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Groot, N.M.S. de

Leiden University Scholary Publications

Mapping and Ablation of Atr ial T ac h y Ar r h y th m ias  From Signal to SubstrateNatasja MS de GrootThe research described in this thesis was performed at the department of cardiology and cardiothoracic su rgery of the L eiden U niv ersity M edical C enter, L eiden and the department of physiology, C ardiov ascu lar R esearch Institu te M aastricht, M aastricht U niv ersity, the N etherlands.Financial contribution to the costs associated with the publication of this thesis from:B iosense W ebster/ Johnson &  Johnson M edical B V , S t Ju de M edical N ederland B V , G u idant N ederland B V , B oston S cientifi c N ederland, M erck , S harp &  D ome, B ard E lectrophysiology, P hilips M edical S ystems, S iemens, S erv ier, A stellas P harmas, Toshiba M edical S ystems N ederland B V , M edtronic B V  and V itatron.C opyright ©  N atasja M .S  de G root, 2 0 0 6 , L eiden, the N etherlandsN o parts of this pu blication may be reprodu ced, stored or transmitted in any form or by any means withou t prior permission of the au thor. C ov er design by N atasja M S  de G rootL ay ou t by:B u ijten &  S chipperheijnP rinted by:B u ijten &  S chipperheijn, A msterdam, the N etherlandsIS B N -1 0  9 0 -9 0 2 0 9 6 0 -3IS B N -1 3  9 7 8 -9 0 -9 0 2 0 9 6 0 -9Mapping and Ablation of Atrial TachyArrhythmias From Signal to SubstrateP roe fschriftter verkrijging vande graad van Doctor aan de Universiteit Leiden,op gez ag van de Rector Magnificus Dr. D.D. Breimer,hoogleraar in de faculteit der Wiskunde enNatuurwetenschappen en die der Geneeskunde,volgens besluit van het College voor Promotieste verdedigen op donderdag 14  september 2006klokke 13.4 5  uurdoorNatasja Mireille Silvia de Grootgeboren te H eemstedein 1972PromotiecommissiePromotores: Prof. Dr. M. J. SchalijProf. Dr. M. A. Allessie, Universiteit van MaastrichtR eferent: Prof. Dr. Ir. J. M. T. de Bakker, Academisch Medisch CentrumO v erig e commissieleden: Prof. Dr. E. E. van der Wall Prof. Dr. A. C. Gittenberger-de Groot Prof. R. DionDr. N.A. BlomDr. U. Schotten, Universiteit van MaastrichtF inancial support by the Netherlands Heart F oundation for the publication of this thesis is gratefully acknowledged.Als je doet wat je leuk vindt, hoef je nooit hard te werkenMahatma Gandhidank z ij mijn oudersTable of ContentsPrologue 9Chapter 1  Mapping of atrial tachyarrhythmias Introduction and outline of this thesis 1 3Chapter 2Analysis of temporal irregularity of atrial fibrillation cycle length 7 5Chapter 3S wave predominance of epicardial electrograms during atrial fibrillation in humans: indirect evidence for a role of the thin subepicardial layer 1 0 1Chapter 4Comparison of epicardial breakthrough of fibrillation waves between patients with acute and chronic atrial fibrillation 1 2 3Chapter 5Conduction properties of fibrillation waves in the epicardial plane in patients with acute and chronic atrial fibrillation 1 4 9Chapter 6Degree of fractionation of atrial fibrillation electrograms during acuteand chronic AF 1 6 9Chapter 7Epicardial high density mapping of bachmann’s bundle in humans with chronic atrial fibrillation 1 95Chapter 8Epicardial multi-site high density mapping as a new approach to identify the substrate of atrial fibrillation 2 1 16Chapter 9Three-dimensional catheter positioning during radiofrequency catheter ablation in patients: first application of a real-time position management system 235Chapter 10Three-dimensional distribution of bipolar atrial electrogram voltages in patients with congenital heart disease 255Chapter 11Voltage and activation mapping: how the recording technique affects the outcome of catheter ablation procedures in patients with congenital heart disease 273Chapter 12Ablation of macro-reentrant and focal atrial arrhythmias in patients with congenital heart defects after surgery: the role of circumscribed areaswith heterogeneous conduction 293Chapter 13Fractionated atrial potentials: markers of the origin of focal atrial tachycardia 315Chapter 14Fusion of electroanatomical activation maps and multislice computed tomography to guide ablation of a focal atrial tachycardia in a Fontan patient 333Chapter 15General discussion 343Epilogue 369Summary and Conclusions 3 7 3Samenvatting en Conclusies 3 8 3L ist of Publications 3 9 3Curriculum V itae 4 0 5789Prologue1011Prologu eAtrial tachyarrhythmias are defined as supraventricular tachycardias that do not require the atrioventricular node or ventricular tissue for initiation and perpetuation. It is ex pected that the number of patients presenting with atrial tachyarrhythmias will continue to rise in the nex t decades. This is mainly caused by ageing of our population as the incidence of atrial tachyarrhythmias is higher in older subjects. In addition, there is also a growing group of patients presenting with atrial tachyarrhythmias who have had corrective or palliative cardiac surgery for congenital heart defects. Refinement of surgical techniques has resulted in an improved life ex pectancy of this patient group. As the incidence of atrial tachyarrhythmias increases over time, late post-operative atrial tachyarrhythmias in subjects with congenital heart defects is nowadays becoming a more frequently encountered clinical problem. Another new growing patient population pre-senting with atrial tachyarrhythmias are endurance athletes as ex cessive sports activity is a risk factor for development of, for ex ample, atrial fibrillation. Atrial tachyarrhythmias can result in electrophysiological, structural and/or functional alterations of the myocardium ( tachycardia-induced cardiomyopathy)  and treatment is therefore essential. Pharmacological treatment of atrial tachyarrhythmias is often in-effective and limited by side effects. In the last decades, technological progress has resulted in development of ( catheter based and surgical)  ablation therapy. The introduction of ablative therapy has made it possible to treat atrial tachyarrhythmias curatively. In order to successfully eliminate atrial tachyarrhythmias by catheter ablation, correct diagnosis of the underlying mechanism of the arrhythmia is essential. The surface electrocardiogram is often not reliable and cardiac mapping is therefore compulsory to diagnose an atrial tachyarrhythmias for ex ample as a focal atrial tachycardia, typical ( counter)  clockwise atrial fl utter, atypical atrial fl utter or an incisional atrial tachycardia. Data acquired by cardiac mapping also determines the mode of ablative therapy ( e.g. focal application or construction of linear lesions) . Y et, ablative therapy is not always successful which may be caused by insufficient understanding of the mechanism of the arrhythmia. Also, recur-rences after ablation may be caused by progressive atrial myopathy or by incomplete ablative lesions. Ex perimental and clinical mapping studies per se are essential in order to continue to increase our knowledge of atrial tachyarrhythmias and to provide a basis for development of innovative therapies or to improve ex isting treatment modalities.12

Mapping and ablation of atrial tachyarrhythmias : from signal to substrate

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Mapping and ablation of atrial tachyarrhythmias : from signal to substrate

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