2011 10 黃金gap detect of afl
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2011 10 黃金gap detect of afl
- 1. How to Identify the Conduction Gaps in the Atrial Flutter using Non-Contact Mapping Jin-Long Huang, MD, Ph D. Cardiovascular Center, Taichung-Veterans General Hospital National Yang-Ming University, Taipei, Taiwan
- 3. Reentry Circuit of Common Atrial Flutter Morady F. N Engl J of Med. 1999;340:534-544.
- 4. ECG Comparison Counterclockwise Clockwise Singer: Interventional Electrophysiology. Williams & Wilkins 1997; 356. positive inferiorly and in V6, and negative in lead V1.
- 5. A new electrocardiographic algorithm to differentiate upper loop re-entry from reverse typical atrial flutter Yuniadi Y , Tai CT , Huang JL , Chen SA . J Am Coll Cardiol. 2005 Aug 2;46(3):524-8
- 6. Reverse typical AFL Upper Loop AFL
- 9. Oblique View of Right Atrium Crista Terminalis Pectinate Muscle Orifice of Coronary Sinus Superior Vena Cava Fossa Ovalis Eustachian Ridge Inferior Vena Cava Netter F. Atlas of Human Anatomy. 1989;Plate 208.
- 10. Catheter Location for Atrial Flutter Ablation Free wall Crista Used with permission of Dr. Brian Olshansky.
- 11. Atrial Flutter Ablation Cosio FG. Am J Cardiol. 1993; 71:705-709.
- 12. Isthmus Conduction Block Singer: Interventional Electrophysiology. Williams & Wilkins 1997; 367. How do you know isthmus block ??
- 13. Characteristic of Unipolar Electrogram
- 15. Group I (n=37):complete bidirectional CTI block During CS pacing, the second component of unipolar electrograms showed an R or Rs pattern.
- 16. Group II (n = 12) had incomplete CTI block. The second component of unipolar electrograms showed an rS pattern.
- 17. Group III (n= 3) had complete CTI block with transcristal conduction. The second component of unipolar electrograms showed an rSR pattern.
- 20. A (AFL) a b c a b c B (CS Pacing) Type I pattern: ER block
- 21. A (AFL) a b c abc B (CS Pacing) abc Type II pattern: Block in AFL and Conduction in CS pacing
- 22. A (AFL) a SV b SV c abc SV B (CS Pacing) SV SV SV abc Type III pattern
- 24. Different ablation strategy in the aged during AFL
- 26. CT A young patients with AFL
- 27. An old patients with AFL
- 31. P=0.003 P=0.04 The conduction velocities of the medial CTI were slower in the old group than in the young group.
- 32. Locations of the Slowest Conduction during AFL 6% 40% 33% 21% 13% 8% 71% 8% < 60 y/o > 60 y/o P < 0.01 In regional activation mapping of the AFL, the location of the slowest conduction shifted from the lateral cavotricuspid isthmus (71%) in the young group to the medial cavotricuspid isthmus (40%) in the old group.
- 33. A: 43 yr male PNV= -4.2 mV B: 79 yr male PNV= -3.9 mV SVC IVC SVC IVC CT SVC IVC SVC IVC CT
- 35. What else? Besides activation mapping!! Substrate analysis!!
- 38. Where is the target ?
- 39. I V1 6 7 8 9 10 11 ˙ 9 LVZ LVZ Ablation line Figure 3-B Atypical AFL (Upper loop reentry) Voltage map Virtual electrograms Activation Isochronal map Septum LVZ CT
- 41. A: SR C: LAL pacing B: CSO pacing D: Atypical flutter % of global maximum PNV Septum Lateral wall CT IVC SVC 1 2 3 1 2 3 Voltage map: Normalized to Global Maximal PNV 1.5 mV 2.1 mV 3.4 mV 1.2 mV 0.2 mV 0.8 mV
- 42. B C F LVZ LVZ LVZ LVZ LVZ LVZ LVZ LVZ A B C D E F Virtual 10 11 12 13 14 15 H: Virtual electrograms A G: Intracardiac tracing A B C D E F E D LVZ LVZ LVZ LVZ
- 43. LVZ LVZ IVC SVC Virtual 1 2 3 1 LVZ Voltage mapping before ablation Voltage mapping after ablation % of global maximum PNV Virtual 1 2 3 1 2 3 IVC 3 2 Pacing from CSO Pacing from CSO
- 45. A: PNV voltage map B: Isopotential activation maps C: Unipolar Eg 1 2 3 4 5 LVZ LVZ Isthmus 1 2 3 4 5 (1) (2) (3) (4) (6) (5) SVC IVC CT 5 4 3 2 1 1 2 3 4 5 CT 1 2 3 4 5 CT 1 2 3 4 5 CT 1 2 3 4 5 1 2 3 4 5 % of global maximum PNV
- 46. Ratio to the maximal peak negative voltage Normalized Negative Unipolar Voltage Maximal peak negative voltage of a selected beat
- 47. Identify the Protected Isthmus: bordered by the low voltage zones Isthmus LVZ Convergence of voltage lines
- 48. LVZ LVZ LVZ LVZ LVZ LVZ LVZ LVZ LVZ LVZ LVZ LVZ % of global maximum PNV Protected Isthmus during RA AFL in 6 pts
- 53. 謝謝
Notes de l'éditeur
- Anatomic barriers within the right atrium sustain the macro-reentry circuit. The AV node plays no part in the flutter circuit, so drugs aimed at altering the conduction of the AV node have no effect on the atrial rate.
- Note that the inferior leads (II, III and aV F ) of counterclockwise flutter have a characteristic initial, broad “sawtooth” negative deflection followed by a less pronounced positive wave. In contrast, clockwise flutter has predominately upgoing flutter waves in the inferior leads that are typically notched and end with a slightly negative component.
- A review of landmarks is helpful, before discussing ablation techniques.
- This slide depicts termination of atrial flutter during RF current delivery.
- Before the ablation, pacing near the CS os would allow the impulse to travel in both directions, eventually colliding on the lateral wall. After ablation, pacing near the CS os only allows the impulse to travel in one direction, eventually terminating at the line of block.