area with a diameter less than 3 cm. If less than 85% of the cycle length was recorded because of AT termination or transition, the putative mechanism was assigned based on entrainment characteristics from different parts of the atrium and responses to adenosine …”

Section: Methodsmentioning

confidence: 99%

“…If less than 85% of the cycle length was recorded because of AT termination or transition, the putative mechanism was assigned based on entrainment characteristics from different parts of the atrium and responses to adenosine. [3][4][5] The ablation strategies involved creating linear lesions between inexcitable barriers, such as atriotomy scars, pre-existing scars, valve annuli, and the vena cavae. Areas of scar were identified as low voltage (<0.05 mV) and conduction block was identified by the presence of double potentials during AT or sinus rhythm.…”

Section: Methodsmentioning

confidence: 99%

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Regional isolation in the right atrium with disruption of intra‐atrial conduction after catheter ablation of atrial tachycardia

Markowitz

Choi

Daian

et al. 2019

Cardiovasc electrophysiol

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Background Ablation of atrial tachycardia (AT) that occurs after cardiac surgery or prior ablation often requires complex lesion sets. In combination with the pre‐existing atrial scar, these lesion sets may result in inadvertent intra‐atrial conduction block. This study reports the phenomenon of incidental isolation of right atrial (RA) regions that occurs secondary to AT ablation, which in some cases results in profound bradycardia due to sinus exit block. Methods and Results Intracardiac electrograms were examined in consecutive patients who underwent AT ablation in the RA. Cases of localized isolation of the RA were defined as areas that developed electrical dissociation during ablation. Of 132 patients having ablation in both the RA free wall and the cavotricuspid isthmus (CTI), 10 (7.6%) developed unintentional isolation of the lateral RA. Five of these patients had prior mitral valve surgery, comprising 12.2% of all 41 patients with mitral surgery who underwent ablation in the CTI and the RA free wall. All patients with regional isolation had a pre‐existing scar in the lateral wall of the RA. In six patients, isolation of the lateral RA resulted in profound bradycardia due to exit block from the peri‐sinus node myocardium. Conclusions Complex ablation lesions in patients with prior valve surgery, prior ablation, or atrial myopathy may result in unintended localized conduction block in the RA. In some cases, isolation of the lateral RA can result in complete sinus exit block with profound bradycardia requiring pacemaker implantation.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Regional isolation in the right atrium with disruption of intra‐atrial conduction after catheter ablation of atrial tachycardia

Markowitz

Choi

Daian

et al. 2019

Cardiovasc electrophysiol

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“…was applied to tachycardias that demonstrated continuous fractionated electrograms, which encompassed most of the tachycardia cycle length and were recorded over a small area with a multi-spline or spiral mapping catheter or an ablation catheter ( Figure 1) 1,2 With the advent of ultrahigh density mapping, circuits of small dimensions can be defined with higher resolution and it is possible to identify reentrant pathways around central lines of block with isthmus channel(s) embedded within the scar borders ( Figure 1). 3 These maps demonstrate slow conduction in various segments of the circuit and a high degree of wavefront curvature around the ends of a central line of block. Both macro-and localized reentrant atrial tachycardias (ATs) can exist as dual loop tachycardias with a central common pathway.…”

Section: Overview Of Tachycardia Mechanisms In the Left Atriummentioning

confidence: 95%

“…The distinction of macroreentry and localized reentry is largely arbitrary, but recent publications have defined localized reentry as an activation circuit with a diameter of <2 to 3 cm. Historically, the term “microreentry” was applied to tachycardias that demonstrated continuous fractionated electrograms, which encompassed most of the tachycardia cycle length and were recorded over a small area with a multi‐spline or spiral mapping catheter or an ablation catheter (Figure ) With the advent of ultrahigh density mapping, circuits of small dimensions can be defined with higher resolution and it is possible to identify reentrant pathways around central lines of block with isthmus channel(s) embedded within the scar borders (Figure ) . These maps demonstrate slow conduction in various segments of the circuit and a high degree of wavefront curvature around the ends of a central line of block.…”

Section: Overview Of Tachycardia Mechanisms In the Left Atriummentioning

confidence: 99%

Approach to catheter ablation of left atrial flutters

Markowitz

Thomas

Liu

et al. 2019

Cardiovasc electrophysiol

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Left atrial tachycardias (ATs) most commonly occur after catheter or surgical ablation of atrial fibrillation and in patients with atrial myopathies. Pre‐existing scar in the left atrium (LA) can result in complex circuits, sometimes with narrow channels that can be detected with high‐resolution mapping. The most common forms of macroreentrant AT from the LA are variants of peri‐mitral and roof‐dependent reentry. Localized reentrant rhythms occur in the setting of fibrosis that gives rise to slow conduction and may occur adjacent to areas of prior ablation. The approach to treating these ATs involves first identifying the left atrial origin, defining the tachycardia circuit – which can be facilitated by ultrahigh density mapping and entrainment – and selecting a suitable isthmus to target for ablation. An important endpoint in ablating left atrial flutters is to establish and confirm bidirectional line of the block. Challenges in ablating these ATs include the presence of multiple tachycardias, defining circuits with complex activation patterns and achieving durable lines of block, particularly in the lateral mitral isthmus. Progress in treating these arrhythmias has come from new mapping technologies and the recognition of epicardial connections that allow for persistent conduction across ablation lesions. Also, advances in delivering energy to obtain complete transmural lesions promise to improve the long‐term success of ablating ATs from the LA.

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“…These circuits were around a fixed scar or line of conduction block. [ 64 ] However, wavefront collision or artefacts can mimic microreentrant ATs, thereby leading to misinterpretation of the tachycardia circuit. [ 65 ] Entrainment pacing from at least two separate points along the circuit should be performed to confirm whether these microreentrant ATs are active or passive in the atrial arrhythmias.…”

Section: Mapping and Ablationmentioning

confidence: 99%

Atrial Tachycardias After Atrial Fibrillation Ablation: How to Manage?

Hung

Chang

Wang

et al. 2020

Arrhythm Electrophysiol Rev

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With catheter ablation becoming effective for non-pharmacological management of AF, many cases of atrial tachycardia (AT) after AF ablation have been reported in the past decade. These arrhythmias are often symptomatic and respond poorly to medical therapy. Post-AF-ablation ATs can be classified into the following three categories: focal, macroreentrant and microreentrant ATs. Mapping these ATs is challenging because of atrial remodelling and its complex mechanisms, such as double ATs and multiple-loop ATs. High-density mapping can achieve precise identification of the circuits and critical isthmuses of ATs and improve the efficacy of catheter ablation. The purpose of this article is to review the mechanisms, mapping and ablation strategy, and outcome of ATs after AF ablation.

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Characterizing localized reentry with high-resolution mapping: Evidence for multiple slow conducting isthmuses within the circuit

Cited by 41 publications

References 15 publications

Regional isolation in the right atrium with disruption of intra‐atrial conduction after catheter ablation of atrial tachycardia

Regional isolation in the right atrium with disruption of intra‐atrial conduction after catheter ablation of atrial tachycardia

Approach to catheter ablation of left atrial flutters

Atrial Tachycardias After Atrial Fibrillation Ablation: How to Manage?

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