From Signals to Colours: A Case-based Atlas of Electroanatomic Mapping in Complex Atrial Arrhythmias

194 Pages·2007·28.23 MB·English

by  Roberto De Ponti (auth.)

Romane 4-09-2007 13:46 Pagina I
Roberto De Ponti
From Signals to Colours
A Case-based Atlas of Electroanatomic Mapping in
Complex Atrial Arrhythmias
Romane 4-09-2007 13:46 Pagina III
Roberto De Ponti
From Signals to Colours
A Case-based Atlas of Electroanatomic
Mapping in Complex Atrial Arrhythmias
Based on the experience of the Project of ElectroAnatomic
mapping in Complex arrhythmia Evaluation (PEACE)
Romane 4-09-2007 13:46 Pagina IV
Roberto De Ponti
Department of Heart Sciences
University of Insubria-Varese
Ospedale di Circolo and Macchi Foundation
Varese,Italy
ISBN 978-88-470-0648-5 Springer Milan Berlin Heidelberg New York
e-ISBN 978-88-470-0649-2
Library of Congress Contro Number 2007931631
Springer is part of Springer Science+Business Media
springer.com
© Springer-Verlag Italia 2008
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned,
specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted
only under the provisions of the Italian Copyright Law in its current version, and permission for use must always be
obtained from Springer. Violations are liable to prosecution under the Italian Copyright Law.
The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and
therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application
contained in this book. In every individual case the user must check such information by consulting the relevant
literature.
Cover layout: Simona Colombo, Milan,Italy
Typesetting: Compostudio, Cernusco s/N (Milan), Italy
Printing and binding: Grafiche Porpora, Segrate (MI), Italy
Springer-Verlag Italia S.r.l., Via Decembrio 28, I-20137 Milan, Italy
Printed in Italy
Romane 4-09-2007 13:46 Pagina V
To my wife Cristina and to our son Riccardo.
...I am just wondering how life would have been without them.
Romane 4-09-2007 13:46 Pagina VII
Foreword
The diagnosis and treatment ofarrhythmias are major commitments ofour School ofCardiol-
ogy.Indeed,the field ofcardiac arrhythmias is broad and often difficult;time and dedication are
required to yield the necessary expertise. Since the early days, technology has made essential
contributions to the study ofcardiac arrhythmias and,over the years,electrophysiology has pro-
gressed from intracavitary signals recorded on seemingly endless printouts to computer-generat-
ed maps that three-dimensionally reconstruct the electrical activity of the heart. I remember
when,at the end of1970s,our department received its first multi-channel computerised mapping
system,developed as a prototype by an Italian company.It was nearly 2 m tall,had a tiny black
and green screen and an entire afternoon was often required to elaborate and transfer data it ac-
quired.Nevertheless,it was a valuable support to our work and crucial to our effort to start the
program of mapping-guided antiarrhythmic surgery. At that time, intraoperative maps were
printed out on a white sheet ofpaper and consisted ofrectangles filled by dots,numbers,and lines,
from which the three-dimensional shape of the mapped heart chamber was hard to imagine.
Nonetheless,while in those days the technology was limited,all the basic concepts needed for sig-
nal analysis and arrhythmia diagnosis were already known.The relationship between technolo-
gy and knowledge has been a mutually reinforcing one,and,at that time,resulted in our ability
to cure many forms ofarrhythmias by surgical ablation.Although in the early phases,intraoper-
ative mapping followed by computation and elaboration ofthe map were time-consuming to the
surgeon,the urgent desire to proceed with the intervention and to cure the patient was usually
satisfied within minutes by the provision ofaccurate and useful information.
Over the last decade,new technologies have been widely introduced in the field ofintervention-
al electrophysiology.Mapping technology is now so sophisticated that three-dimensional recon-
struction ofa heart chamber by electroanatomic mapping,which combines spatial and electrical
information,is possible with an accuracy ofless than 1 mm.This has become even more attractive
with imaging integration, in which a three-dimensional rendering of a magnetic resonance or
computed tomography image is superimposed onto the electroanatomic mapping.This process al-
lows real-time navigation ofthe mapping catheter based on a high-resolution image ofthe heart.
How should we react to this unparalleled and explosive evolution oftechnology? In the literature,
there is a wide body ofevidence that electroanatomic mapping has improved the outcome ofthe
ablation procedure for several arrhythmias and it has led to new and “non-conventional”proce-
dures.Nonetheless,further progress will not be possible ifwe expect that the diagnosis and treat-
ment ofarrhythmias can be relegated to stand-alone computers acting as “autopilots”for electro-
physiology.As technology increases,our knowledge must increase as well.The enormous amount
ofdata provided by new technologies has to be analysed and interpreted to provide new answers
to new questions.
Romane 4-09-2007 13:46 Pagina VIII
VIII Foreword
This is the approach taken in this book by Roberto De Ponti,with whom,after having shared
some ofthe earlier days ofelectrophysiology,I have observed and experienced the impressive de-
velopments that have been made in this field over the past several years.This book is an example
of how technology and knowledge can merge to advance the frontiers in the study of cardiac ar-
rhythmias.I have been overwhelmed by the enthusiasm ofthose who have joined our group,and
by their willingness to discuss and interpret electroanatomic mapping data of complex arrhyth-
mias.Let us hope that this is just the beginning and that the best is still to come.
July 31,2007
Jorge A.Salerno-Uriarte
Department ofHeart Sciences
University ofInsubria-Varese
Ospedale di Circolo and Macchi Foundation
Varese,Italy
Romane 4-09-2007 13:46 Pagina IX
Preface
What is a complex case? Although the concept of what is complex may be personal,there is a
common sense ofcomplexity in electrophysiology.In most cases,a complex case involves a patient
who comes or is referred after a single or multiple unsuccessful procedures in other centres and is
still suffering from the same or a similar arrhythmia.Some other cases are expected to be complex
prior to the first procedure,because the patient has an acquired or a congenital heart disease and
previously underwent complex cardiac surgery. Yet, in other circumstances, the case becomes
complex directly before our eyes,when,for example,during the electrophysiology procedure we
realise that what was expected to be a typical atrial flutter based on surface electrocardiogram
turns out to be not dependent on cavotricuspid isthmus conduction and requires solid mapping
data in order to be successfully treated. Only in a few cases, very rarely to be honest, is the ar-
rhythmia less complex than expected.In these cases,the main difficulty often arises from the fact
that the operator has to stick to the evidence and not be prejudiced by the beliefthat the case has
to be necessarily complex,based on the pre-procedural evaluation.
In 2003,the Project ofElectroAnatomic mapping for Complex Arrhythmia Evaluation (PEACE)
was initiated in Italy and coordinated by our Center.This book represent the result of this expe-
rience.The aim of the project and therefore of this book was to obtain as much information as
possible from electroanatomic mapping in order to obtain a correct diagnosis and define a ration-
al ablation strategy in a “learning before burning”process.In this book,the reader will find very
few conventional electrophysiology signal recordings–only those that were deemed necessary.
There are many other books and papers,written by brilliant authors,including pioneers in this
field,showing conventional tracings in complex arrhythmias.What we want to present in “From
Signals to Colours”is the outstanding and unparalleled contribution ofelectroanatomic mapping
in the muddy field ofcomplex atrial arrhythmias.This does not mean that conventional electro-
physiology has been forgotten or abolished. Far from being in conflict with what is considered
conventional in electrophysiology, electroanatomic mapping is, in fact, based on conventional
recordings,and black and white conventional signals are embedded and integrated in a colour-
coded electroanatomic map to obtain a more complete and more intuitive display ofthe electrical
activation of a given heart chamber during a given arrhythmia.Some of the results obtained by
this project are shown in the 25 cases presented in this book. Basically, this project’s major
achievements have been procedure simplification and increased success rate,obtained widely and
in a replicable way among centres,when complex arrhythmias are approached.
The project could not have been developed and, consequently, the book could not have been
written without the personal and active contribution ofall participants.Their names and centres
are listed below.
Romane 4-09-2007 13:46 Pagina X
X Preface
• Department ofHeart Sciences,University ofInsubria – Ospedale di Circolo and Macchi Founda-
tion,Varese: Raffaella Marazzi, Fabrizio Caravati, Luigi Addonisio, Lucia De Luca,Valerio De
Sanctis, Luigi Di Biase, Gianluca Gonzi, Luca Panchetti and Jorge A. Salerno-Uriarte. Depart-
ment ofRadiology ofthe same Institution:Domenico Lumia and Carlo Fugazzola
• Interventional Cardiology Unit,Circolo Hospital,Busto Arsizio,Varese:Giulia Filippini and Et-
tore Petrucci
• Diagnostic and Interventional Electrophysiology Unit,Civile Hospital,Camposampiero,Padua:
Piero Turrini,Stella Baccilieri and Roberto Verlato
• Department ofCardiology,Villa Pini d’Abruzzo Hospital,Chieti:Raffaele Luise
• Cardiology Unit,Conegliano Veneto Hospital,Conegliano Veneto,Treviso:Leonardo Corò,Lui-
gi Sciarra and Pietro Delise
• Electrophysiology Unit,Department ofCardiology,S.Carlo Hospital,Milan:Daniele Malaspina
and Massimo Pala
• Cardiology Department, Civile Hospital, Mirano,Venice: Franco Zoppo, Francesca Zerbo and
Emanuele Bertaglia
• Departmant ofCardiology,C.C.dott.Pederzoli,Presidio Ospedaliero ULSS22,Peschiera del Gar-
da,Verona:Antonio Fusco and Alfredo Vicentini
• Arrhythmia Unit,Cardio-Thoracic Department,University of Pisa,Pisa:Giuseppe Arena,Ezio
Soldati and Maria Grazia Bongiorni
• Interventional Cardiology Unit,S.Maria Nuova Hospital,Reggio Emilia:Fabio Quartieri,Nico-
la Bottoni and Carlo Menozzi
• Institute ofCardiology,Department ofCardiovascular Medicine,Catholic University ofthe Sa-
cred Heart,Rome:Antonio Dello Russo,Michela Casella and Gemma Pelargonio
• Department of Pediatric Cardiology,Bambino Gesù Hospital,Rome: Massimo Stefano Silvetti
and Fabrizio Drago
• Electrophysiology Laboratory,Cardiology Unit,S.Chiara Hospital,Trento:Massimiliano Mari-
ni and Maurizio Del Greco.Department ofRadiology ofthe same Institution:Maurizio Centonze
I feel personally very much in debt with Gabriele Fischetto and Andrea Lenzi for ideating,de-
veloping and supporting the PEACE.
Being formatted as an atlas,this book focuses on images.For each case,a briefpresentation is
given and the narrative ofthe procedure is oriented towards a complete understanding ofimages.
Among them, electroanatomic maps obviously represent the vast majority and they are left as
they are generated by the system,with the addition ofsome asterisks or arrows in a very few cas-
es.This has been made on the assumption that they are or,however,should become self-explana-
tory and in this process reading ofthe initial chapter on methodology is ofcrucial importance.A
briefcommentary completes each case,underlining what we have learned from the procedure and
Romane 4-09-2007 13:46 Pagina XI
Preface XI
making correlations with other cases presented in the book.Only essential references are report-
ed,since in-depth discussion ofeach topic possibly brought up by each case is beyond the aims of
this book.
Comparison ofdifferent experiences and constructive discussion have always been the funda-
mentals of this project.Therefore,anyone willing to join the group should feel free to access the
open forum at [email protected] for further discussion and feed-back.On my side,I would be
very satisfied ifthis experience could minimally contribute in rendering less challenging the ap-
proach to complex cases in some other center,as it did in ours.
April 30,2007
Roberto De Ponti
Department ofHeart Sciences
University ofInsubria-Varese
Ospedale di Circolo and Macchi Foundation
Varese,Italy
Some ofthe members ofthe “Project ofElectroAnatomic mapping in Complex arrhythmia Evalu-
ation” (PEACE) during a break in the meeting on October 22, 2005 at the Villa Porro Pirelli,
Varese,Italy