practical vt ablation cases with high density mapping · practical vt ablation cases with high...
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Practical VT ablation cases withhigh density mapping
P Maury, University Hospital Toulouse France
with the Rhythmia system
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Disclosure
P Maury
I do not have any potential conflict of interest
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A means to an aim
8 Fr Bidirectional Catheter
Mini-Basket Electrode Catheter (Orion, Boston Scientific)
64 Low NoiseElectrodes
Magnetic & Impedance
LocationSensors
8 SplinesEach with 8electrodes
2.5 mm inter-electrode
0.4 mm2
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a very solid and cleveralgorithm for VT
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Cycle lenght stability morphology
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TO ALLOW ULTRA HIGH DEFINITION
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… Very Quick Mapping …
9 min8000 points
800 points35 sec
courtesy from F Sacher
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Analysis of some VT circuits
PACE 2018
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34 5
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VT circuit
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?
!
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Substrate mapping using UHD ?
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Substrate vs activation mapping
VISTA trial
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« historically »
reference values for distinguishing normal and abnormal EGMsCarto and Navistar catheter
RV (4 patients) and/or LV (4 patients) in 6 patients without structural heart disease.71 to 168 endocardial sites/ventricle
mean bipolar electrogram amplitude normal RV 3.76+/- 1.7 mV 95% of all RV bipolar electrogram > 1.44 mV
mean bipolar electrogram amplitude normal LV 4.86 +/- 3.1 mV 95% of all LV bipolar electrograms > 1.55 mV
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bipolar electrogram amplitude
- amount of healthy tissue under electrode- size of electrode and bipole- hypertrophy of CM- direction of activation, dipole orientation- synchronization of cells- refractory periods (cycle length)- contact- filtering- impedance- amplification- animal model only one voltage scale is not correct
need to be adapted to each case
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excellent correlation of areas of low voltage and scars on MRI in dog infarctionsusing 1-2 mV scale
mean resolution of 2.8 +/- 0.6 mm
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scale 0.5-1.5 mV
infarction in swine95% normal value in healthy myocardium> 1.5 mV
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• In 8 chronically infarcted ovine• MRI• Endo-epi map with Orion (Rhythmia system)• Endo: 8012 ±3370 points, Epi: 30232 ±10530 pts
• Fusion and determination of voltage tsd
Voltage Threshold
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Voltage Threshold
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Atrial pacing RV pacing LV pacing
Martin C, et al. Circ EP 2019 (in press)
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Atrial pacing RV pacing LV pacing
Martin C, et al. Circ EP 2019 (in press)
Scar area larger during atrial pacing vs RV or LV pacingLAVAs area smaller during atrial pacing vs RV or LV pacing
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« one aquisition two maps technique »
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Automated detection of LAVAs
Lumipoint ™
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Automated detection of fractionnated potentials
Lumipoint ™
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original mapAutomated correction of wrong annotations
Lumipoint ™
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manual reannotation (around 90 min) automated reannotation (around 2 min)
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sinusal
Narrow QRS VT
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unmappable fast VT (but not while on Impella)
260 bpm
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1
23MUSIC software
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Conclusion
Ultra high definition has become mandatory in VT ablation in SHD
the Rhythmia system provides sufficiant resolutionfor highlighting complex VT mechanisms
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