Electro-anatomical Mapping of the Heart: An Illustrated Guide to the Use of the Carto System

99 Pages·2006·1.69 MB·English

by  Josef

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Electro-anatomical
Mapping of the Heart
An Illustrated Guide to the Use of the CARTO™ System
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CARTO™ system is a registered trademark of Biosense Webster, Inc., Diamond Bar, CA, USA.
Published by Remedica
Commonwealth House, 1 New Oxford Street, London, WC1A 1NU, UK
Civic Opera Building, 20 North Wacker Drive, Suite 1642, Chicago, IL 60606, USA
[email protected]
www.remedicabooks.com
Tel: [phone]
Fax: [phone]
Publisher: Andrew Ward
In-house editors: Nicky Fernando and Catherine Harris Booth
Design and artwork: AS&K Skylight Creative Services
© 2006 Remedica
While every effort is made by the publisher to see that no inaccurate or misleading data, opinions, or statements appear in this book, they wish to make
it clear that the material contained in the publication represents a summary of the independent evaluations and opinions of the authors. As a
consequence, the authors, publisher, and any sponsoring company accept no responsibility for the consequences of any inaccurate or misleading data
or statements. Neither do they endorse the content of the publication or the use of any drug or device in a way that lies outside its current licensed
application in any territory.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
Remedica is a member of the AS&K Media Partnership
ISBN-13: 978 1 901346 98 5
ISBN-10: 1 901346 98 6
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library.
Printed in Spain.
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Electro-anatomical
Mapping of the Heart
An Illustrated Guide to the Use of the CARTO™ System
Josef Kautzner, MD, PhD
Professor of Medicine
Department of Cardiology
Institute for Clinical and Experimental Medicine
Prague
Czech Republic
Anders Kirstein Pedersen, MD, PhD
Associate Professor of Cardiology
Skejby Sygehus
Aarhus University Hospital
Denmark
Petr Peichl, MD
Fellow in Cardiology
Department of Cardiology
Institute for Clinical and Experimental Medicine
Prague
Czech Republic
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CONTENTS
Preface ix
Abbreviations xi
1. Electro-anatomical Mapping 1
1.1 Basic Principles of Electro-anatomical Mapping 2
1.1A General concepts 2
1.1B Spectrum of electro-anatomical maps 5
1.1C Limitations of electro-anatomical mapping 7
1.2 Set-up for the Mapping Procedure 8
1.2A Location of the reference patch 8
1.2B Selection of the reference signal – the key to success 9
1.2C Setting up the window of interest 9
1.3 Mapping Technique 13
1.3A CARTO mapping of cardiac chambers 13
1.3B Maintaining endocardial contact with the mapping catheter 17
1.4 Annotation of Electro-anatomical Maps 18
1.4A How to annotate electrograms 18
1.4B How to differentiate atrial from ventricular local electrograms 18
1.4C How to define myocardial scar 18
1.4D How to evaluate a line of block 21
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CONTENTS
1.5 Diagnosis of Arrhythmias 22
1.5A Mechanism of arrhythmias 22
1.5B The importance of entrainment mapping during CARTO procedures 24
1.5C New map or re-map? 25
1.6 Advanced Mapping Techniques 26
1.6A Qwikmapping 26
1.6B Image integration 26
2. Normal and Abnormal Conduction of the Heart 31
2.1 Virtual Model of the Heart 32
2.2 Normal Electrical Activation of the Atria and Ventricles 32
2.3 Activation Patterns in Ventricular Conduction Disturbances 35
2.3A Left bundle branch block and left ventricular conduction abnormalities 35
2.3B Left anterior hemiblock accompanied by right bundle branch block 35
2.4 Activation Patterns During Different Pacing Modes 37
2.4A Right ventricular apical pacing 37
2.4B Biventricular pacing 38
2.4C Right ventricular bifocal pacing 38
2.4D Single-site left ventricular pacing 38
3. Clinical Application of Electro-anatomical Mapping in the Treatment of Arrhythmias 41
3.1 Focal Atrial Tachycardias 43
3.2 Typical Atrial Flutter 45
3.2A Typical atrial flutter 45
3.2B Reverse typical flutter 47
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CONTENTS
3.3 Atypical Atrial Flutter 49
3.3A Non-surgical right atrial macro-reentrant tachycardias 49
3.3B Post-incisional right atrial tachycardias 50
3.3C Left atrial macro-reentrant tachycardias 51
3.3D Left septal atrial flutter 51
3.3E Post-ablation left atrial tachycardias 52
3.3F Macro-reentrant tachycardias after correction of complex congenital heart disease 52
3.4 Atrial Fibrillation 53
3.4A Segmental pulmonary vein isolation 53
3.4B Circumferential ablation around pulmonary vein ostia 55
3.4C Combined technique 56
3.4D Ablation of an electrophysiological substrate 57
3.4E The role of imaging 57
3.5 Atrioventricular Nodal Reentry 60
3.6 Inappropriate Sinus Tachycardia 62
3.7 Accessory Pathways 63
3.8 Idiopathic Focal Ventricular Tachycardia 65
3.8A Ventricular tachycardia originating from the right ventricular outflow tract 65
3.8B Ventricular tachycardia originating from the left ventricular outflow tract 67
3.8C Right ventricular outflow tract versus left ventricular outflow tract site of origin 67
3.8D Other locations of the arrhythmogenic focus in idiopathic ventricular tachycardias 67
3.9 Idiopathic Reentrant Ventricular Tachycardia (Fascicular) 70
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CONTENTS
3.10 Post-myocardial Infarction Ventricular Tachycardia 71
3.10A Mapping during ventricular tachycardia 71
3.10B Ablation of stable ventricular tachycardia 72
3.10CSinus rhythm substrate mapping 72
3.10DAn integrated approach 73
3.10E Epicardial approach 73
3.11 Ventricular Tachycardias in Dilated Cardiomyopathy 75
3.12 Ventricular Tachycardias in Right Ventricular Arrhythmogenic Cardiomyopathy 76
3.13 Post-incisional Ventricular Tachycardias 78
3.14 Catheter Ablation of Ventricular Fibrillation 80
References 83
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PREFACE
Mapping of the heart is one of the principal techniques used in the diagnosis and treatment of cardiac arrhythmias.
Electrical activity of the heart can be recorded from the body surface (ECG mapping), from the surface of the heart
(epicardial mapping) or from the endocardium (endocardial mapping). Signals can be acquired simultaneously from
various sites or sequentially, point-by-point, and these data can be visualized in different formats. The power of
computer processing opened new horizons in cardiac mapping. The so-called electro-anatomical mapping system
(CARTO™, Biosense Webster, Inc., Diamond Bar, CA, USA), developed in the mid-nineties, represents one of the most
successful systems for detailed endocardial/epicardial mapping of cardiac arrhythmias. For the first time in history,
it allowed superimposition of 3D anatomy and local electrograms. The major advantages of the system comprise direct
visualization of the activation pattern of individual arrhythmias, catheter navigation to the desired arrhythmic substrate
during radiofrequency ablation and minimal need for fluoroscopy.
Since its introduction into the clinical arena, the use of the electro-anatomical mapping system has continued to grow.
This book reviews the main clinical applications of the CARTO system, and provides recommendations for the
mapping and treatment of a wide range of arrhythmias. We hope that the combined experience of our two centers will
provide practical assistance to those just starting to use this system.
Besides explanation of basic principles of the mapping procedure, major sections of the book deal with the use of the
CARTO system in individual types of arrhythmias. For each arrhythmia, a review of published data is presented
together with a recommended strategy for mapping and ablation. All sections are supported by images in order to
facilitate the learning process. Finally, the text is accompanied by a selection of the most relevant references.
Josef Kautzner, MD, PhD
Anders Kirstein Pedersen, MD, PhD
Petr Peichl, MD
March 2006
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