9/7/2012 Mitral & Tricuspid Annular Atrial Tachs: Anatomic Distribution Use of the ECG for localizing atrial Superior Tricuspid Annulus Left Fibrous Trigone 38 (19%) tachycardias Right Fibrous AV ATach Foci Trigone • Jonathan Kalman Posterior MV Royal Melbourne Hospital Anterior HBE Melbourne, Australia TV CS (No disclosures) Mitral Annulus 8 (4%) ATach Foci Inferior Morton et al, JCE 2001 Kistler et al, JACC 2003 Atrial Tachycardia 144 (73%) RA Anatomic Distribution: Total AT & Incessant AT Medi et al, JACC 2009 – Crista Terminalis – 62 (31%) Total AT (n) Incessant AT (n) % Site Incessant – Para-hisian – 22 (11 %) 100 – CS Os – 16 (8%) 84 – 3 (1.5%) – Septal 80 – RAA – 3 (1.5%) 59 60 53 (27%) LA 40 – Pul Veins – 35 (18%) 22 18 – Lt septum – 3 (1 %) 20 11 4 – LAA – 3 (1%) 0 – CS Body – 3 (2%) CT TA/MA PVs Perinodal LAA/RAA CS Anatomic Distribution Anatomic AT Site 1
9/7/2012 Multipolar mapping to detect activation pattern change P WAVE ALGORITHM Kistler, JACC 2006 neg/pos I V1 neg pos/neg iso pos iso/pos aVF V1 V6 ABL Sinus Sinus Atrial Tach bifid in II V2 – 4 R.Septum CT aVL HBE &/or V1 pos Perinodal Halo-d yes neg no pos yes no V1 P wave: CS os neg in all - neg or pos/neg: specificity 100% RA focus SMA neg in all sinus CT LS inf.leads inf.leads P wave - pos or neg/pos: sensitivity 100% LA focus. NCC yes no no +/- pos yes CS LPV TA CT TA RPV body LAA RPV RAA Halo-p 3D Activation Map to localize Identify P wave morphology and onset RA Appendage AT Ventricular ectopy/pacing or adenosine to unmask P wave RAO I LAO Bipolar activation time (pre P) II 70 III Activation time (ms) 60 aVR p=ns 50 aVL 40 aVF V1 30 20 V2 10 V3 0 V4 Successful Unsuccessful V5 sites sites V6 2
9/7/2012 AT Age distribution A Novel Pacing Maneuver to Localize Focal AT Mohamed, Klein, JCE 2007 Mode of AT initiation Crista AT vs Other AT p<0.05 321 ATs Heck, HRS 2011 Cristal AT Other AT P Number 117 (36%) 204 (64%) p<0.05 Age 57 ± 14 47 ± 20 <0.0001 Female:male 75:25 50:50 <0.0001 Structural Ht Disease 28% 19% 0.05 p=ns Anatomic Location on Crista Superior 46% Mid 49% Inferior 5% 3
9/7/2012 Multiple Focal Atrial Tachycardias 22 yr old with incessant ATach Superior CT Hillock et al, Heart Rhythm 2007 Pt Age Duration (yrs) AT 1 AT 2 AT 3 I II 1 48 12 TA TA V1 V6 2 60 11 CS os CT HBE 3 63 7 CT R septal TA CSd 4 58 1.5 MA RUPV 5 59 2 CT CS os CS CSp 6 61 8 CS os CT- mid SVC/RA CT 1,2 7 28 16 CS os CT AVNRT 8 59 20 CT-high CT-mid 9 53 0.75 MA CT 10 53 4 CT-mid CT-high CT 19,20 All female 7/10 CT focus, 4/10 CS os 22 yr old with incessant ATach LAO Superior CT 22 yr old with ATach Superior CT I II V1 I V6 -20ms II ABL III aVR CSd aVL SVC RAO aVF CT CSp V1 CT 1,2 V2 FO V3 CS Os V4 V5 IVC CT 19,20 V6 4
9/7/2012 Electro-anatomic map 31 yr old male: Incessant Tachycardia I SVC-RA Jn II III LA aVR aVL aVF RA V1 V2 V3 V4 V5 V6 II RSPV vs. Superior CT Kistler, JACC 2006 V1 “Bump” V6 Tc P wave in V1 RSPV RIPV High CT RSPV ABL I Termination CT: biphasic in V1 or if I HBE II pos also pos in SR of AT in II CS d III III LSPV RSPV: positive AVR AVR AVL CS p AVL Ao RAA AVF AVF Lasso V1 V1 Crista Guided SVC PV Isolation V6 RSPV V6 AEB SR SR AEB 5
9/7/2012 PV Tachycardia RF Ablation 24 yr old woman, incessant AT Kistler Circ 2003, Teh JCE 2010 I Induction Spontaneous/Isuprel – 43 II (talking/coughing-6) III PES/Burst pacing – 0 aVR Recurrence Same location – 7/43 aVL New Focus – 1/43 aVF Long term AF 2/43 6 ± 4 yrs F/up V1 development V2 Anatomic location Ostial – 41 V3 Within PV - 2 V4 RF Approach Focal – 39 V5 V6 PV Isolation - 4 24 yr old woman, LAO LSPV vs LAA AT: P waves incessant AT LAA LIPV LAA Kistler, JACC 2006 LSPV I I LSPV Tc P wave II -55ms II V1 iso or neg in lead I V6 III RF on AVR + V1-6 Abl d AVL bifid pos in lead II &/or V1 RAO AVF Abl p Sensitivity 82% V1 HBE Specificity 98% CSd PPV 88% NPV 97% CSp V6 6
9/7/2012 18 yr old boy p/w severe CHF, Incessant tachycardia 120 bpm 24 yr old ♀ , incessant AT anterior base of LAA I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 EP, ECG & RFA of LAA AT Yamada, Kay HR 2007 RA Appendage Tachycardia • 13 pts, 7 m, mean age 30 yrs. Sporadic - 5, Incessant /continuous – 8 Figure 2 • 13/13 at base of LAA (11 medial, 2 lateral) LAO RAO • RFA successful in 13/13 with 11 ± 5 RFs Neg P wave I & aVL (12/13): Sens 92%, Spec 97% PPV 92%; NPV 97% TA TA 7
9/7/2012 Characterization of focal right atrial RAA Tachycardia – ECG Morphology appendage tachycardia Freixa, J.Brugada. Europace 2008 Roberts-Thomson et al, J Cardiovasc Electrophysiol 2007 I • 15/186 (8%) pts undergoing RFA for AT • V1 /V2 II • Tip of RAA - 9 pts (60%), base of RAA - 6 pts (40%) – neg in 10/10 III – notching 6/10 • 5 /15 pts irrigated RF aVR • Variable precordial • RAAT pts vs other AT pts aVL transition to pos in – ↑ male (66% vs. 38%; p = 0.013) V6 aVF – younger (32 yrs vs. 55 yrs; p = 0.001) V1 • II, III, aVF – Low amplitude pos – ↑incessant tachycardia (53% vs. 16%; p = 0.001) V2 9/10 V3 – LV dysfunction (27 % vs. 5%; ps = 0.018). V4 – RFA effective in all pts (100 vs. 75%; p = 0.022) V5 – No recurrences (0 vs. 8%) mean f-up 37 months. V6 22 yr old male incessant RAA AT: Focal AT from the RAA Unsuccessful ablation (3 rd attempt) Roberts-Thomson et al, J Cardiovasc Electrophysiol 2007 (irrigated RF to 35W) • 10/261(3.8%) pts undergoing RFA for focal AT • 9 males, mean age 39 years • Symptoms mean 4.1 years. • Tachycardia – incessant 7 pts, spontaneous 1 pt, induced by PES 2 pts • Tachy-mediated cardiomyopathy – 5 pts (mild 3, severe 2). • Anatomic location – Base 8; tip 2 • Successful RFA 10/10(irrigated RF in 8/10; 25-30W); – No recurrence @ mean f-up of 8 mths 8
9/7/2012 CS os vs. Rt Perinodal vs. Lt Septal Right Left CS os perinodal Septal Anatomy I CT II SVC RAA III CS Os Tc P wave - viewed aVR -/+ or iso/+ in V1 aVL from RAA aVF neg in II, III, aVF posterior V1 TA + aVL IVC V6 ECG of Focal AT Superior Tricuspid Annulus vs RAA from Kistler, JACC 2006 SUP TA RAA RAA Non-Coronary • ECG appearance similar I Aortic Sinus • V1 II Ouyang et al, JACC 2006 – neg in 100% III • Lead I & aVL – notching 60% AVR – pos 9/9 • Late transition to pos in V6 AVL • II, III, aVF • V1 & V2 AVF – Low amplitude pos 90% – neg/pos 9/9 V1 • • II, III, & aVF TV – neg/pos in 7/9 HBE – neg in 1/9 CS – pos in 1/9 V6 9
9/7/2012 67 yr woman 10 yr Hx SVT 52 yr woman p/w paroxysmal AT I I II II III III aVR aVR aVL aVL aVF aVF V 1 V1 V 2 V2 V 3 V3 V 4 V 5 V4 V 6 V6 Peri-nodal ATach: Onset of AT with VAAV response Successful RF Site I I II II V1 V1 V6 HBE -58ms to P wave ABL CS d HBE CS d CS p CS p 10
9/7/2012 Lt septal: -30 Rt perinodal: -25 NCC: -15 41 yr male 5 yr Hx SVT I II I V1 II III ABL aVR aVL HBE aVF V 1 CS d V 2 V 3 V 4 V 5 CS p V 6 V6 Rt perinodal: -30 Lt septal: -20 NCC: -15 NC aortic sinus I Mapping II “left septal” AT V1 ABL Rt Peri-nodal HBE Lt Peri-nodal CS d CS p V6 11
9/7/2012 Mitral annular AT EP properties of para-Hisian AT Teh HR 2010 RSPV LSPV Iwai, Lerman. Heart Rhythm 2011 LAA • 38 pts (mean age 63yrs; 23 female) • Origin anteroseptal TA * MA • Narrow P wave Ao • Adenosine termination 34/35 pts. • RFA attempt 30/38 pts(79%); successful 26/30(87%) • Access from NC aortic sinus in 4 pts • CONCLUSIONS: LA • Properties consistent with AT from TA, MA * Abl Ao MV • Should be considered a subset of “annular” ATs. • Mechanism c/w cAMP-mediated triggered activity. LV His RV CS Mitral Annular Tachycardia: Mapping and Ablation of AT P Wave Morphology Tc P wave • Anatomy/Anatomic distribution I II -/+ in V1 III iso or - aVL • P wave useful aVR Sensitivity 88% aVL aVF Specificity 99% – (normal anatomy/no prior AF ablation) V 1 V 2 LAO • Locations in close anatomic proximity V 3 CT V 4 MAP V 5 • Range of mapping tools HBE CS V 6 12
9/7/2012 Does LV function recover completely after TCM? Controls AT-NEF AT-LEF P 47 ± 4 52 ± 4 45 ± 5 value (n=20) (n=15) (n=18) Age, years 0.7 64 ± 2 67 ± 3 65 ± 2 Male, n (%) 13 (65) 5 (53) 12 (71) 0.7 97 ± 3 94 ± 3 103 ± 5 Rest HR,bpm 0.7 24 ± 1 25 ± 1 25 ± 1 eGFR, ml/min 0.2 75 ± 7 59 ± 11 BMI, kg/m 2 0.4 Mths post-RF - 1 Ling, Heart Rhythm Boston 2012 Recovery of tach-mediated cardiomyopathy post RFA MRI – LV morphology • Return to normal in 29/30 pts at mean 2.8 mths • No recurrence of LV dysfunction or late arrhythmias at 20 mths f/up Medi et al, JACC 2009 Controls AT-NEF AT-LEF P 84 ± 3 85 ± 4 102 ± 5* value (n=20) (n=15) (n=18) 31 ± 2 30 ± 2 41 ± 3* 56% LV EDVI, ml/m 2 <0.05 56 ± 3 54 ± 5 56 ± 5 LV ESVI, ml/m 2 <0.01 21 ± 1 22 ± 1 22 ± 1 LV mass I, g/m 2 0.9 LA area (4C), 35% 0.9 cm 2 Ling, Heart Rhythm Boston 2012 Pre-ablation Late post-ablation 13
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