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Setting up a 3D map for atrial arrhythmias

Raja Selvaraj
Cardiac Electrophysiologist
Professor of Cardiology
JIPMER

Roles and Responsibilities

  • Take ownership and participate actively in the mapping process
  • Sit at the console if possible
  • Make sure you can review the signals

Signals > Colours

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Hardware

Multi electrode catheter

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Deflectable Sheath

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Multi Electrode Mapping

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High density mapping

  • More detailed maps
  • Shorter time to create map
  • Verification / re-annotation difficult or impossible
  • Not totally equivalent to point by point mapping

Automatic mapping - High density without MEM

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Including entrainment

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Imaging

  • CT merge
  • ICE - With or without integration

Deciding on chamber to map

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Approach to catheter ablation of left atrial �utters Steven M. Markowitz MD, George Thomas MD, Christopher F. Liu MD, Jim W. Cheung MD, James E. Ip MD, Bruce B. Lerman MD. JCE 2019

**

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Miyazaki H, Stevenson WG, Stephenson K, Soejima K, Epstein LM. Entrainment mapping for rapid distinction of left and right atrial tachycardias. Heart Rhythm. 2006 May;3(5):516-23. doi: 10.1016/j.hrthm.2006.01.014. Epub 2006 Feb 28. PMID: 16648054.

Setting the window of interest

Seeing the P wave

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Choosing a reference

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Timing Reference

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P wave in relation to reference

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P wave in relation to reference

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Window onset

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De Ponti method

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De Ponti R, Verlato R, Bertaglia E, Del Greco M, Fusco A, Bottoni N, Drago F, Sciarra L, Ometto R, Mantovan R, Salerno-Uriarte JA. Treatment of macro-re-entrant atrial tachycardia based on electroanatomic mapping: identification and ablation of the mid-diastolic isthmus. Europace. 2007 Jul;9(7):449-57. doi: 10.1093/europace/eum055. Epub 2007 May 3. PMID: 17478460.

No clear isoelectric segment

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Long P wave duration in relation to CL

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Selvaraj RJ et al. Chasing red herrings: making sense of the colors while mapping. Circ Arrhythm Electrophysiol. 2014 Jun;7(3):553-6.

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Selvaraj RJ et al. Chasing red herrings: making sense of the colors while mapping. Circ Arrhythm Electrophysiol. 2014 Jun;7(3):553-6.

P end to P end

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Mechulan A, Bun SS, Masse A, Peret A, Leong-Feng L, Pons F, Bouharaoua A, Dieuzaide P, Prévot S. An improved window of interest for electroanatomical mapping of atrial tachycardia. J Interv Card Electrophysiol. 2022 Jan;63(1):29-37. doi: 10.1007/s10840-021-00940-0. Epub 2021 Jan 27. PMID: 33506319; PMCID: PMC8755667.

Window length

  • 80% of CL
  • 90% of CL
  • 100% of CL

Why not 100% ?

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Advanced visualization aids

LAT histogram

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Use of the LAT histogram “trough” to identify the slow conduction channel in complex congenital heart disease macro re-entrant arrhythmias. Nathan Denham, Andrew Ha, Raja Selvaraj, Krishnakumar Nair. CJC Pediatric and Congenital Heart Disease 2024

Ripple maps

2019_rajendran_upper_loop_frac_egm.jpg

Ripple maps

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Luther V, Linton NW, Koa-Wing M, Lim PB, Jamil-Copley S, Qureshi N, Ng FS, Hayat S, Whinnett Z, Davies DW, Peters NS, Kanagaratnam P. A Prospective Study of Ripple Mapping in Atrial Tachycardias: A Novel Approach to Interpreting Activation in Low-Voltage Areas. Circ Arrhythm Electrophysiol. 2016 Jan;9(1):e003582. doi: 10.1161/CIRCEP.115.003582. PMID: 26757985.

Coherent mapping

coherence.jpg

Anter E, Duytschaever M, Shen C, Strisciuglio T, Leshem E, Contreras-Valdes FM, Waks JW, Zimetbaum PJ, Kumar K, Spector PS, Lee A, Gerstenfeld EP, Nakar E, Bar-Tal M, Buxton AE. Activation Mapping With Integration of Vector and Velocity Information Improves the Ability to Identify the Mechanism and Location of Complex Scar-Related Atrial Tachycardias. Circ Arrhythm Electrophysiol. 2018 Aug;11(8):e006536. doi: 10.1161/CIRCEP.118.006536. PMID: 30354312.

Summary

  • Set up and mapping is not automatic
  • Understand and participate in the process
  • Basic concepts - series of articles in Circ Arrhythmia 2010-2011
  • Constantly evolving set of tools