电生理标测

NavX
++ ++ ++ +++ +++ Any +
Non-contact Mapping
Operation Principle
Unstable Ischemic VT Mapping
CL: 370 ms Courtesy: German Heart Center Munich
Mapping PACs that Trigger AF
Electroanatomic Mapping:
State of the Art
October 1, 2009
Jun Dong M.D. Ph.D
Outlines

Introduction to cardiac mapping 3D electroanatomic mapping systems and clinical applications Recent development


Electroanatomical Mapping Systems Contact Mapping Systems
– CARTO – NavX – RPM


Non-contact Mapping System
– EnSite Array
Outlines

Introduction to cardiac mapping 3D electroanatomic mapping systems and clinical applications
Dong J et al. JCE 2006
Carto Maps
42 ms 6.75 mV
SVC MA
-34 ms 0.06 mV
TA
CS
Activation Map
Voltage Map
Carto Maps
Mesh Map
Propagation Map
Carto Procedure: Work Flow


Focal Atrial Tachycardia
CL 230 ms
Dong J, et al. Heart Rhythm 2005
FAT with unusual origin

female, 69 yrs Frequent PSVT
CL 410 ms

Marine J, Nazarian S, Bilchick K, Dong J. Heart Rhythm 2007
Carto
Replicates anatomy without distortion Ease of use Activation mapping Respiration compensation Other catheter visualization Ablation catheter Image integration +++ +++ +++ + Specific +


Outlines

Introduction to cardiac mapping
Cardiac mapping begins…
Original ECG device of Dr. Willem Einthoven in 1901
Cardiac Mapping in the Era of Catheter Ablation
Courtesy: Timm Dickfeld
NavX: Activation Mapping
Courtesy: German Heart Center Munich
Image Registration with NavX
LA Registration error : 2.5 mm West JJ, et al. JCE 2009
Set up
Reconstruct Carto Map
Elucidate mechanism of arrhythmias
Design ablation strategy
Guide catheter navigation and ablation
Clinical Applications

Complex arrhythmias requiring detailed analysis of electro-anatomic relationship: Atypical AFL, monomorphic VT, focal tachy… Stable atrial or ventricular arrhythmias Anatomically based ablations: AF, nonmappable ischemic or non-ischemic VT
Activation Mapping of Ischemic VT
Reddy VY, et al. Circulation 2007
Stevenson ET, et al. JACC 1997
百度文库
Substrate Mapping for Non-Mappable Ischemic VT
Ablation Strategy for Non-Mappable Ischemic VT
Macro Reentrant Atrial Tachycardia
LA Macro Reentrant Atrial Tachycardia Following MVR
Ouyang F et al, Circulation 2002
Intraatrial Reentrant tachycardias following Mustard OP
FAT with unusual origin
SVC Aorta
RCA
R
LCA
L
N
MV
RA
LA
TV MV TV LAO Cranial
His
His
LAO Caudal
Marine J,Nazarian S, Bilchick K, Dong J. Heart Rhythm 2007
FAT From Non-coronary cusp
CartoSound
Courtesy: Biosense Webster
CartoSound
Courtesy: Biosense Webster
Packer D et al. Europace 2008.
Image Integration of Scar for VT Ablation
Bogun F et al. JACC 2009 Fahmy T et al. Heart Rhythm 2008



Carto 3?
Electroanatomic Mapping with NavX System
Catheter Tracking
Z Y X
Courtesy: German Heart Center Munich
3D reconstruction and catheter visualization



Outlines

Introduction to cardiac mapping 3D electroanatomic mapping and clinical applications
– Contact mapping – Non-contact mapping


Recent Development
MV LV
Local Activation Time
Surface ECG
Local ECG
LAT
LAT
LAT
Window of Interest
Surface ECG
WOI
Reference channel
WOI
MAP
LAT
Creating Carto Map
Image Registration with Carto


Conventional Mapping
Ablation target identified by intracardiac ECG criteria Catheter navigation guided by fluoroscopy only
Low level electroanatomic mapping
Atrial Baffle
d-TGA
Post Mustard OP
SVC
LAA
MA
IVC
Image-Guided ablation of IART in Mustard Pt

Male, 33 yrs d-TGA, Mustard Procedure at 2 yrs 2 yrs AFL with systemic hypotension, multiple cardioversion

Electroanatomic Mapping with CARTO
System Components
Location pad
NaviStar
Communication Unit
Catheter Tracking
Catheter Orientation
Reference Electrogram
Marchlinski F et al. Circulation 2000.
Pulmonary Ablation for AFib
Tailored PV Ablation
Dong J and Dickfeld T. Herzschr Elektrophys. 2007
Enemies and “Cures”


AVNRT Ablation
His CS Abl RAO
Accessory Pathway Ablation
MA
RV
CS LAO
Limitations of Conventional Mapping

Inability of accurately associate EGM with precise location Endocardial surface invisible with fluoro, target sites can only be approximated Inability of accurately returning to a previously mapped site Radiation exposure
Courtesy: German Heart Center Munich
EnSite: RA Flutter Mapping
Tai CT, et al. JACC 2004
Pitfalls of Non-Contact Mapping

Insufficient geometry reconstruction: e.g. LAA and PVs. Inaccurate localization when > 4 cm. Maps are highly sensitive to filter settings. Inability of simultaneous multiple chamber mapping.

Identify, characterize, and localize an arrhythmia Forms the foundation for guiding ablation therapies Key to success: understanding electrical and anatomic relationship



Electroanatomic Mapping: Concept

3D map reconstruction to represent target cardiac chamber anatomy Superimposition of electrical information on 3D maps Non-fluoro visualization of mapping/ablation catheters
Ao

“RV”
“LV”
Image-Guided ablation of IART in Mustard Pt
SR
AFL
AFL
Image-Guided ablation of IART in Mustard Pt
Image-Guided ablation of IART in Mustard Pt

Patient movement Transient events/ unstable AT/VT Inadequate 3D reconstuction Time-consuming point acquisition
General anesthesia Non-contact mapping Image registration