This Article Abstract Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nademanee, K. Articles by Ngarmukos, T. Search for Related Content PubMed PubMed Citation Articles by Nademanee, K. Articles by Ngarmukos, T.

A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate

Koonlawee Nademanee, MD, FACC^*,*, John McKenzie, MD^*, Erol Kosar, MD^*, Mark Schwab, MD^*, Buncha Sunsaneewitayakul, MD, Thaveekiat Vasavakul, MD^*, Chotikorn Khunnawat, MD^* and Tachapong Ngarmukos, MD

^* Pacific Rim Electrophysiology Research Institute, Inglewood, California, USA
Chulalongkorn University, Bangkok, Thailand
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

View larger version (20K): [in a new window]   Figure 1 Examples of complex fractionated atrial electrograms (CFAE): (A) Shows fractionated electrograms with continuous prolonged activation complex over the posterior septal areas. (B) Shows another type of CFAE at the left atrium (LA)-roof where electrograms with a very short cycle length, compared with the rest of the atria, were recorded. CS = coronary sinus.

View larger version (38K): [in a new window]   Figure 2 An example of electroanatomic mapping (CARTO) of a patient with permanent atrial fibrillation. (A) Complex fractionated atrial electrograms (CFAE) are seen over the right atrial (RA) septum1–2 and RA septum3–4; in contrast, the lateral wall of the RA shows discrete organized single-potential atrial electrograms (RA1–2 and RA3–4). (B) Electroanatomic mapping voltage map presents the posteroanterior view. Pink dots are areas of CFAEs along both sides of the atrial septum. (C) Left anterior oblique view of the CARTO voltage map displaying ablation points (red dots). Left atrial (LA)1–2 and LA3–4 are the intracardiac recordings from the superior-anterior aspect of the interatrial septum (arrow). (D) Termination of the tachycardia during the ablation. LIPV = left inferior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.

View larger version (47K): [in a new window]   Figure 3 Based on electroanatomic mapping (CARTO), the biatrial replica could be divided into the nine separate areas: 1) septum including the Bachmann bundle; 2) left posteroseptal mitral annulus and coronary sinus ostium; 3) pulmonary veins; 4) roof of the left atrium; 5) mitral annulus; 6) cavotricuspid isthmus; 7) crista terminalis; 8) right and left atrial appendages; and 9) superior vena cava-right atrial junction. LAO = left anterior oblique; PA = posterior anterior.

View larger version (70K): [in a new window]   Figure 6 (A) Electrocardiogram showing recurrent atrial flutter of the same patient from Figure 6. (B) The map of the activation wave front during tachycardia; the color range depicts red as the earliest activation and magenta as the latest. The arrow points to the electrogram of the mapping electrodes at the left atrial roof where complex fractionated atrial electrograms with mid-diastolic potentials were recorded. Radiofrequency application at this site terminated the tachycardia (C). Biomap D = distal electrodes; Biomap P = proximal electrodes; CS = coronary sinus.

View larger version (88K): [in a new window]   Figure 7 Posteroanterior (PA) views of four maps from four patients: N. H. and T. W. (left) were patients with paroxysmal atrial fibrillation (AF), and J. G. and G. S. (right) were patients with chronic AF. Ablations performed during AF at various areas of the left atrium (red dots) resulted in arrhythmia termination. CS = coronary sinus; LA = left atrium; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RA = right atrium; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.

View larger version (43K): [in a new window]   Figure 4 An example of type 1 atrial fibrillation (AF). This patient had symptomatic paroxysmal AF and had failed multiple drugs. The top panel shows the biatrial map (mesh presentation) in the anterior posterior view. The arrow points to the electrogram recorded from the inferolateral (inf lat) aspect of the right atrium. Note that the cycle length of the complex fractionated atrial electrograms in this area was quite short, only 90 ms. Radiofrequency ablation applications at this site terminated AF (lower panel) and rendered it noninducible. CS = coronary sinus.

View larger version (55K): [in a new window]   Figure 5 (A) Shows failure of external (top panel) and internal (lower panel) cardioversion to convert atrial fibrillation (AF) in patients with chronic permanent AF. (B) Voltage mapping with intracardiac recordings before and after ablations. The color range depicts red as the lowest voltage and blue and magenta as the highest voltage. The distribution of complex fractionated atrial electrograms was confined largely on the posterior wall of the left atrium, mitral annulus, and septum. (C) Shows the electrograms recorded from the mapping catheters at the left posteroseptal areas. Note that there are conduction blocks between these areas and the distal (Dis) coronary sinus (CS). The atrial activation at this site was 115 ms earlier than the P wave, and radiofrequency (RF) application here terminated the tachycardia (D). Biomap D = distal electrodes; Biomap P = proximal electrodes; prox = proximal; RSPV = right superior pulmonary vein.