Pulmonary vein potential mapping in atrial fibrillation with high density and standard spiral (lasso) catheters: A comparative study

Figures

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  Fig. 1. Endocardial signals and fluoroscopic view of the High Density Mesh Mapper (HDMM) in ablation position. The HDMM is a non-deflectable, 8F expandable mesh- configured electrode catheter, consisting of two opposing 16 electrode pairs. The interwoven electrodes allow for complete circumferential mapping of the Pulmonary vein by staggered recording configuration between the electrodes 1–3; 2–4; 3–5 etc. up to 31–1; 32–2. In total, 32 unipolar or bipolar electrograms can be simultaneously recorded. From the top to the bottom: Surface ECG leads: I, II, aVF, V1, V6. Endo-cardiac signals: Coronary sinus CS 1/2, HDMM circumference 1/3, 2/4 until 31/1, 32/2. Example of typical endocardial signals prior to ablation located at the ostium of the Right superior Pulmonary Vein. Of the two components recorded, the first one is the atrial signal, indicated by the thick arrows, the second component of the fragmented signal is the Pulmonary Vein Potential, here indicated by the thin arrows.

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  Fig. 2. The High Density Mesh Mapper (HDMM) in place at the left atrium–pulmonary vein junction closed to the right superior pulmonary vein (RSPV). (A) The catheter is not fully expanded like an umbrella, in this situation the catheter is half streched with the tip deep in the pulmonary vein and the shaft outside the vein. The de-isolated zone of the HDMM-catheter where the recording of the endocardial signals is performed is marked with an arrow. (B) The RSPV in which the catheter is located. (C) The same PV, now the Cryoballon with the mapping catheter (Achive) behind the balloon.

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  Fig. 3. (A) The High Density Mesh Mapper (HDMM) in place at the Left Atrium-Pulmonary Vein junction closed to the Left Superior Pulmonary Vein (LSPV). The catheter is fully expanded like an umbrella, in this situation the catheter is fully stretched with the tip deep in the Pulmonary Vein (PV) and the shaft outside the PV. The de-isolated zone of the HDMM, where the recording of the endocardial signals is performed is marked with arrows. (B) The same PV, now the Cryoballoon with mapping catheter (Achive) behind the balloon, (B) with, and (C) without contrast medium, different LAO views.

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  Fig. 4. (A) Endocardial signals of the High Density Mesh Mapper (HDMM) prior cryoballoon ablation. Confirmation of Pulmonary Vein Potentials (PVP׳s) in 4 of 4 quadrants. Proof of clumsy atrial signals (thick arrows) and tiny PV-signals, latter indicated by the thin arrow, directly after the atrial signal. Some of the atrial and PVP׳s are more or less fused. Arrangement of ECG leads and catheter, see Fig. 1. (B) Re-map with the High Density Mesh Mapper (HDMM, B) and the Achive Catheter (AC, C) after Cryoballoon ablation. Proof of tiny Pulmonary Vein Potentials (PVP׳s) remaining in two quadrants, between HDMM 6/8 and 12/14. PVP׳s, indicated by the thin arrows, prior to that the typical clumsy atrial signals, here indicated by the bulky arrows. Due to the ablation, there is already a certain delay between the two signals as compared to Fig. 1, where the signals are more or less fused. (C) No further PVP׳s are recorded in the same position. (D) Re-map with the High Density Mesh Mapper (HDMM) after Re-ablation. Reapplication of further energy to the same Pulmonary Vein, now demonstrating complete isolation of the PV also with the HDMM. There are no longer any tiny PV-signals traceable,…

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  Fig. 5. Technical structure of the High Density Mesh Mapper (HDMM) and the Achive Catheter (AC). Division of the HDMM, 32 poles, panel on the left, and the AC, 8 poles, panel on the right in four quadrants. Due to the number of electrodes, the HDMM consists of 4×8=32 poles and the AC of 4×2=8 poles. To map and describe the entire circumference of both catheters, each quadrant is equivalent to 25% (8 poles in each quadrant in the HDMM, 2 poles in each quadrant of the AC. 1 Quadrant equates 1–8 PVPs in the HDMM and 1-2PVPs in the AC, this means 25% PVP circumference, 2 Quadrants equates 9–16 PVPs in the HDMM and 3–4 PVPs in the AC, this means 50% PVP circumference, consistent for the next two 100% PVP circumference. For example: HDMM 32 PVPs, AC 8 PVPs (equivalent 100% / 100%); HDMM 19 PVPs in 3 of 4 quadrants (equivalent 75%), AC 5 PVPs in 3 of 4 quadrants (equivalent 75%).

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  Fig. 6. Mapping results in 24 patients with the High Density Mesh Mapper (HDMM) and the Achive Catheter (AC) prior to ablation (X-axis). Y-axis: number of quadrants. Analysis in each quadrant for both catheters. Of 384 PV-quadrants/24 patients analyzed, identification of PVPs in 279/384 quadrants in the HDMM group = 73% and identification of PVPs in 192/384 quadrants in the AC group = 50%, (P < 0.05).