Visualizing Localized Reentry With Ultra-High Density Mapping in Iatrogenic Atrial Tachycardia: Beware Pseudo-Reentry.
Luther, Vishal MRCP *; Sikkel, Markus MRCP, PhD *; Bennett, Nathan MEng; Guerrero, Fernando BSc; Leong, Kevin MRCP; Qureshi, Norman MRCP, PhD; Ng, Fu Siong MRCP, PhD; Hayat, Sajad A. MRCP, PhD; Sohaib, S.M. Afzal MRCP, PhD; Malcolme-Lawes, Louisa MRCP, PhD; Lim, Elaine BSc; Wright, Ian BSc; Koa-Wing, Michael MRCP, PhD; Lefroy, David C. MA, FRCP; Linton, Nick W.F. MEng, MRCP, PhD; Whinnett, Zachary MRCP, PhD; Kanagaratnam, Prapa PhD; Davies, D. Wyn MD; Peters, Nicholas S. MD; Lim, Phang Boon MRCP, PhD
Circulation: Arrhythmia and Electrophysiology.
10(4):e004724, April 2017.
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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.
(C) 2017 American Heart Association, Inc.