https://doi.org/10.1007/s00392-024-02526-y
1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie und internistische Intensivmedizin Kiel, Deutschland; 2Abbott Medical GmbH Eschborn, Deutschland
Atrial pace mapping (APM) is a method used to localize the origin of non-sustained atrial rhythms. Automated intracardiac pattern matching (aICPM) has recently been introduced into the Carto-3 mapping system and has been shown to enhance APM by making it more precise, objective, and faster. The Ensite™X system does not provide an ICPM algorithm but allows the creation of automated ECG-score maps where specific ECG leads can be selected for pattern matching. We propose a novel workflow for mapping and ablating non-PV triggers, utilizing an automated ECG pattern-matching algorithm of the EnsiteX system using intracardiac unipolar atrial signals.
Methods:
We prospectively assessed the feasibility and precision of APM enhanced by aICPM in 10 patients with atrial fibrillation (AF) who underwent a redo procedure using the EnsiteX system with successful induction of non-pulmonary vein (PV) triggers. APM of non-PV triggers was performed with aICPM using three unipolar signals from the catheter in the coronary sinus and three from the high right atrium (Figure). The six electrodes were connected to the precordial ECG leads to pass the signals to the ECG matching algorithm of the EnsiteX system, creating matching score maps (Figure2). Ablation was performed at the site with the best IC pattern similarity.
Results:
Reproducible induction of non-sustained atrial tachycardia (AT) or non-PV triggers (premature atrial contractions [PAC] or AT runs transformed to AF) was observed in 10 patients (7 with AT and 4 with PAC, with one patient exhibiting both) with a median cycle length of 320 ms [270, 410]. APM revealed the origin of non-PV triggers in all 10 patients (Figure), with a median best IC pattern similarity score of 80% [71.5%, 89%]. The top 10% best IC pattern matching strata area was 0.2 cm² [0.2, 1.6]. The median number of points per map was 78 [70.5, 89.5], with a median time to create a score map of 4.03 min [2.86, 6.3]. Radiofrequency ablation was successful in all but one case, where an AF trigger originating from the vein of Marshall required ethanol ablation. The median ablation time was 134 s [84, 193.5], and the median ablation area was 2.0 cm² [1.35, 2.7]. During a follow-up period of 3.7 months [3.26, 4.53], only one patient experienced AF recurrence.
Conclusion:
Atrial pace mapping enhanced by automatic intracardiac pattern matching for localizing the origin of non-sustained AT and non-PV triggers is feasible, when double-chamber unipolar atrial referent electrograms are passed to the EnsiteX system's ECG matching algorithm.