Noncontact three-dimensional mapping and ablation of upper loop re-entry originating in the right atrium
Ching-Tai Tai, MD*,*,
Jin-Long Huang, MD*,
Yung-Kuo Lin, MD*,
Ming-Hsiung Hsieh, MD*,
Pi-Chang Lee*,
Yu-An Ding, MD*,
Mau-Song Chang, MD* and
Shih-Ann Chen, MD*
* Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Figure 1 Radiographs showing a multielectrode array balloon catheter (M) in the right atrium, a Halo catheter around the tricuspid annulus, and a decapolar catheter in the coronary sinus (CS). (A) Right anterior oblique view. (B) Left anterior oblique view.
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Figure 2 (A) Isopotential maps showing the activation sequence (frames 1 to 6) of counterclockwise upper loop re-entry in the right posterior oblique view. Color scale for each isopotential map has been set so that white indicates most negative potential and blue indicates least negative potential. The activation wavefront propagates down the anterolateral right atrium (RA) near the superior vena cava (SVC) (frame 1) to the middle and inferior anterolateral RA (frame 2), then splits into two wavefronts (frame 3); one passes around the area of functional block, and the other passes through the cavotricuspid isthmus. The wavefront in the lateral RA continues through the gap (g) in the crista terminalis (CT) (frame 4) to the superior posterior RA (frame 5) and activates the atrial wall surrounding the SVC before reactivation of the anterolateral RA once again. (B) The virtual electrograms from the area of functional block (virtual 11 to 15) and the CT (virtual 16 to 20) including the conduction gap (virtual 16 to 18) demonstrate double potentials. The numbers 1 to 6 represent the time points at which the isopotential maps have been displayed in A. IVC = inferior vena cava.
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Figure 3 (A) Isopotential maps showing the activation sequence (frames 1 to 6) of clockwise upper loop re-entry in the right posterior oblique view. Color scale for each isopotential map has been set so that white indicates most negative potential and blue indicates least negative potential. The activation wavefront propagates backward and downward from the superior anteromedial right atrium (RA) near the RA appendage (frame 1) to the middle posterior RA (frame 2), then splits into two wavefronts; one passes close to the crista terminalis (CT) (frame 3), and the other passes through the septal RA (it is not shown in the figure). The wavefront in the posterior RA continues through the gap (g) in the CT (frame 4) to the lateral RA and around the area of functional block (frame 5), then activates the anterolateral RA (frame 6) before reactivation of the superior anteromedial RA once again. (B) The virtual electrograms from the CT (11 to 14) and the area of functional block (15 to 19) demonstrate double potentials. The numbers 1 to 6 represent the time points at which the isopotential maps have been displayed in A. IVC = inferior vena cava; SVC = superior vena cava.
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Figure 4 (A) Isopotential maps showing the activation sequence (frames 1 to 3) of atrial pacing before ablation. Color scale for each isopotential map has been set so that white indicates most negative potential and blue indicates least negative potential. The activation wavefront propagates downward from the superior anterior right atrium (RA) (frame 1) to middle anterolateral RA and splits into two wavefronts (frame 2); one passes through the gap (g) in the crista terminalis (CT) and activates superior posterolateral RA (frame 3), and the other passes through the lateral cavotricuspid isthmus. (B) Isopotential maps showing the activation sequence (frames 1 to 3) of atrial pacing after ablation. Color scale for each isopotential map has been set so that white indicates most negative potential and blue indicates least negative potential. The activation wavefront propagates downward from the superior anterior RA (frame 1) to middle anterolateral RA (frame 2) and splits, into two wavefronts (frame 3); one passes around the cranial end of the CT and activates the superior posterior RA, and the other passes through the lateral cavotricuspid isthmus. L10 to L15 represent the radiofrequency ablation lesions. (C) Before ablation the virtual electrograms near the conduction gap in the CT demonstrate fractionated potentials. (D) After ablation the virtual electrograms near the conduction gap in the CT demonstrate double potentials, suggesting conduction block. IVC = inferior vena cava; SVC = superior vena cava.
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