Intra-procedural evaluation of the cavo-tricuspid isthmus anatomy with different techniques: comparison of angiography and intracardiac echocardiography

Hisazaki, Kaori; Kaseno, Kenichi; Miyazaki, Shinsuke; Amaya, Naoki; Hasegawa, Kanae; Shiomi, Yuichiro; Takahashi, Naoto; Ikeda, Hiroyuki; Fukuoka, Yoshitomo; Morishita, Tetsuji; Ishida, Kentaro; Uzui, Hiroyasu; Tada, Hiroshi

doi:10.1007/s00380-019-01394-1

Cited by 5 publications

(7 citation statements)

References 10 publications

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“…This phenomenon might emerge because of anatomical specificity. In fact, it has been shown that the anatomical structure of the CTI is more complex than that of the pulmonary vein, as represented by the eustachian ridge and pouch 9 , 11 . These structures may cause the creation of a P-vector.…”

Section: Discussionmentioning

confidence: 99%

“…Although the issue of catheter movement due to respiration cycles has been overcome using deep sedation, to overcome insufficient catheter contact and stability against the tissue due to the anatomical complexity represented by pouch and eustachian ridge remains challenging. Techniques for CTI anatomy evaluation during the procedure, namely angiography or intracardiac echocardiography (ICE), are effective but somewhat troublesome 10 , 11 , because angiographic imaging is not a real-time evaluation of the catheter-CTI contact situation, and ICE images tend to be obscure, especially in the proximal area where the eustachian ridge is observed. Therefore, to overcome this problem, we focused on other parameters, particularly the contact vector direction (CVD).…”

Section: Introductionmentioning

confidence: 99%

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Effect of contact vector direction on achieving cavotricuspid isthmus block

Sumi

Hoshiyama

Morihisa³

et al. 2023

Sci Rep

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Cavotricuspid isthmus (CTI) ablation is an important treatment strategy for CTI-dependent atrial flutter (AFL). The location of the catheter contact area is confirmed by the contact vector direction (CVD) through three-dimensional mapping during the procedure. However, the relationship between CVD during radiofrequency ablation and its efficacy in achieving CTI block has not been clarified. This study aimed to investigate the relationship between CVD and efficacy in achieving CTI block. CVDs during radiofrequency ablation were divided into proximal vectors against the distal tip (P-vector) and other vectors (normal-vector). In 39 patients who underwent CTI linear ablation, the CTIs were divided into two segments: the tricuspid valve area (anterior) and inferior vena cava area (posterior). The frequency of the residual conduction gap was compared between segments in which the P- and normal-vectors were observed. P-vectors were observed in 13 of the 78 segments. The median ablation index was not significantly different between segments in which the P-vector and normal-vector were observed (398.2 [384.2–402.2] vs. 393.3 [378.3–400.1], p = 0.15). However, residual conduction gaps were significantly more frequently observed in the segment in which the P-vector was observed than those in which only the normal-vector was observed (6/13, 46.2% vs. 3/65, 4.6%; p < 0.01). During a 6-month follow-up, two patients required a second session of ablation due to AFL recurrence. A residual conduction gap was observed in one patient at the site where the P-vector was observed in the first session. Avoiding the P-vector might be an important factor in improving CTI block and reducing AFL recurrence.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Effect of contact vector direction on achieving cavotricuspid isthmus block

Sumi

Hoshiyama

Morihisa³

et al. 2023

Sci Rep

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“… 6 A previous study reported the utility of the delineation of the SEP by ICE and a 3D mapping system for an effective CTI ablation avoiding RF deliveries in the SEP and steam‐pops. 2 However, the delineation of the CTI is time‐consuming and requires an expert technique of ICE use, which sometimes fails to detect the SEP. 2 If a power‐controlled RF is delivered in the undetectable SEP, there is a risk for steam pops, which sometimes cause right atrial perforations. 7 , 8 Therefore, a reliable modality able to detect the SEP and provide a safety‐net such as a tissue‐temperature controlled ablation in an undetectable SEP is warranted.…”

Section: Discussionmentioning

confidence: 99%

“…Radiofrequency (RF) ablation of the cavotricuspid isthmus (CTI) is a highly successful procedure for typical atrial flutters (AFLs), and bidirectional block of the CTI is a commonly determined endpoint 1 . The combined use of intracardiac echocardiography (ICE) and a 3D mapping system is useful to delineate the CTI anatomy including a subeustachian pouch (SEP) and the Eustachian ridge 2 . However, the SEP often hinders the completion of bidirectional block of the CTI and sometimes causes steam‐pops during a power‐controlled RF application with an irrigated ablation catheter 3 .…”

Section: Introductionmentioning

confidence: 99%

“… 1 The combined use of intracardiac echocardiography (ICE) and a 3D mapping system is useful to delineate the CTI anatomy including a subeustachian pouch (SEP) and the Eustachian ridge. 2 However, the SEP often hinders the completion of bidirectional block of the CTI and sometimes causes steam‐pops during a power‐controlled RF application with an irrigated ablation catheter. 3 Therefore, the management of the RF applications within the SEP is a key to complete the CTI line without any complications.…”

Section: Introductionmentioning

confidence: 99%

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Novel “red‐bull sign” during cavotricuspid isthmus ablation: Indication of an ablation catheter stuck in the subeustachian pouch

Hirata

Nagashima

Watanabe

et al. 2022

Journal of Arrhythmia

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Background A subeustachian pouch (SEP) often hinders the completion of a cavotricuspid isthmus (CTI) ablation of typical atrial flutter (AFL) and sometimes causes steam‐pops during a power‐controlled ablation. We hypothesized that real‐time bull's‐eye monitoring of the catheter surface temperature might be useful to locate the SEP where the temperature can rise rapidly, and a temperature‐controlled ablation might avoid steam pops. This study aimed to demonstrate this hypothesis. Methods A temperature‐controlled CTI ablation with a QDOT MICRO™ catheter (n = 10) and a conventional power‐controlled CTI ablation (n = 10) were performed with an output power of 35 W. During the RF application, the bull's eye monitor for monitoring the catheter surface temperatures was assessed. A “red‐bull sign” was defined as an entire red‐colored bull's‐eye monitor, indicating that the catheter‐tip temperature of all 6 thermocouples rose rapidly over 47°C. Results In a total of 115 lesions (12 ± 3 per patient), a “red‐bull sign” was observed in 39 (33.9%) lesions where the RF output was reduced to 26 ± 8 W. All 39 “red‐bull sign” lesions corresponded to the location of the SEP as delineated by ICE before the ablation. The red‐bull sign accurately indicated the presence of a SEP with a sensitivity of 84.7% and specificity of 100%. Bidirectional block of the CTI was completed in all patients in either catheter group without any steam‐pops. Conclusion Real‐time surface temperature monitoring and a red‐bull sign might be useful to detect the SEP. A temperature‐controlled CTI ablation with the QDOT MICRO catheter might be safe for avoiding steam pops.

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