Patterns and Characteristics of SKYLINE-Lumipoint Feature in the Catheter Ablation of Atypical Atrial Flutter: Insight from a Novel Lumipoint Module of Rhythmia Mapping System

Figures

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  Figure 1. Illustration of stepwise approach in application of LUMIPOINT & Skyline for aAFL in a patient with prior cardiac surgery. In frame (A), 1 denotes first step to determine the possible main circuit in isochronal map; 2 denotes second step to scan the Skyline, identify the GAH-valley, and check the corresponding highlighted area in isochronal map; and 3 denotes third step to confirm the wave-front property and characteristics of local signals in highlighted area. In frame (B), ablation lesion set showed initial cavo-tricuspid isthmus (CTI) linear ablation failed to terminate the atrial flutter; instead, focal ablation at the highlighted area by Skyline valley successfully terminated atrial flutter to sinus rhythm (SR). In the first step, isochronal map showed two reentry circuits, one with macro-reentry counterclockwise atrial flutter and the other with localized reentry confined at mid-septum. Without entrainment, we cannot confirm the mechanism. Therefore, we started with CTI linear ablation instead of focal ablation because macro-reentry CTI dependent atrial flutter was more prevalent, and focal ablation in mid-septum took more risk in AV node injury. Since activation sequence…

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  Figure 2. A case of localized reentry aAFL.

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  Figure 3. A case of multiple-loop (figure-of-eight) macro-reentry aAFL. Right panel shows wave-front propagating through a slow conduction region at the lateral mitral annulus before diverging into three different activation wave-fronts; critical slow conduction along with LSPV ridge (a), wave-front collision (b), and another region of slow conduction along the LIPV ridge (c).

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  Figure 4. (A) GAH-Valley Score at the Successful Site. (B) Distributions of GAH-Scores in different types of Reentry aAFLs. In the localized reentry, the highlighted area of GAH-Valley scores < 0.2 significantly matched with the successful ablation sites, compared with both macro- and multiple-loop reentry aAFLs (Left). Likewise if excluding the multiple-loop reentry (Right).

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  Figure 5. The proposed stepwise approach in LumipointTM module to identify practical ablation sites in patients with aAFL.