1. Implication of 3D Mapping in EP
KCGMH
陳勉成 主任

2. Cardiac Arrhythmias

3. Indications for Radiofrequency
Catheter Ablation
• Wolff-Parkinson-White Syndrome (WPW)
• Atrioventricular Nodal Reentrant Tachycardia (AVNRT)
• Atrial Flutter
• Atrial Fibrillation (AF)
• Ventricular Tachycardia (VT)
• Atrial Tachycardia (AT)
• Others

4. Sequence of the Flow in a Typical EP
and Ablation Procedure
• Preparation of the Patient
• Insertion of sheaths and Electrode catheters
• Basic EPS study to get the basic data
• Induction of the Arrhythmia
• Diagnosis of the Arrhythmia
• Ablation of the Arrhythmia (if indicated)
• Confirmation of Therapy Success

5. Classification of Tachycardia
 Tachycardia are classified as focal or
macro reentrant tachycardia
 Focal tachycardia exhibit activation spreading
from a single focus either radically, circularly or
centrifugally without an electrical activation
spanning the tachycardia cycle length
(right atrial activation is considerably shorter
than the tachycardia cycle length–about 14%)
(Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)

6. Classification of Tachycardia
 Macro reentrant tachycardia
 typical atrial flutter
lower loop reentry,
double loop reentry,
left atrial macro reentrant
tachycardia, scar-related AT,
reverse typical atrial flutter and right atrial free wall macro reentry
 The various patterns are:
 Single loop (like typical atrial flutter)
 Figure of eight (made up of two loops)
 Reentry through narrow channels adjacent to scar,
anatomic barriers (i.e. tricuspid annulus)
(Zipes DP, Jalife J. Cardiac Electrophysiology: From cell to bedside, 4th edition. 2004; pg. 500-501)

7. Arrhythmia Mechanisms
• Automaticity
• Triggered Activity
• Reentry

8. Everything should be made
as simple as possible,
but not simpler.
by Albert Einstein

9. Map Concept
Surface Temperature Animated Propagation Map

10. Color-coded Isochrones
Anatomic
Representation
Activation
Times

11. “Roving” catheters enable Endocardial
isochronal maps
Advantage -
percutaneous
procedure
Disadvantage - takes a
long time; requires a
stable rhythm

13. 1993 - Isochronal meet 3-D graphics...
maps
meet 3-D graphics...
...Electro-anatomic mapping is born

14. 1995 –
Epicardial “plaque” electrodes
move endocardial...
• Location of catheter
electrodes, which enables
– geometry creation
– boundary-element
calculations
– navigation
• Detection of cardiac
electrical activity
• Combined, these functions
enable non-contact
mapping
...Graydon Beatty conceives the Array, non-contact mapping, establishes Endocardial Solutions, Inc.

15. ≅
15

16. ≅
16

24. QuickTime™ and a
H.264 decompressor
are neede d to see this picture.
24

26. EnGuide location relative to E1 and E2

27. How Created the Geometry
of Non Contact Map

28. Identify Anatomy….

29. One Beat to Analysis Virtual
Unipolar Signal Analysis

30. Ablation Site and
Confirm the Tracing Virtual
If you are an operator,
tell me, where you
want to target ?

32. Successful to Complete line

33. Double Potentials
• Double potentials are indicative of a line of block
• Lines of block are either fixed or functional
– Atriotomy sites and the Eustachian ridge are examples of fixed lines
of block
– Evidence exists that block in region of Cristal terminals during atrial
flutter is a form of functional conduction block

38. Is True or False DSM ?

39. 2003 - Isochronal meet 3-D graphics...
maps meet 3-D graphics...
Contact Mapping is born

40. Contact
Mapping
Surface-based
5.6 kHz (Classic) /8.138KHz.
(Velocity) current signals
emitted from 3 pairs of
surface electrodes
Each catheter electrode
located 93 times per second
Simultaneously view up to
12 catheters and 64
electrodes
All chamber navigation

41. Bipolar Signal and Multiple Catheters

42. •
Realwith NavX Navigation
Minimize fluoro
Time

43. Create Geometry by
any Roving Catheters
LSPV
RSPV
RMPV
LIPV
LA RIPV
RA
CS
IVC

44. Respiration Compensation

45. Validation of Computed Tomography Image Integration into the
EnSite NavX Mapping System to Perform Catheter Ablation of
Atrial Fibrillation
Journal of Cardiovascular Electrophysiology
Volume 19, Issue 8, pages 821-827, 26 MAR 2008 DOI: 10.1111/j.1540-8167.2008.01127.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1540-8167.2008.01127.x/full#f1

46. Validation of Computed Tomography Image Integration into the
EnSite NavX Mapping System to Perform Catheter Ablation of
Atrial Fibrillation
Journal of Cardiovascular Electrophysiology
Volume 19, Issue 8, pages 821-827, 26 MAR 2008 DOI: 10.1111/j.1540-8167.2008.01127.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1540-8167.2008.01127.x/full#f1

47. No fluoroscopic Three Dimensional Mapping
for Arrhythmia Ablation : Tool or Toy ?
Methods
We compared the results of 88 arrhythmia ablations (79
patients) using CARTO with 100 ablations (94 patients)
using the conventional technique.
The ablations were separated into four groups:
 AV nodal reentrant tachycardia (AVNRT)
 Atrial tachycardia/flutter
 ventricular tachycardia (VT)
 bypass tract tachycardia.
J Cardiovasc Electrohysio, Vol. 11, pp.239-243,March 2000

48. No fluoroscopic Three Dimensional Mapping
for Arrhythmia Ablation : Tool or Toy ?
Result
The ablation outcomes were excellent and comparable in all four types of the
arrhythmias between the two techniques.
Fluoroscopy time was shorter using the CARTO technique:
10 ± 7 versus 27 ± 15 minutes for AVNRT (P <0.01),
18 ± 17 versus 44 ± 23 minutes for atrial tachycardia and flutter (P < 0.01)
15 ± 12 versus 34 ± 31 minutes for VT (P < 0.05)
21 ± 14 versus 53 ± 32 minutes for by pass tract tachycardia (P < 0.01).
Conclusion
The electro anatomic three-dimensional mapping technique reduced fluoroscopy
time
J Cardiovasc Electrohysio, Vol. 11, pp.239-243,March 2000

49. 3D for you is …………..?

50. What do you see ?

51. Where is the face
in this picture?

52. Do not worry about your
difficulties in Mathematics.
I can assure you mine are
still greater.
by Albert Einstein

53. THANK YOU FOR
YOUR ATTENATION