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Computer-assisted animation of atrial tachyarrhythmias recorded with a 64-electrode basket catheter

^a Deutsches Herzzentrum München and Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany

View larger version (68K): [in a new window]   Figure 1 A, Simultaneous recordings of the surface ECG, leads I and aVF, and 56 bipolar electrograms from the BC in a patient with focal AT. The first beat is a sinus beat. The next three beats are tachycardia beats. His bundle potential is recorded in electrode pairs F2–3 and F3–4. The asterisks show the earliest spot of activation during sinus rhythm (SR) and AT. Spline A was located in the anterolateral RA, splines B and C in the lateral region, splines D and E in the posterior region and splines G and H across the tricuspid valve. The activation times are marked with red bars. B, Animated maps of the SR (upper panel) and AT (lower panel) beats. Planar and three-dimensional options are shown. During SR the impulse emerged in the high lateral area (spline B1–2) and propagated rapidly down the lateral wall. The complete activation of the RA took 85 ms. During focal AT, the earliest activity emerged in the mid-posterior wall (spline E4–5). The activation sequence of the RA was entirely different from that of SR. The complete activation of the RA took 95 ms.

View larger version (76K): [in a new window]   Figure 2 Multifocal right AT. Upper panel, Multiple bipolar BC electrograms. Three different firing foci are marked by arrows. The first beat originated in the low lateral region of the RA (electrodes A7–8). The second and third beats originated in close vicinity to each other in the high posterior wall (electrodes D2–3 and D1–2). Lower panel, Animated maps of the beats shown in the upper panel. Despite the fact that beats 2 and 3 originated in close vicinity, the activation patterns of the RA were clearly different. Map A corresponds to beat 1; map B to beat 2; and map C to beat 3.

View larger version (60K): [in a new window]   Figure 3 Left AT. A, Fluoroscopic views of the BC. Small white circles mark the positions of electrode pairs G1–2 and H7–8 located in the high anteroseptal and low posteroseptal regions. Red letters mark splines located anteriorly. B, Simultaneous recordings of the surface ECG, leads I and aVF, and bipolar electrograms from the BC and CS. Electrode pairs G1–2 and H7–8 (arrows) record the earliest activation in the RA. C, Animated maps of the BC recordings. Left panel, First 15 ms of activation in the RA. Right panel, Complete activation of the RA.

View larger version (57K): [in a new window]   Figure 4 Upper panel, Simultaneous surface ECG leads II and III and BC and CS recordings in a patient with counterclockwise AF. Splines A and B were located in the anterolateral region; spline C in the septal region; spline D in the posterior region; spline E in posterolateral region; and splines F through H in the lateral region of the RA. The BC was inserted from the jugular vein. Complete coverage of the reentry circuit is demonstrated. Lower panel, Animated maps. A, Isthmus conduction. B, First 30 ms of activation in the septal and posterior walls. C, After 100 ms, the activation reaches the roof of the RA. D, Craniocaudal activation of the lateral region. E, Locations of the BC splines versus anatomic structures of the RA. The proximal pole of the BC is located over the inferior vena cava–tricuspid valve isthmus.

View larger version (68K): [in a new window]   Figure 5 Activation patterns in a patient with atypical AF. Reentry involving the lower RA traveled around the inferior vena cava in a clockwise direction. The cycle length was 186 ms. Splines H and A are located in the lateral region; splines B and C in the posterior region; splines D, E and F in septal region; and spline G in anteroseptal region of the RA. Electrode pairs 7–8 were located in the lower RA. Left panel, Reentrant impulse is divided into two wave fronts: the first one shortcuts in the posterolateral wall (B4–5) and reenters the isthmus region, and the second goes up the lateral wall and down the septal wall. Right panel, By the time the second wave front reaches the low septal region, the first wave front passes through the isthmus and reactivates the lateral wall.

View larger version (61K): [in a new window]   Figure 6 Figure-eight reentry in a patient with atypical AF. The zone of slow conduction is located in the posterior RA (splines E and F). Crowded isochrones alongside splines D and F indicate functional lines of block. A, The exit of impulse from the common pathway. B, Impulse propagation in two loops located in the posterolateral (splines C and D) and septal regions (splines G and H) of the RA and merge of both wavefronts at the level of electrode pairs E5–6 and F5–6. C, Activation through the common pathway located in the posterior wall. The cycle length of the AF was 166 ms.