2006 bologna, caso clinico. ablazione transcatetere di tachicardia atriale incisionale

1. INCISIONALINCISIONAL
LEFT ATRIAL TACHYCARDIALEFT ATRIAL TACHYCARDIA
(case report)(case report)
Stefano Nardi, MD
AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNI
DIPARTIMENTO CARDIOTORACOVASCOLAREDIPARTIMENTO CARDIOTORACOVASCOLARE
STRUTTURA COMPLESSA DI CARDIOLOGIASTRUTTURA COMPLESSA DI CARDIOLOGIA
STRUTTURA SEMPLICE DI ARITMOLOGIASTRUTTURA SEMPLICE DI ARITMOLOGIA
LABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONELABORATORIO DI ELETTROFISIOLOGIA ED ELETTROSTIMOLAZIONE

2. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
NavXTM
System (ESI, St. Jude Medical)
represents a novel MAPPINGMAPPING and
NAVIGATIONNAVIGATION system that allows the
possibility to create a 3D geometry of the
heart, valves and vessels, using cutaneous
patches, and moreover to visualize up to 12
conventional cardiac catheters
INTRODUCTIONINTRODUCTION

3. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
END-POINTEND-POINT
• RECONSTRUCTIONRECONSTRUCTION of a surface model ofof a surface model of
the LA endocardiumthe LA endocardium
• IDENTIFIEDIDENTIFIED the operative mechanism of ATthe operative mechanism of AT
• DESCRIBEDESCRIBE the EA characteristicsthe EA characteristics
• ASSESSASSESS the effect of RF lesion at thethe effect of RF lesion at the
identified target siteidentified target site

4. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• 56 years-old men with previous MITRALMITRAL
VALVEVALVE replacement with prosthetic valve
(rheumatic valvular disease)
• SIX MONTH LATERSIX MONTH LATER cardiopalm, first
paroxysmal then permanent.
• The ECGECG surface reveals an AT with stable CL
• Previously TWO INEFFECTIVE ECV.TWO INEFFECTIVE ECV.
• AT duration was 12 months, despite using three
different AADsAADs (Sotalol, Flecainide and
Amiodaron) alone or with class IV
METHODSMETHODS

5. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• Symptomatic for progressive DYSPNEADYSPNEA, with
reducing TOLERANCETOLERANCE to the EFFORTEFFORT, and
with a progressive DETERIORATIONDETERIORATION of
QOLQOL and NYHANYHA class (III).
• The TTETTE analysis reveals a LALA enlargement
with LVLV dysfunction (LA size at TTE was 50
mm and LVEF ≈35%).
METHODSMETHODS

6. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• INCESSANT ATINCESSANT AT with
stable CL (320 ms)
• POSITIVEPOSITIVE P wave in V1
• P wave, in the inferior
limbs, DIFFERENTDIFFERENT from
typical AFl
ECG DATAECG DATA

7. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• OCTAPOLAROCTAPOLAR catheter in the CS (reference NavX)
• OCTAPOLAROCTAPOLAR catheter at the His bundle/RBB
• 20-polar CIRCULARCIRCULAR mapping catheter into the RA
• LONG SHEETLONG SHEET inserted into the RA
• Transeptal catheterization with BRKBRK needle
• An irrigated tip IRVINE (SJM)IRVINE (SJM) catheter into LA.
SETTINGSETTING

8. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• Both BIPOLARBIPOLAR and UNIPOLARUNIPOLAR signal EGM were
filtered at bandpass settings of 30 to 500 Hz
and 0.05 to 200 Hz, and were digitally recorded.
• Systemic IV ANTICOAGULATIONANTICOAGULATION was starting
with heparin-Na+ after transeptal puncture
• ANGIOGRAMANGIOGRAM of the PVs, was performed in two
different axis (LAO/RAO), before mapping
• ACTACT was mantaining between 250 and 300s.
SETTINGSETTING

9. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
MAPPINGMAPPING

10. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
MAPPINGMAPPING

11. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• VIRTUAL GEOMETRYVIRTUAL GEOMETRY correlate closely with ANATOMIC
model, EP recordings and FLUOROSCOPIC images
• ILATILAT defined as continuous
sequence of LA activation with
earliest activation adjacent to
latest activation.
• FRACTIONEDFRACTIONED and DOUBLEDOUBLE
POTENTIALSPOTENTIALS at the roof
and posterior wall of the LA
(left atriotomy)
• ENTRAINMENT PACINGENTRAINMENT PACING
at the target site reveal a
MAPPINGMAPPING

12. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• PULSESPULSES of RFRF (rose dots) were applied in order to create
a block-line at the “target” site.
• CURRENT DELIVERYCURRENT DELIVERY
started at 20 W power and
gradually increased
(continuous monitoring of
impedance, temperature, EGM)
• RFRF was maintained until the
bipolar atrial potential
recorded decreased by 80%
or split into double potentials
(conduction block).
ABLATIONABLATION

13. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
CURRENT DELIVERYCURRENT DELIVERY was terminated if:
• DISAPPEARINGDISAPPEARING of LA potential
• FAILUREFAILURE to reach end-point after 120 s
• Suddenly IMPEDANCE RISEIMPEDANCE RISE

14. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
ABLATIONABLATION

15. • The OPERATIVEOPERATIVE
MECHANISMMECHANISM of
AT was correctely
identified
Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
ABLATIONABLATION
• ILATILAT as dual-loop
• CONDUCTIONCONDUCTION
BLOCKBLOCK across the
isthmus was able to
interrupt the AT

16. • ECHOCARDIOGRAPHYECHOCARDIOGRAPHY after ablation
Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
POST-ABLATIONPOST-ABLATION
MANAGEMENTMANAGEMENT
• SYSTEMIC ANTICOAGULATIONSYSTEMIC ANTICOAGULATION was
starting with heparin-Na+ six hours after the
end of the procedure
• ORAL ANTICOAGULATIONORAL ANTICOAGULATION 24 hs later

17. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• After 6 month FU, FREEFREE from AT without AADs.
• Our FU consists in PERIODICPERIODIC clinical CTR,
baseline ECG and Holter monitoring (each month)
• IMPROVEMENTIMPROVEMENT of Clinical parameters
(QOL, effort’s tollerance, NYHA) and Echo
parameters (LVEF 50%).
POST-ABLATIONPOST-ABLATION
MANAGEMENTMANAGEMENT

18. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• CONVENTIONALCONVENTIONAL
MAPPINGMAPPING is not really
appropriate for ILATILAT
mapping, because very
limited understanding of
these complex arrhythmias
(highly variable from one
patient to the other).
• The MAIN DRAWBACKMAIN DRAWBACK
of EP criteria is that the
reconstruction of complete
circuit(s) is EXTREMELYEXTREMELY
DIFFICULTDIFFICULT to achieve.
CONCLUSION (1)CONCLUSION (1)

19. Incisional Left Atrial TachycardiaIncisional Left Atrial Tachycardia
• NAVX TECHNOLOGYNAVX TECHNOLOGY allows a REALISTIC 3DREALISTIC 3D
• The catheter tracking and 3-D
construction is feasible using
CUTANEOUS PATCHESCUTANEOUS PATCHES and
CONVENTIONALCONVENTIONAL Catheters
• This approach may be USEFULUSEFUL
in the treatment of pts with
cardiac arrhythmias where
ablation therapy is primarily
ANATOMICALLY BASEDANATOMICALLY BASED
CONCLUSION (2)CONCLUSION (2)