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Questions and Answers
What does a PPI-TCL difference of ⱕ50 ms at the proximal CS suggest?
What does a PPI-TCL difference of ⱕ50 ms at the proximal CS suggest?
- A left atrial tachycardia
- LA tachycardia is likely
- AT involving the right pulmonary vein region (correct)
- Common RA flutter
What is the specificity of the algorithm for identifying LA origin compared to RA origin in group I?
What is the specificity of the algorithm for identifying LA origin compared to RA origin in group I?
- 94%
- 88%
- 100% (correct)
- 86%
When is a PPI-TCL difference greater than 50 ms at the high RA significant?
When is a PPI-TCL difference greater than 50 ms at the high RA significant?
- It likely identifies AT from the lateral RA
- It indicates RA tachycardia
- It suggests LA tachycardia (correct)
- It indicates LA tachycardia is likely
What was the positive predictive value of the algorithm for predicting the correct ablation region?
What was the positive predictive value of the algorithm for predicting the correct ablation region?
Which of the following indicates involvement of the atria adjacent to the mitral annulus?
Which of the following indicates involvement of the atria adjacent to the mitral annulus?
What does the abbreviation TCL stand for in the context of atrial tachycardias?
What does the abbreviation TCL stand for in the context of atrial tachycardias?
Which area of the heart is specifically associated with lateral atrial tachycardia?
Which area of the heart is specifically associated with lateral atrial tachycardia?
What is the significance of the postpacing interval (PPI) compared to the tachycardia cycle length (TCL)?
What is the significance of the postpacing interval (PPI) compared to the tachycardia cycle length (TCL)?
Which of the following ATs is defined by a circuit adjacent to the right pulmonary veins?
Which of the following ATs is defined by a circuit adjacent to the right pulmonary veins?
Which statistic indicates the accuracy of the developed algorithm for identifying the successful ablation region?
Which statistic indicates the accuracy of the developed algorithm for identifying the successful ablation region?
What does the term 'mitral AT' refer to?
What does the term 'mitral AT' refer to?
What were the postpacing interval measurements for AT involving the mitral isthmus compared to the left pulmonary vein region?
What were the postpacing interval measurements for AT involving the mitral isthmus compared to the left pulmonary vein region?
In which group was the algorithm for identifying the ablation region developed?
In which group was the algorithm for identifying the ablation region developed?
What percentage of patients underwent closure for an atrial septal defect in group II?
What percentage of patients underwent closure for an atrial septal defect in group II?
Which procedure had the highest percentage of patients undergoing atrial fibrillation ablation?
Which procedure had the highest percentage of patients undergoing atrial fibrillation ablation?
What was the left ventricular ejection fraction in group I?
What was the left ventricular ejection fraction in group I?
What percentage of patients in group I had prior catheter ablation for atrial flutter?
What percentage of patients in group I had prior catheter ablation for atrial flutter?
How many ATs were examined in total in group I?
How many ATs were examined in total in group I?
What is the tachycardia cycle length (TCL) reported for the last tracing?
What is the tachycardia cycle length (TCL) reported for the last tracing?
Which region had 15 ATs noted from the study?
Which region had 15 ATs noted from the study?
What is the primary purpose of the algorithm developed in the study?
What is the primary purpose of the algorithm developed in the study?
What was the PPI-TCL difference when entrainment was performed from high RA?
What was the PPI-TCL difference when entrainment was performed from high RA?
How was the difference between postpacing interval (PPI) and tachycardia cycle length (TCL) utilized in this study?
How was the difference between postpacing interval (PPI) and tachycardia cycle length (TCL) utilized in this study?
What was the sensitivity and specificity of the algorithm in the validation cohort?
What was the sensitivity and specificity of the algorithm in the validation cohort?
What was a significant finding regarding PPI-TCL difference at the proximal coronary sinus (CS)?
What was a significant finding regarding PPI-TCL difference at the proximal coronary sinus (CS)?
Which group had the algorithm developed and later validated in this study?
Which group had the algorithm developed and later validated in this study?
What was the impact of limited entrainment mapping in the study's conclusions?
What was the impact of limited entrainment mapping in the study's conclusions?
What aspect of tachycardia circuits was primarily focused on in this study?
What aspect of tachycardia circuits was primarily focused on in this study?
Which specific patient population was evaluated in this research?
Which specific patient population was evaluated in this research?
What was the mean age of the patients included in the study?
What was the mean age of the patients included in the study?
How many patients had atrial tachycardia (AT) not due to reentry through the subeustachian isthmus?
How many patients had atrial tachycardia (AT) not due to reentry through the subeustachian isthmus?
What procedure did systemic anticoagulation aim to achieve during LA mapping and ablation?
What procedure did systemic anticoagulation aim to achieve during LA mapping and ablation?
Which mapping system was used for activation sequence mapping?
Which mapping system was used for activation sequence mapping?
What was the primary outcome of successful ablation in the study?
What was the primary outcome of successful ablation in the study?
What type of catheterization was performed for left atrial (LA) mapping?
What type of catheterization was performed for left atrial (LA) mapping?
How many consecutive patients were included in the study?
How many consecutive patients were included in the study?
What was calculated from the conduction time between the last stimulus that entrained tachycardia and the second beat after the stimulus?
What was calculated from the conduction time between the last stimulus that entrained tachycardia and the second beat after the stimulus?
What indication suggests that entrainment may be misleading in diagnosing automatic tachycardias?
What indication suggests that entrainment may be misleading in diagnosing automatic tachycardias?
How is the post-pacing interval (PPI) affected in cases where the pacing site is close to the reentrant circuit?
How is the post-pacing interval (PPI) affected in cases where the pacing site is close to the reentrant circuit?
What challenge might arise when distinguishing between focal and macroreentrant atrial tachycardias?
What challenge might arise when distinguishing between focal and macroreentrant atrial tachycardias?
What effect do antiarrhythmic drugs have on conduction delay and diagnostic accuracy?
What effect do antiarrhythmic drugs have on conduction delay and diagnostic accuracy?
What assumption can be made about overdrive suppression with repeated pacing at the same rate?
What assumption can be made about overdrive suppression with repeated pacing at the same rate?
What is the relevance of isolated channels between scars in reentrant atrial tachycardia?
What is the relevance of isolated channels between scars in reentrant atrial tachycardia?
What characterizes the post-pacing intervals observed in the focus site compared to distant sites?
What characterizes the post-pacing intervals observed in the focus site compared to distant sites?
What consideration might affect the success of pacing techniques in entrainment mapping?
What consideration might affect the success of pacing techniques in entrainment mapping?
Flashcards
Atrial Flutter (AFL)
Atrial Flutter (AFL)
A type of supraventricular tachycardia characterized by rapid, regular atrial contractions.
Negative Predictive Value (NPV)
Negative Predictive Value (NPV)
The probability that a person without the condition will receive a negative test result.
Positive Predictive Value (PPV)
Positive Predictive Value (PPV)
The probability that a person with the condition will receive a positive test result.
Pulmonary Veins (PVs)
Pulmonary Veins (PVs)
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Post-pacing Interval (PPI)
Post-pacing Interval (PPI)
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Tachycardia Cycle Length (TCL)
Tachycardia Cycle Length (TCL)
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Algorithm for Ablation Region
Algorithm for Ablation Region
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Entrainment at High RA
Entrainment at High RA
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PPI-TCL Difference
PPI-TCL Difference
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RA Flutter vs AT
RA Flutter vs AT
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LA Tachycardia
LA Tachycardia
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Pulmonary Vein or Mitral Annulus AT
Pulmonary Vein or Mitral Annulus AT
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Distal CS and Mitral Annulus
Distal CS and Mitral Annulus
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Far-field Potential
Far-field Potential
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Local Potential
Local Potential
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Entrainment Slowing
Entrainment Slowing
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PPI (Post-Pacing Interval)
PPI (Post-Pacing Interval)
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Macro-reentrant Tachycardia
Macro-reentrant Tachycardia
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Focal Tachycardia
Focal Tachycardia
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Overdrive Suppression
Overdrive Suppression
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Return Cycle Length
Return Cycle Length
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What is the aim of Entrainment Mapping?
What is the aim of Entrainment Mapping?
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Why is it important to distinguish between left and right atrial tachycardia?
Why is it important to distinguish between left and right atrial tachycardia?
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How is the PPI-TCL difference calculated?
How is the PPI-TCL difference calculated?
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What does a PPI-TCL difference of less than 50ms at the high RA suggest?
What does a PPI-TCL difference of less than 50ms at the high RA suggest?
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What does a PPI-TCL difference of more than 50ms at the high RA suggest?
What does a PPI-TCL difference of more than 50ms at the high RA suggest?
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What does a PPI-TCL difference of less than or equal to 50ms at the proximal CS indicate?
What does a PPI-TCL difference of less than or equal to 50ms at the proximal CS indicate?
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What does a PPI-TCL difference of less than or equal to 50ms at the proximal CS suggest for LA tachycardia?
What does a PPI-TCL difference of less than or equal to 50ms at the proximal CS suggest for LA tachycardia?
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What does a PPI-TCL difference of less than or equal to 50ms at the distal CS indicate?
What does a PPI-TCL difference of less than or equal to 50ms at the distal CS indicate?
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Entrainment
Entrainment
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High Right Atrium (RA)
High Right Atrium (RA)
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Proximal Coronary Sinus (PCS)
Proximal Coronary Sinus (PCS)
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Left Atrium (LA)
Left Atrium (LA)
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Mitral Annulus
Mitral Annulus
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What is an ablation procedure?
What is an ablation procedure?
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What is the main purpose of ablation for atrial tachycardias (ATs)?
What is the main purpose of ablation for atrial tachycardias (ATs)?
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What is a reentrant circuit in the heart?
What is a reentrant circuit in the heart?
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How is activation sequence mapping used in ablation procedures?
How is activation sequence mapping used in ablation procedures?
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What is the PPI-TCL difference?
What is the PPI-TCL difference?
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How is the PPI-TCL difference used in practice?
How is the PPI-TCL difference used in practice?
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What does a PPI-TCL difference of less than or equal to 50ms at the proximal coronary sinus (PCS) indicate?
What does a PPI-TCL difference of less than or equal to 50ms at the proximal coronary sinus (PCS) indicate?
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What does a PPI-TCL difference greater than 50ms at the high right atrium (RA) indicate?
What does a PPI-TCL difference greater than 50ms at the high right atrium (RA) indicate?
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Study Notes
Entrainment Mapping for Rapid Distinction of Left and Right Atrial Tachycardias
- Background: Distinguishing left from right atrial tachycardia is crucial for ablation procedures.
- Objective: Develop and validate a simple algorithm to predict reentrant atrial tachycardia (AT) circuit location based on limited entrainment mapping in the right atrium (RA) and coronary sinus (CS).
- Methods: 180 patients with organized reentrant AT underwent entrainment mapping at the high RA, proximal CS, and distal CS. The difference between post-pacing interval (PPI) and tachycardia cycle length (TCL) was calculated. AT circuit location was determined by mapping and ablation. An algorithm was developed from 104 ATs in a first group (90 patients) and validated in a second group (90 new patients).
- Results: A 50ms PPI-TCL difference at the high RA differentiate RA reentrant circuits from left atrial (LA)reentrant circuits. Analyzing PPI-TCL at proximal CS differentiated common flutter from lateral RA circuits and perimitral from right pulmonary vein/septal reentry circuits in LA circuits. An algorithm with 94% sensitivity, 88% specificity, and 93% predictive accuracy for successful ablation site localization was established.
- Conclusion: Limited entrainment from sites within the RA can help rapidly identify the AT location, guiding further mapping and potentially avoiding unnecessary transseptal procedures.
Study Population and Methods
- Patient Inclusion Criteria: Organized reentrant AT (<20ms A-A interval variability) with a macroreentrant circuit (activation sequence and entrainment mapping showing widely separated sites).
- Total Patients: 180 consecutive patients (135 male).
- Patient Age: Mean age 56 ± 11 years (range 20-85).
- Entrainment Sites: High RA, proximal CS, and distal CS.
- Mapping: 7Fr quadripolar catheters with a 4-mm distal electrode (electroanatomic mapping system). Cardiac electrogram (ECG) electrodes used.
- Anticoagulation: Systemic anticoagulation (heparin) maintained activated clotting times (250-350 seconds) during LA mapping and ablation.
- Ablation: Radiofrequency catheter ablation to transect reentrant circuit using energy input (20-30W to 50W, temperatures 50°C-60°C), aiming to eliminate or interrupt conduction areas.
Mapping and Catheter Ablation Procedure Details
- Electrode Placement: High RA, proximal, and distal Coronary sinus placement (within 1cm for proximal and >3cm for distal).
- Stimulation: Train of atrial stimuli (10mA, 2ms) 10-30ms shorter than TCL for sufficient duration.
- PPI Measurement: Measured from the last stimulus to the first peak of the next electrogram at the pacing site or adjacent proximal recording electrodes.
- ECG/Electrogram Analysis: used to assess activation sequences for AT circuit localization
- Activation sequence mapping: Electroanatomic mapping aided by use of Electroanatomic mapping systems to locate reentrant circuits.
Additional Details
- AT classification: Based on interruption site during ablation.
- Data Analysis: Generalized estimating equations to accommodate multiple observations in patients. Chi-square analysis for categorical variables. Statistical significance considered at P <0.05.
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