Emergence of Multielectrode Mapping
2016; Lippincott Williams & Wilkins; Volume: 9; Issue: 6 Linguagem: Inglês
10.1161/circep.116.004281
ISSN1941-3149
AutoresRoderick Tung, Kenneth A. Ellenbogen,
Tópico(s)Atrial Fibrillation Management and Outcomes
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 9, No. 6Emergence of Multielectrode Mapping Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBEmergence of Multielectrode MappingOn the Road to Higher Resolution Roderick Tung, MD and Kenneth A. Ellenbogen, MD Roderick TungRoderick Tung From the Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, IL (R.T.); and Division of Cardiology, Virginia Commonwealth University Medical Center, Richmond (K.A.E.). and Kenneth A. EllenbogenKenneth A. Ellenbogen From the Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, IL (R.T.); and Division of Cardiology, Virginia Commonwealth University Medical Center, Richmond (K.A.E.). Originally published15 Jun 2016https://doi.org/10.1161/CIRCEP.116.004281Circulation: Arrhythmia and Electrophysiology. 2016;9:e004281The technological imperative is changing the field of electrophysiology, and we are currently at a crossroads in complex ablation. The rapid emergence of electroanatomic mapping with multielectrode catheters was spawned out of both intellectual necessity (desire for mechanistic insights into arrhythmias) and clinical necessity (to expedite mapping time). During the 1980s, mapping with single-point catheters and multielectrode catheters was proven to be useful for arrhythmia substrate characterization in the intraoperative setting.1,2 In 1999, single-point catheter-based mapping was first validated using the CARTO system by Callans et al3 in a porcine model of myocardial infarction. This validation was performed with 75 endocardial points, and the electroanatomic map obviated the reliance on fluoroscopic substrate-based ablation within regions of low voltage and quickly became the central platform for scar-based ventricular tachycardia (VT) procedures. Seventeen years later, the validation of an automated mapping system (Rhythmia; Boston Scientific, Natick, MA) with microelectrodes on a miniature basket catheter was demonstrated in a porcine model, with an average of >8000 mapping points.4,5 It is a foregone conclusion that as a field, we are already on the road to higher resolution with multielectrode catheters becoming the new mainstay for mapping of complex arrhythmias. Several questions require further examination as the optimal role of multielectrode mapping remains to be fully defined (1) How did we get here? (2) What are the obstacles that lie ahead? (3) Where is our ultimate destination?See Article by Tschabrunn et alHow Did We Get Here?Multielectrode catheters have been implemented routinely for rapid diagnosis for supraventricular tachycardias using coronary sinus activation and in the anterolateral right atrium for cavotricuspid isthmus flutter since the early 1990s.6 However, simultaneous acquisition of this electrical information into electroanatomic mapping systems to detail scar did not gain popularity throughout the 1990s to early 2000s, as the accuracy of these points remained in question because of variable tissue contact. A prevalent view was a healthy skepticism for the accuracy of voltage information because of the inability to insure adequate contact with multiple electrodes.The impedance-based electrofield system (NAVX; St. Jude Medical, Minneapolis, MN) was the first commercial mapping system that allowed for simultaneous voltage and activation acquisition from any catheter, regardless of model, make, configuration, and electrode number. Patel et al7 first demonstrated the use with a 5-splined catheter (Pentaray; Biosense Webster, Diamond Bar, CA) to rapidly map left atrial flutters in the inaugural issue of this journal. In 2009, we began a series of experiments at University of California at Los Angeles to directly compare the accuracy of single-point acquisition with multielectrode mapping of ventricular scar in a porcine infarct model with extrapolation to human cases. To our knowledge, this was the first validation of multielectrode mapping in the epicardium and endocardium of left ventricle, where ≈3-fold increases in mapping density could be achieved in the same time period using a duodecapolar catheter.8,9 In 2014, multielectrode mapping was incorporated in the magnetically based mapping system (CARTO MEMS; Biosense Webster). This signified the adoption of the undeniable trend in high-density mapping as an initial multielectrode catheter failed to gain clinical popularity (Qwikmap; Biosense Webster). In 2012, a novel spatiotemporal mapping system (Topera; Abbott Medical, Chicago, IL) using a 64-electrode basket catheter for biatrial panoramic mapping of atrial fibrillation reinvigorated the field with new focus aimed to investigate the electrophysiological mechanisms of fibrillatory conduction.10Obstacles AheadSimultaneous multielectrode mapping introduces an entirely new set of challenges from a purist perspective. Although a large number of points can be acquired quickly and the aesthetic appearance of electroanatomic maps is improved as the result of less interpolation, the accuracy of these points needs to be verified with respect to electrogram integrity and annotation. Even with the most sophisticated automated mapping technology, it is likely that human input will always be needed to over-read electroanatomic mapping data because of noise, artifacts, and near-field versus far-field determination. Currently, ripple mapping displays are the only commercially available system that allows for the annotation of multiple near-field electrogram components at a single site.11 Manual correction of a fully automated map can be paradoxically time-consuming if there are an overabundance of neighboring points around an inaccurate annotation.Electrogram voltages are dependent on the electrode size, spacing, and the angle of the incident wavefront to the catheter.12 The universally implemented 1.5-mV threshold for ventricular scar,3,13 derived from a standard ablation catheter, is unlikely to be consistent across the new assortment of catheters that are available in the electrophysiologists toolbox for multielectrode mapping (Figure;Table). For this reason, individualized validation is required, and comparative studies are needed. In real-world practice, mapping points acquired from a multipolar catheter and single-point catheter are frequently combined on the same map, and this may result in inaccurate depictions of complex scar or activation patterns.Table. Summary of Various Electrode Configurations, Sizes, and Relative Spacing With Commonly Used CathetersModelManufacturerElectrodesTip Electrode Size, mmRing Electrode Size, mmSpacing (Edge-to-Edge)Spacing Recorded (Center-to-Center)Ablation catheters ThermoCool STBiosense Webster43.511-6-23.25 ThermoCool SFBiosense Webster43.512-5-24.25 NavistarBiosense Webster44/811-7-43.50 CoolFlexSt. Jude Medical4410.5-5-22.75 Safire/Cool PathSt. Jude Medical4422-5-25.00 FlexAbilitySt. Jude Medical4411-4-13.50 TacticathSt. Jude Medical43.512-5-24.25 Blazer II/OIBoston Scientific4422.5-2.5-2.54.50 MiFiBoston Scientific4…11.5 mm2.50Multielectrode mapping PentaRayBiosense Webster20…12-6-23.00 DecapolarBiosense Webster102.412-8-23.00 LassoBiosense Webster20…12-6-23.00 Duodecapolar (Livewire)St. Jude Medical20212-2-23.00 IntellaMap OrionBoston Scientific64…0.9×0.451.6 mm2.50 Constellation (60 mm)Boston Scientific64…1.5 mm56.50 Inquiry OptimaSt. Jude Medical24…11-4.5-1… Inquiry AFocus IISt. Jude Medical20…14…Download figureDownload PowerPointFigure. Electrode size and spacing on a ThermoCool SF Ablation Catheter.In this context, Tschabrunn et al14 present an original article comparing myocardial scar characterization in a swine model with a multielectrode catheter (Pentaray) with a standard ablation catheter. By examining the normal distribution in 3 healthy swine, the authors report similar statistical 95% thresholds with a Pentaray compared with ablation catheter (1.48 versus 1.61 mV), consistent with the widely implemented 1.5-mV value. By using a left anterior descending occlusion-reperfusion infarct model (n=11), the authors report that when using a 1.5-mV threshold, scar areas were 22% smaller when mapped with a multielectrode catheter with 1-mm electrode size. Furthermore, dense scar regions of <0.5 mV were 47% smaller when using a Pentaray compared with an ablation catheter. Greater tissue heterogeneity within scar was observed as the authors localized reentrant circuits to mixed scar areas with relatively preserved voltage channels with histological confirmation. Pacing thresholds were lower during pacing within scar from smaller electrodes, suggesting a greater ability to capture viable near-field tissue within dense scar.On the surface, the take-home message from this work may be that smaller electrode catheters increase the sensitivity to identify normal surviving bundles of myocardium during sinus rhythm and VT, relative to large tipped catheters. Although this may indeed the cases, there are several variables that are present in this well-designed study that may further contribute to these findings. Beyond electrode size, interelectrode spacing is different, and even further confounded by whether the spacing is calculated as edge-to-edge (1 mm ThermoCool ST versus 2 mm Pentaray) or center-to-center (3.25 ThermoCool ST versus 3.0 mm Pentaray). The density of mapping achieved with multielectrode platform was over double the number of points sampled with the ablation catheter (986 versus 462; P 4× the mapping density achieved with a Pentaray, the authors reported that scar areas were larger with small electrodes because of less far-field sensing. Although these findings are in contrast with the present study, substrate variability accounts for some of these differences. More importantly, the data may be more similar if the scar area calculations used in these studies were purely based on the 95% statistical threshold derived from the respective model. Furthermore, differences in scar area are likely if a remap is performed with the same catheter and density.Where Is Our Final Destination?Like with television technology, there is likely to a limit to higher resolution where appreciable differences may not be discernible to the human eye. In clinical medicine, this limit may be the line where there is not measurable difference in patient outcomes. For example, the creation of a map for typical atrial flutter or a focal arrhythmia with >1000 points will likely not translate into greater freedom from clinical recurrence. With mapping density, it may be reasonable to hypothesize that increasing density from 100 to 500 points may be clinically impactful, but the utility of adding another 1000 points to a 5000 point map may have diminishing returns. Activation mapping of focal and reentrant rhythms is frequently localized to a small region of interest, obviating the need for high-density mapping remote from these critical sites. Prospective studies comparing multielectrode cases with point-by-point strategies may be insightful. As we continue along this road to higher resolution, we hope to be guided by thoughtful mechanistic investigation that can be translated to clinical practice, like the work presented by Tschabrunn et al14 in this issue.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Roderick Tung, MD, The University of Chicago Medicine, Center for Arrhythmia Care, 5841 S. Maryland Ave MC 6080, Chicago, IL 60637. E-mail [email protected]References1. Kienzle MG, Miller J, Falcone RA, Harken A, Josephson ME. Intraoperative endocardial mapping during sinus rhythm: relationship to site of origin of ventricular tachycardia.Circulation. 1984; 70:957–965.LinkGoogle Scholar2. Cassidy DM, Vassallo JA, Miller JM, Poll DS, Buxton AE, Marchlinski FE, Josephson ME. Endocardial catheter mapping in patients in sinus rhythm: relationship to underlying heart disease and ventricular arrhythmias.Circulation. 1986; 73:645–652.LinkGoogle Scholar3. Callans DJ, Ren JF, Michele J, Marchlinski FE, Dillon SM. Electroanatomic left ventricular mapping in the porcine model of healed anterior myocardial infarction. Correlation with intracardiac echocardiography and pathological analysis.Circulation. 1999; 100:1744–1750.LinkGoogle Scholar4. Tschabrunn CM, Roujol S, Nezafat R, Faulkner-Jones B, Buxton AE, Josephson ME, Anter E. A swine model of infarct-related reentrant ventricular tachycardia: Electroanatomic, magnetic resonance, and histopathological characterization.Heart Rhythm. 2016; 13:262–273. doi: 10.1016/j.hrthm.2015.07.030.CrossrefMedlineGoogle Scholar5. Tanaka Y, Genet M, Chuan Lee L, Martin AJ, Sievers R, Gerstenfeld EP. Utility of high-resolution electroanatomic mapping of the left ventricle using a multispline basket catheter in a swine model of chronic myocardial infarction.Heart Rhythm. 2015; 12:144–154. doi: 10.1016/j.hrthm.2014.08.036.CrossrefMedlineGoogle Scholar6. Feld GK, Fleck RP, Chen PS, Boyce K, Bahnson TD, Stein JB, Calisi CM, Ibarra M. Radiofrequency catheter ablation for the treatment of human type 1 atrial flutter. Identification of a critical zone in the reentrant circuit by endocardial mapping techniques.Circulation. 1992; 86:1233–1240.LinkGoogle Scholar7. Patel AM, d'Avila A, Neuzil P, Kim SJ, Mela T, Singh JP, Ruskin JN, Reddy VY. Atrial tachycardia after ablation of persistent atrial fibrillation: identification of the critical isthmus with a combination of multielectrode activation mapping and targeted entrainment mapping.Circ Arrhythm Electrophysiol. 2008; 1:14–22. doi: 10.1161/CIRCEP.107.748160.LinkGoogle Scholar8. Tung R, Nakahara S, Ramirez R, Gui D, Magyar C, Lai C, Fishbein M, Shivkumar K. Accuracy of combined endocardial and epicardial electroanatomic mapping of a reperfused porcine infarct model: a comparison of electrofield and magnetic systems with histopathologic correlation.Heart Rhythm. 2011; 8:439–447. doi: 10.1016/j.hrthm.2010.10.044.CrossrefMedlineGoogle Scholar9. Nakahara S, Tung R, Ramirez RJ, Michowitz Y, Vaseghi M, Buch E, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K. Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation of hemodynamically unstable ventricular tachycardia.J Am Coll Cardiol. 2010; 55:2355–2365. doi: 10.1016/j.jacc.2010.01.041.CrossrefMedlineGoogle Scholar10. Narayan SM, Krummen DE, Shivkumar K, Clopton P, Rappel WJ, Miller JM. Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial.J Am Coll Cardiol. 2012; 60:628–636. doi: 10.1016/j.jacc.2012.05.022.CrossrefMedlineGoogle Scholar11. Linton NW, Koa-Wing M, Francis DP, Kojodjojo P, Lim PB, Salukhe TV, Whinnett Z, Davies DW, Peters NS, O'Neill MD, Kanagaratnam P. Cardiac ripple mapping: a novel three-dimensional visualization method for use with electroanatomic mapping of cardiac arrhythmias.Heart Rhythm. 2009; 6:1754–1762. doi: 10.1016/j.hrthm.2009.08.038.CrossrefMedlineGoogle Scholar12. Anter E, Josephson ME. Substrate mapping for ventricular tachycardia.JACC Clin Electrophysiol. 2015; 1:341–352.CrossrefMedlineGoogle Scholar13. Marchlinski FE, Callans DJ, Gottlieb CD, Zado E. Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy.Circulation. 2000; 101:1288–1296.LinkGoogle Scholar14. Tschabrunn CM, Roujol S, Dorman NC, Nezafat R, Josephson ME, Anter E. High-resolution mapping of ventricular scar: comparison between single and multielectrode catheters.Circ Arrhythm Electrophysiol. 2016; 9:e003841. doi: 10.1161/CIRCEP.115.003841.MedlineGoogle Scholar15. Irie T, Yu R, Bradfield JS, Vaseghi M, Buch EF, Ajijola O, Macias C, Fujimura O, Mandapati R, Boyle NG, Shivkumar K, Tung R. Relationship between sinus rhythm late activation zones and critical sites for scar-related ventricular tachycardia: systematic analysis of isochronal late activation mapping.Circ Arrhythm Electrophysiol. 2015; 8:390–399. doi: 10.1161/CIRCEP.114.002637.LinkGoogle Scholar16. Berte B, Relan J, Sacher F, Pillois X, Appetiti A, Yamashita S, Mahida S, Casassus F, Hooks D, Sellal JM, Amraoui S, Denis A, Derval N, Cochet H, Hocini M, Haissaguerre M, Weerasooriya R, Jais P. Impact of electrode type on mapping of scar-related VT.J Cardiovasc Electrophysiol. 2015; 26:1213–1223. doi: 10.1111/jce.12761.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lee A, Walters T, Alhede C, Vittinghoff E, Sievers R and Gerstenfeld E (2020) Standard peak-to-peak bipolar voltage amplitude criteria underestimate myocardial scar during substrate mapping with a novel microelectrode catheter, Heart Rhythm, 10.1016/j.hrthm.2019.10.013, 17:3, (476-484), Online publication date: 1-Mar-2020. Tung R (2019) Substrate Mapping in Ventricular Arrhythmias, Cardiac Electrophysiology Clinics, 10.1016/j.ccep.2019.08.009, 11:4, (657-663), Online publication date: 1-Dec-2019. Tzou W and Tschabrunn C (2019) Looking Near and Far, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2019.07.005, 5:10, (1141-1143), Online publication date: 1-Oct-2019. Jiang R, Buch E, Gima J, Upadhyay G, Nayak H, Beaser A, Aziz Z, Shivkumar K and Tung R (2019) Feasibility of percutaneous epicardial mapping and ablation for refractory atrial fibrillation: Insights into substrate and lesion transmurality, Heart Rhythm, 10.1016/j.hrthm.2019.02.018, 16:8, (1151-1159), Online publication date: 1-Aug-2019. Shen M and Knight B (2019) Value of high-density mapping in the electrophysiology laboratory, Current Opinion in Cardiology, 10.1097/HCO.0000000000000576, 34:1, (6-15), Online publication date: 1-Jan-2019. Dukkipati S, Whang W, Miller M, Koruth J and Reddy V (2019) Ablation of Unstable Ventricular Tachycardia and Ventricular Fibrillation Catheter Ablation of Cardiac Arrhythmias, 10.1016/B978-0-323-52992-1.00032-6, (543-563.e3), . Issa Z, Miller J and Zipes D (2019) Advanced Mapping and Navigation Modalities Clinical Arrhythmology and Electrophysiology, 10.1016/B978-0-323-52356-1.00006-2, (155-205), . Chrispin J, Keramati A, Assis F, Misra S, Zghaib T, Berger R, Calkins H and Tandri H (2018) Correlation of right ventricular multielectrode endocardial unipolar mapping and epicardial scar, Pacing and Clinical Electrophysiology, 10.1111/pace.13299, 41:4, (345-352), Online publication date: 1-Apr-2018. Pürerfellner H (2018) High-density Mapping – Toy or Tool?, European Journal of Arrhythmia & Electrophysiology, 10.17925/EJAE.2018.4.2.47, 4:2, (47), . Chaturvedi V, Maille B and Gupta D (2017) Bipolar voltage analysis with multi-electrode mapping, Journal of Cardiovascular Electrophysiology, 10.1111/jce.13238, 28:11, (E3-E3), Online publication date: 1-Nov-2017. Beaser A and Tung R (2017) Law of Spatial Averaging During Endocardial Voltage Mapping, Circulation: Arrhythmia and Electrophysiology, 10:10, Online publication date: 1-Oct-2017. Leshem E, Tschabrunn C, Jang J, Whitaker J, Zilberman I, Beeckler C, Govari A, Kautzner J, Peichl P, Nezafat R and Anter E (2017) High-Resolution Mapping of Ventricular Scar, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2016.12.016, 3:3, (220-231), Online publication date: 1-Mar-2017. June 2016Vol 9, Issue 6 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.116.004281PMID: 27307521 Originally publishedJune 15, 2016 Keywordselectrodescatheterscardiac arrhythmiasEditorialselectrophysiologytachycardia, ventricularPDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-Defibrillator
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