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Circ Arrhythm Electrophysiol. 2017 Apr;10(4). pii: e004724. doi: 10.1161/CIRCEP.116.004724.

Visualizing Localized Reentry With Ultra-High Density Mapping in Iatrogenic Atrial Tachycardia: Beware Pseudo-Reentry.

Author information

1
From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.).
2
From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.). pblim@imperial.ac.uk.

Abstract

BACKGROUND:

The activation pattern of localized reentry (LR) in atrial tachycardia remains incompletely understood. We used the ultra-high density Rhythmia mapping system to study activation patterns in LR.

METHODS AND RESULTS:

LR was suggested by small rotatory activations (carousels) containing the full spectrum of the color-coded map. Twenty-three left-sided atrial tachycardias were mapped in 15 patients (age: 64±11 years). 16 253±9192 points were displayed per map, collected over 26±14 minutes. A total of 50 carousels were identified (median 2; quartiles 1-3 per map), although this represented LR in only n=7 out of 50 (14%): here, rotation occurred around a small area of scar (<0.03 mV; 12±6 mm diameter). In LR, electrograms along the carousel encompassed the full tachycardia cycle length, and surrounding activation moved away from the carousel in all directions. Ablating fractionated electrograms (117±18 ms; 44±13% of tachycardia cycle length) within the carousel interrupted the tachycardia in every LR case. All remaining carousels were pseudo-reentrant (n=43/50 [86%]) occurring in areas of wavefront collision (n=21; median 0.5; quartiles 0-2 per map) or as artifact because of annotation of noise or interpolation in areas of incomplete mapping (n=22; median 1, quartiles 0-2 per map). Pseudo-reentrant carousels were incorrectly ablated in 5 cases having been misinterpreted as LR.

CONCLUSIONS:

The activation pattern of LR is of small stable rotational activations (carousels), and this drove 30% (7/23) of our postablation atrial tachycardias. However, this appearance is most often pseudo-reentrant and must be differentiated by interpretation of electrograms in the candidate circuit and activation in the wider surrounding region.

KEYWORDS:

atrial fibrillation; cardiac electrophysiology; fibrosis; tachycardia, supraventricular

PMID:
28356307
DOI:
10.1161/CIRCEP.116.004724
[Indexed for MEDLINE]
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