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Electro-anatomical Mapping of the Heart An Illustrated Guide to the Use of the CARTO™ System Josef Kautzner Anders Kirstein Pedersen Petr Peichl
Electro-anatomical Mapping of the Heart An Illustrated Guide to the Use of the CARTO™ System
Josef Kautzner Anders Kirstein Pedersen Petr Peichl
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Electro-anatomical Mapping of the Heart An Illustrated Guide to the Use of the CARTO™ System
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CARTO™ system is a registered trademark of Biosense Webster, Inc., Diamond Bar, CA, USA. Published by Remedica Commonwealth House, 1 New Oxford Street, London, WC1A 1NU, UK Civic Opera Building, 20 North Wacker Drive, Suite 1642, Chicago, IL 60606, USA
[email protected] www.remedicabooks.com Tel: +44 20 7759 2999 Fax: +44 20 7759 2901 Publisher: Andrew Ward In-house editors: Nicky Fernando and Catherine Harris Booth Design and artwork: AS&K Skylight Creative Services © 2006 Remedica While every effort is made by the publisher to see that no inaccurate or misleading data, opinions, or statements appear in this book, they wish to make it clear that the material contained in the publication represents a summary of the independent evaluations and opinions of the authors. As a consequence, the authors, publisher, and any sponsoring company accept no responsibility for the consequences of any inaccurate or misleading data or statements. Neither do they endorse the content of the publication or the use of any drug or device in a way that lies outside its current licensed application in any territory. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher. Remedica is a member of the AS&K Media Partnership ISBN-13: 978 1 901346 98 5 ISBN-10: 1 901346 98 6 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. Printed in Spain.
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Electro-anatomical Mapping of the Heart An Illustrated Guide to the Use of the CARTO™ System
Josef Kautzner, MD, PhD Professor of Medicine Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czech Republic Anders Kirstein Pedersen, MD, PhD Associate Professor of Cardiology Skejby Sygehus Aarhus University Hospital Denmark Petr Peichl, MD Fellow in Cardiology Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czech Republic
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CONTENTS Preface
ix
Abbreviations
xi
1.
Electro-anatomical Mapping
1
1.1 Basic Principles of Electro-anatomical Mapping 1.1A General concepts 1.1B Spectrum of electro-anatomical maps 1.1C Limitations of electro-anatomical mapping
2 2 5 7
1.2 Set-up for the Mapping Procedure 1.2A Location of the reference patch 1.2B Selection of the reference signal – the key to success 1.2C Setting up the window of interest
8 8 9 9
1.3 Mapping Technique 1.3A CARTO mapping of cardiac chambers 1.3B Maintaining endocardial contact with the mapping catheter
13 13 17
1.4 Annotation of Electro-anatomical Maps 1.4A How to annotate electrograms 1.4B How to differentiate atrial from ventricular local electrograms 1.4C How to define myocardial scar 1.4D How to evaluate a line of block
18 18 18 18 21
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CONTENTS
2.
3.
vi
1.5 Diagnosis of Arrhythmias 1.5A Mechanism of arrhythmias 1.5B The importance of entrainment mapping during CARTO procedures 1.5C New map or re-map?
22 22 24 25
1.6 Advanced Mapping Techniques 1.6A Qwikmapping 1.6B Image integration
26 26 26
Normal and Abnormal Conduction of the Heart
31
2.1 Virtual Model of the Heart
32
2.2 Normal Electrical Activation of the Atria and Ventricles
32
2.3 Activation Patterns in Ventricular Conduction Disturbances 2.3A Left bundle branch block and left ventricular conduction abnormalities 2.3B Left anterior hemiblock accompanied by right bundle branch block
35 35 35
2.4 Activation Patterns During Different Pacing Modes 2.4A Right ventricular apical pacing 2.4B Biventricular pacing 2.4C Right ventricular bifocal pacing 2.4D Single-site left ventricular pacing
37 37 38 38 38
Clinical Application of Electro-anatomical Mapping in the Treatment of Arrhythmias
41
3.1 Focal Atrial Tachycardias
43
3.2 Typical Atrial Flutter 3.2A Typical atrial flutter 3.2B Reverse typical flutter
45 45 47
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3.3 Atypical Atrial Flutter 3.3A Non-surgical right atrial macro-reentrant tachycardias 3.3B Post-incisional right atrial tachycardias 3.3C Left atrial macro-reentrant tachycardias 3.3D Left septal atrial flutter 3.3E Post-ablation left atrial tachycardias 3.3F Macro-reentrant tachycardias after correction of complex congenital heart disease
49 49 50 51 51 52 52
3.4 Atrial Fibrillation 3.4A Segmental pulmonary vein isolation 3.4B Circumferential ablation around pulmonary vein ostia 3.4C Combined technique 3.4D Ablation of an electrophysiological substrate 3.4E The role of imaging
53 53 55 56 57 57
3.5 Atrioventricular Nodal Reentry
60
3.6 Inappropriate Sinus Tachycardia
62
3.7 Accessory Pathways
63
3.8 Idiopathic Focal Ventricular Tachycardia 3.8A Ventricular tachycardia originating from the right ventricular outflow tract 3.8B Ventricular tachycardia originating from the left ventricular outflow tract 3.8C Right ventricular outflow tract versus left ventricular outflow tract site of origin 3.8D Other locations of the arrhythmogenic focus in idiopathic ventricular tachycardias
65 65 67 67 67
3.9 Idiopathic Reentrant Ventricular Tachycardia (Fascicular)
70
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3.10 Post-myocardial Infarction Ventricular Tachycardia 3.10A Mapping during ventricular tachycardia 3.10B Ablation of stable ventricular tachycardia 3.10C Sinus rhythm substrate mapping 3.10D An integrated approach 3.10E Epicardial approach
71 71 72 72 73 73
3.11 Ventricular Tachycardias in Dilated Cardiomyopathy
75
3.12 Ventricular Tachycardias in Right Ventricular Arrhythmogenic Cardiomyopathy
76
3.13 Post-incisional Ventricular Tachycardias
78
3.14 Catheter Ablation of Ventricular Fibrillation
80
References
viii
83
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PREFACE Mapping of the heart is one of the principal techniques used in the diagnosis and treatment of cardiac arrhythmias. Electrical activity of the heart can be recorded from the body surface (ECG mapping), from the surface of the heart (epicardial mapping) or from the endocardium (endocardial mapping). Signals can be acquired simultaneously from various sites or sequentially, point-by-point, and these data can be visualized in different formats. The power of computer processing opened new horizons in cardiac mapping. The so-called electro-anatomical mapping system (CARTO™, Biosense Webster, Inc., Diamond Bar, CA, USA), developed in the mid-nineties, represents one of the most successful systems for detailed endocardial/epicardial mapping of cardiac arrhythmias. For the first time in history, it allowed superimposition of 3D anatomy and local electrograms. The major advantages of the system comprise direct visualization of the activation pattern of individual arrhythmias, catheter navigation to the desired arrhythmic substrate during radiofrequency ablation and minimal need for fluoroscopy. Since its introduction into the clinical arena, the use of the electro-anatomical mapping system has continued to grow. This book reviews the main clinical applications of the CARTO system, and provides recommendations for the mapping and treatment of a wide range of arrhythmias. We hope that the combined experience of our two centers will provide practical assistance to those just starting to use this system. Besides explanation of basic principles of the mapping procedure, major sections of the book deal with the use of the CARTO system in individual types of arrhythmias. For each arrhythmia, a review of published data is presented together with a recommended strategy for mapping and ablation. All sections are supported by images in order to facilitate the learning process. Finally, the text is accompanied by a selection of the most relevant references.
Josef Kautzner, MD, PhD Anders Kirstein Pedersen, MD, PhD Petr Peichl, MD March 2006
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ABBREVIATIONS 3D = three-dimensional AF = atrial fibrillation Ant = anterior Ao = aorta ARVC = arrhythmogenic right ventricular cardiomyopathy AT = atrial tachycardia AV = atrioventricular aVF = augmented electrocardiographic leads from the foot aVL = augmented electrocardiographic leads from the left arm AVNRT = atrioventricular nodal reentrant tachycardia aVR = augmented electrocardiographic leads from the right arm CRT = cardiac resynchronization therapy CS = coronary sinus CT = computed tomography ECG = electrocardiogram EP = electrophysiological ICE = intracardiac echocardiography Inf = inferior IVC = inferior vena cava IVS = interventricular septum LA = left atrium Lat = lateral LATs = local activation times LBBB = left bundle branch block LCA = left coronary artery LIPV = left inferior pulmonary vein
LPB = left posterior bundle LSPV = left superior pulmonary vein LV = left ventricle LVOT = left ventricular outflow tract MA = mitral annulus MI = myocardial infarction MR = magnetic resonance Os = ostium PA = pulmonary artery PPI = post-pacing interval PVs = pulmonary veins RA = right atrium RB = right bundle RBBB = right bundle branch block RCA = right coronary artery RF = radiofrequency RIPV = right inferior pulmonary vein RSPV = right superior pulmonary vein RV = right ventricle RVOT = right ventricular outflow tract SVC = superior vena cava TA = tricuspid annulus VF = ventricular fibrillation VT = ventricular tachycardia WOI = window of interest
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ELECTRO-ANATOMICAL MAPPING 1.1 Basic principles of electro-anatomical mapping 1.2 Set-up for the mapping procedure 1.3 Mapping technique 1.4 Annotation of electro-anatomical maps 1.5 Diagnosis of arrhythmias 1.6 Advanced mapping techniques
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The CARTO™ (Biosense Webster, Inc., Diamond Bar, CA, USA) electro-anatomical system is a powerful tool for mapping cardiac arrhythmias. This chapter explains the basic concepts underlying the CARTO system, highlighting its advantages over conventional mapping techniques and its inherent limitations; recommends a strategy for system set-up; and provides guidance on arrhythmia recognition. Finally, it describes in detail the new advanced mapping features of the system.
1.1 Basic principles of electro-anatomical mapping 1.1A General concepts Conventional electrophysiologic mapping compares local activation times (LATs) at different mapping spots (ie, timing of the local electrograms) with a reference either on the surface electrocardiogram (ECG) or a selected intracardiac signal. A major limitation of this approach is the need for fluoroscopic control of the catheter position. Besides the risk associated with the use of X-rays, fluoroscopy does not provide exact information on the orientation and position of the catheter tip in a three-dimensional (3D) heart chamber. Such information is especially important when repeated catheter navigation to a desired location is required during radiofrequency (RF) ablation. In addition, conventional mapping is largely ineffective for complex reentrant arrhythmias, for which multipolar mapping catheters are required. The CARTO system [1,2] uses low energy electromagnetic fields (from 5 ǂ 10–6 to 5 ǂ 10–5 T) for placement of the catheter tip. Three such fields are generated by magnetic coils located under the examination table; this creates a non-homogeneous electromagnetic field around the patient’s chest (Figures 1 and 2). The mapping catheter contains a magnetic sensor that is located near the distal electrode (Navistar®, Biosense Webster, Inc., Diamond Bar, CA, USA) and permits precise positioning of the catheter in a given electromagnetic field. Resolution is
