V tomto přehledovém článku shrnujeme již zavedené i nové elektroanatomické mapovací systémy a technologie pro katetrizační ablaci arytmií, zejména fi brilace síni. V posledních letech počet katetrizačních ablací exponenciálně roste díky technologickým pokrokům umožňujícím komplexní katétrové ablace. Kvalita současných systémů pro elektroanatomické mapování je dostatečně vysoká jak pro standardní ablace, jako je izolace plicních žil, tak i pro hodnocení a ablaci komplexních arytmií. Nadále jsou vyvíjeny nové nástroje a technologie s cílem usnadnit porozumění arytmiím a zjednodušit tak jejich ablaci. Trend jednoznačně ukazuje odklon od fl uoroskopie k pokročilým technologiím.
In this review, we outline contemporary and upcoming electroanatomic technologies focusing on new mapping tools especially in catheter ablation for atrial fi brillation. The number of catheter ablations has been increasing exponentially in the last few years due to technological advancements enabling complex ablation strategies. The quality of the contemporary systems of electroanatomic mapping is suffi ciently high in terms of both standard ablations, such as isolation of pulmonary veins, and evaluation and elimination of complex arrhythmias. New instruments and devices are coming out to facilitate the proces of understanding arrhythmias and thus simplify their elimination. The trend shows a defl ection from fl uoroscopy towards more advanced technologies.
- Keywords
- CARTO, EnSite NavX, multipolární mapování,
- MeSH
- Echocardiography MeSH
- Electrophysiologic Techniques, Cardiac * methods trends MeSH
- Atrial Fibrillation surgery MeSH
- Fluoroscopy MeSH
- Catheter Ablation MeSH
- Humans MeSH
- Multimodal Imaging MeSH
- Arrhythmias, Cardiac surgery MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
OBJECTIVES: The aim of the study was to determine whether left ventricular electrical potential measured by electromechanical mapping with the NOGA XP system has predictive value for response to CRT. BACKGROUND: Approximately 30% of patients who undergo cardiac resynchronization therapy do not see the expected effects. METHODS: The group of 38 patients qualified for CRT implantation were included in the study, of which 33 patients were analyzed. A 15% reduction in ESV after 6 months of pacing was used as a criterion for a positive response to CRT. The mean value and sum of unipolar and bipolar potentials obtained by mapping with the NOGA XP system and their predictive value in relation to the effect of CRT were analyzed using a bulls-eye projection at three levels: 1) the global value of the left ventricular (LV) potentials, 2) the potentials of the individual LV walls and 3) the mean value of the potentials of the individual segments (basal and middle) of the individual LV walls. RESULTS: 24 patients met the criterion of a positive response to CRT vs. 9 non-responders. At the global analysis stage, the independent predictors of favorable response to CRT were the sum of the unipolar potential and bipolar mean potential. In the analysis of individual left ventricular walls, the mean bipolar potential of the anterior and posterior wall and in the unipolar system, mean septal potential was found to be an independent predictor of favorable response to CRT. In the detailed segmental analysis, the independent predictors were the bipolar potential of the mid-posterior wall segment and the basal anterior wall segment. CONCLUSIONS: Measurement of bipolar and unipolar electrical potentials with the NOGA XP system is a valuable method for predicting a favorable response to CRT.
- Publication type
- Journal Article MeSH
AIMS: Electromechanical coupling in patients receiving cardiac resynchronization therapy (CRT) is not fully understood. Our aim was to determine the best combination of electrical and mechanical substrates associated with effective CRT. METHODS AND RESULTS: Sixty-two patients were prospectively enrolled from two centres. Patients underwent 12-lead electrocardiogram (ECG), cardiovascular magnetic resonance (CMR), echocardiography, and anatomo-electromechanical mapping (AEMM). Remodelling was measured as the end-systolic volume (ΔESV) decrease at 6 months. CRT was defined effective with ΔESV ≤ -15%. QRS duration (QRSd) was measured from ECG. Area strain was obtained from AEMM and used to derive systolic stretch index (SSI) and total left-ventricular mechanical time. Total left-ventricular activation time (TLVAT) and transeptal time (TST) were derived from AEMM and ECG. Scar was measured from CMR. Significant correlations were observed between ΔESV and TST [rho = 0.42; responder: 50 (20-58) vs. non-responder: 33 (8-44) ms], TLVAT [-0.68; 81 (73-97) vs. 112 (96-127) ms], scar [-0.27; 0.0 (0.0-1.2) vs. 8.7 (0.0-19.1)%], and SSI [0.41; 10.7 (7.1-16.8) vs. 4.2 (2.9-5.5)], but not QRSd [-0.13; 155 (140-176) vs. 167 (155-177) ms]. TLVAT and SSI were highly accurate in identifying CRT response [area under the curve (AUC) > 0.80], followed by scar (AUC > 0.70). Total left-ventricular activation time (odds ratio = 0.91), scar (0.94), and SSI (1.29) were independent factors associated with effective CRT. Subjects with SSI >7.9% and TLVAT <91 ms all responded to CRT with a median ΔESV ≈ -50%, while low SSI and prolonged TLVAT were more common in non-responders (ΔESV ≈ -5%). CONCLUSION: Electromechanical measurements are better associated with CRT response than conventional ECG variables. The absence of scar combined with high SSI and low TLVAT ensures effectiveness of CRT.
- MeSH
- Bundle-Branch Block MeSH
- Echocardiography MeSH
- Electrocardiography methods MeSH
- Ventricular Function, Left physiology MeSH
- Cicatrix MeSH
- Humans MeSH
- Cardiac Resynchronization Therapy * adverse effects methods MeSH
- Heart Failure * diagnosis therapy MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
Introduction: Cell therapy has the potential to improve symptoms and clinical outcomes in refractory angina (RFA). Further analyses are needed to evaluate factors influencing its therapeutic effectiveness. Aim: Assessment of electromechanical (EM) parameters of the left ventricle (LV) and investigation of correlation between EM parameters of the myocardium and response to CD133+ cell therapy. Material and methods: Thirty patients with RFA (16 active and 14 placebo individuals) enrolled in the REGENT-VSEL trial underwent EM evaluation of the LV with intracardiac mapping system. The following parameters were analyzed: unipolar voltage (UV), bipolar voltage (BV), local linear shortening (LLS). Myocardial ischemia was evaluated with single-photon emission computed tomography (SPECT). The median value of each EM parameter was used for intra-group comparisons. Results: Global EM parameters (UV, BV, LLS) of LV in active and placebo groups were 11.28 mV, 3.58 mV, 11.12%, respectively; 13.00 mV, 3.81 mV, 11.32%, respectively. EM characteristics analyzed at global and segmental levels did not predict response to CD133+ cell therapy in patients with RFA (Global UV, BV and LLS at rest R = -0.06; R = 0.2; R = -0.1 and at stress: R = 0.07, R = 0.09, R = -0.1, respectively; Segmental UV, BV, LLS at rest R = -0.2, R = 0.03, R = -0.4 and at stress R = 0.02, R = 0.2, R = -0.2, respectively). Multiple linear regression of the treated segments showed that only pre-injection SPECT levels were significantly correlated with post-injection SPECT, either at rest or stress (p < 0.05). Conclusions: Electromechanical characteristics of the left ventricle do not predict changes of myocardial perfusion by SPECT after cell therapy. Baseline SPECT results are only predictors of changes of myocardial ischemia observed at 4-month follow-up.
- Publication type
- Journal Article MeSH
Left ventricle, LV wringing wall motion relies on physiological muscle fiber orientation, fibrotic status, and electromechanics (EM). The loss of proper EM activation can lead to rigid-body-type (RBT) LV rotation, which is associated with advanced heart failure (HF) and challenges in resynchronization. To describe the EM coupling and scar tissue burden with respect to rotational patterns observed on the LV in patients with ischemic heart failure with reduced ejection fraction (HFrEF) left bundle branch block (LBBB). Thirty patients with HFrEF/LBBB underwent EM analysis of the left ventricle using an invasive electro-mechanical catheter mapping system (NOGA XP, Biosense Webster). The following parameters were evaluated: rotation angle; rotation velocity; unipolar/bipolar voltage; local activation time, LAT; local electro-mechanical delay, LEMD; total electro-mechanical delay, TEMD. Patients underwent late-gadolinium enhancement cMRI when possible. The different LV rotation pattern served as sole parameter for patients' grouping into two categories: wringing rotation (Group A, n = 6) and RBT rotation (Group B, n = 24). All parameters were aggregated into a nine segment, three sector and whole LV models, and compared at multiple scales. Segmental statistical analysis in Group B revealed significant inhomogeneities, across the LV, regarding voltage level, scar burdening, and LEMD changes: correlation analysis showed correspondently a loss of synchronization between electrical (LAT) and mechanical activation (TEMD). On contrary, Group A (relatively low number of patients) did not present significant differences in LEMD across LV segments, therefore electrical (LAT) and mechanical (TEMD) activation were well synchronized. Fibrosis burden was in general associated with areas of low voltage. The rotational behavior of LV in HF/LBBB patients is determined by the local alteration of EM coupling. These findings serve as a strong basic groundwork for a hypothesis that EM analysis may predict CRT response.Clinical trial registration: SUM No. KNW/0022/KB1/17/15.
- MeSH
- Biomechanical Phenomena MeSH
- Middle Aged MeSH
- Humans MeSH
- Aged MeSH
- Heart Ventricles physiopathology MeSH
- Cardiac Resynchronization Therapy * methods MeSH
- Heart Failure physiopathology therapy MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Clinical Trial MeSH
- Research Support, Non-U.S. Gov't MeSH
Katetrizační ablace fibrilace síní (FS) přináší celou řadu technických problémů, jako jsou obtížná orientace v levé síni při výrazné variabilitě uspořádání plicních žil, problémy s kontaktem hrotu katetru s tkání a zvýšená zátěž rentgenovým zářením. K jejich překonání byly uvedeny do klinické praxe dva systémy dálkového ovládání katetru. Jeden z nich - systém elektromechanické navigace – se již v řadě center používá jako standardní metoda katetrizační ablace fibrilace síní. Stávající zkušenosti naznačují, že tato metoda má celou řadu výhod. Umožňuje provedení katetrizační ablace standardizovaným způsobem, omezuje únavu operatéra a celkovou radiační zátěž. Robotická navigace dovoluje účinnější aplikaci radiofrekvenčního proudu, a má tedy potenciál i pro dosažení lepší dlouhodobé účinnosti.
Catheter ablation of atrial fibrillation (AF) is associated with many technical challenges such as difficult orientation in the left atrium due to significant variability in the arrangement of pulmonary veins, problems with contact between the tip of the ablation catheter and tissue, and increased radiation dose. Two remote control systems have been introduced into clinical practice to overcome these challenges. One of them – an electromechanical navigation system – has already been used in many centres as a standard method. Current experience suggests that this method has many advantages. It allows a standardized ablation procedure, limits fatigue of the operator and radiation dose. Robotic navigation enables also a more effective application of radiofrequency current and has a potential to achieve a better long-term clinical efficacy.
AIMS: The aim of this study was to determine the relationship between electrical and mechanical activation in heart failure (HF) patients and whether electromechanical coupling is affected by scar. METHODS AND RESULTS: Seventy HF patients referred for cardiac resynchronization therapy or biological therapy underwent endocardial anatomo-electromechanical mapping (AEMM) and delayed-enhancement magnetic resonance (CMR) scans. Area strain and activation times were derived from AEMM data, allowing to correlate mechanical and electrical activation in time and space with unprecedented accuracy. Special attention was paid to the effect of presence of CMR-evidenced scar. Patients were divided into a scar (n = 43) and a non-scar group (n-27). Correlation between time of electrical and mechanical activation was stronger in the non-scar compared to the scar group [R = 0.84 (0.72-0.89) vs. 0.74 (0.52-0.88), respectively; P = 0.01]. The overlap between latest electrical and mechanical activation areas was larger in the absence than in presence of scar [72% (54-81) vs. 56% (36-73), respectively; P = 0.02], with smaller distance between the centroids of the two regions [10.7 (4.9-17.4) vs. 20.3 (6.9-29.4) % of left ventricular radius, P = 0.02]. CONCLUSION: Scar decreases the association between electrical and mechanical activation, even when scar is remote from late activated regions.
- MeSH
- Cicatrix diagnostic imaging MeSH
- Humans MeSH
- Magnetic Resonance Imaging, Cine MeSH
- Heart Ventricles diagnostic imaging MeSH
- Cardiac Resynchronization Therapy * MeSH
- Heart Failure * diagnostic imaging therapy MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
Cardiac resynchronization therapy is a valuable tool to restore left ventricular function in patients experiencing dyssynchronous ventricular activation. However, the non-responder rate is still as high as 40%. Recent studies suggest that left ventricular torsion or specifically the lack thereof might be a good predictor for the response of cardiac resynchronization therapy. Since left ventricular torsion is governed by the muscle fiber orientation and the heterogeneous electromechanical activation of the myocardium, understanding the relation between these components and the ability to measure them is vital. To analyze if locally altered electromechanical activation in heart failure patients affects left ventricular torsion, we conducted a simulation study on 27 personalized left ventricular models. Electroanatomical maps and late gadolinium enhanced magnetic resonance imaging data informed our in-silico model cohort. The angle of rotation was evaluated in every material point of the model and averaged values were used to classify the rotation as clockwise or counterclockwise in each segment and sector of the left ventricle. 88% of the patient models (n = 24) were classified as a wringing rotation and 12% (n = 3) as a rigid-body-type rotation. Comparison to classification based on in vivo rotational NOGA XP maps showed no correlation. Thus, isolated changes of the electromechanical activation sequence in the left ventricle are not sufficient to reproduce the rotation pattern changes observed in vivo and suggest that further patho-mechanisms are involved.
- Publication type
- Journal Article MeSH
Cílem tohoto přehledu je představit stručně dvě moderní technologie navigace katétru na dálku, které se začínají používat v klinické praxi jako podpora katetrizační ablace různých druhů srdečních arytmií. Magnetický navigační systém Niobe využívá dvou objemných magnetů, které generují permanentní magnetické pole a jehož vektory lze měnit v nejrůznějších směrech. Tímto způsobem je ovládán pohyb magnetem vybaveného speciálního katétru v srdci pacienta na dálku. Robotický systém Sensei je založen na principu elektromechanické navigace, kdy je konvenční katétr zasunut do soustavy dvou ohebných metalických zavaděčů, které ovládají na dálku mechanicky pohyby hrotu katétru. Oba systémy dovolují použití trojrozměrných mapovacích systémů k zobrazení mapované srdeční dutiny (CARTO nebo NavX). V současnosti byly publikovány první klinické zkušenosti s oběma systémy. Ty jsou o něco větší se systémem Niobe, neboť je dostupný delší dobu. Očekávají se větší studie, které budou porovnávat výhody navigace katétru na dálku s konvenčně prováděnou katetrizační ablací, a to zejména u složitých substrátů jako jsou ablace fibrilace síní nebo komorových tachykardií. Jejich rozšíření může výrazně minimalizovat radiační zátěž pro pacienty a především pro lékaře.
The goal of this review is to introduce briefly two modern technologies of remote catheter navigation that are being increasingly used in clinical practice as a support of catheter ablation of different types of cardiac arrhythmias. Magnetic navigation system Niobe consists of two large magnets that generate permanent and uniform magnetic field. The vectors of the field can be changed in various directions. This allows remote manipulation of specialized magnet-equipped catheter inside the patient´s heart. Robotic system Sensei is based on electromechanical navigation principle. Conventional ablation catheter is introduced into the assembly of two steerable metallic sheaths that control the movements of the tip of ablation catheter remotely. Both systems allow the concomitant use of 3D mapping systems for visualization of mapped chamber (CARTO or NavX). At present, initial clinical experience with both systems has been published. It is more substantial for the Niobe system, since it is available for longer time. Larger studies are expected that will compare the advantage of remote catheter control with conventional catheter ablation, mainly in complex arrhythmia substrates such as atrial fibrillation or ventricular tachycardias. Their widespread use may significantly minimize radiation burden for patients, and especially for physicians.
- MeSH
- Atrial Fibrillation therapy MeSH
- Financing, Organized MeSH
- Catheter Ablation methods instrumentation trends MeSH
- Coronary Angiography methods instrumentation utilization MeSH
- Humans MeSH
- Body Burden MeSH
- Robotics methods instrumentation trends MeSH
- Catheters, Indwelling trends utilization MeSH
- Imaging, Three-Dimensional methods instrumentation trends MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
