Author + information
- Received May 23, 2018
- Accepted May 31, 2018
- Published online October 15, 2018.
- Rubén Casado Arroyo, MD, PhD∗ ( and )
- Sofia Chatzikyriakou, MD, PhD
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
- ↵∗Address for correspondence:
Dr. Ruben Casado Arroyo, Department of Cardiology Cardiac Electrophysiology and Pacing Section, Erasmus Hospital, Université Libre de Bruxelles, 808 Lennik Street, Brussels 1070, Belgium.
A 53-year-old woman was admitted to the emergency unit due to a short QRS tachycardia at 180 beats/min. The electrophysiological study showed an orthodromic left lateral accessory pathway.
The pathway was mapped using the Advisor high density (HD) grid Catheter Mapping, Sensor Enabled (Abbott, St. Paul, Minnesota). The detailed map of the accessory pathway is described herein.
Using the omnipolar technology (1–3), we were able to identify the trajectory of the accessory pathway. The catheter was located along the mitral annulus, with the distal pole (D1) closer to the ventricular side and the proximal (D4) closer to the atrial side. The best unipolar activation, sharp QS deflection, corresponds to high density pole 1 (HD1) that is shown in Figure 1. Based on this information and this localization of the catheter, the best bipolar activation is presented in Figure 2. We show different catheter bipolar activation in relation to the best unipolar (D1). The first bipolar presented, D1-D2, shows a fusion of ventricular and atrial electrogram. The other bipolar activation presented as vertical bipole D1-C1 and oblique bipole D1-C2 show a clear differentiation of atrial and ventricular signals. Both atrial and ventricular electrograms are clearly separated by a distance. The activation of the accessory pathway continues to D2-D3 and shows a fusion of ventricular and atrial activity being the ventricular amplitude bigger than the atrial. Lastly, D3-D4 bipole shows the reverse, the amplitude of the ventricular activity is smaller than the atrial and an accessory pathway potential can be identified. The ablation catheter was positioned in D3-D4, and a single application was enough to eliminate the accessory pathway. This technology derives the direction of wave front activation from a single point and is independent of catheter orientation (Figure 1, Online Video 1).
This case demonstrates the use of the fixed-spacing grid array catheters. This tool provides reproducible myocardial activation (directionality) in the context of an accessory pathway. Omnipolar voltages analysis provide a better physiological representation of the myocardial substrate. This new technology helps to identify the direction of the wave front activation from a single point (accessory pathway connection) and is independent of catheter orientation. The use of this catheter will improve the results of catheter ablation of accessory pathways.
This is the first case of ablation of an accessory pathway using this new technology that is free of catheter orientation effects and identifies the direction of the pathway between the atrium and the ventricle.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received May 23, 2018.
- Accepted May 31, 2018.
- 2018 American College of Cardiology Foundation
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