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. 1999 Jun;81(6):570–575. doi: 10.1136/hrt.81.6.570

Mapping and ablation of ventricular tachycardia with the aid of a non-contact mapping system

R Schilling 1, N Peters 1, D Davies 1
PMCID: PMC1729051  PMID: 10336912

Abstract

OBJECTIVE—Treatment of ventricular tachycardia (VT) in coronary heart disease has to date been limited to palliative treatment with drugs or implantable defibrillators. The results of curative treatment with catheter ablation have proved disappointing because the complexity of the VT mechanism makes identification of the substrate using conventional mapping techniques difficult. The use of a mapping technology that may address some of these issues, and thus make possible a cure for VT with catheter ablation, is reported.
PATIENTS AND INTERVENTION—The non-contact system, consisting of a multielectrode array catheter (MEA) and a computer mapping system, was used to map VT in 24 patients. Twenty two patients had structural heart disease, the remainder having "normal" left ventricles with either fasicular tachycardia or left ventricular ectopic tachycardia.
RESULTS—Exit sites were demonstrated in 80 of 81 VT morphologies by the non-contact system, and complete VT circuits were traced in 17. In another 37 morphologies of VT 36 (30)% (mean (SD)) of the diastolic interval was identified. Thirty eight VT morphologies were ablated using 154 radiofrequency energy applications. Successful ablation was achieved by 77% of radiofrequency within diastolic activation identified by the non-contact system and was significantly more likely to ablate VT than radiofrequency at the VT exit, or remote from diastolic activation. Over a mean follow up of 1.5 years, 14 patients have had no recurrence of VT and only two target VTs have recurred. Five patients have had recurrence of either slower non-sustained, undocumented or fast non-target VT. Five patients have died, one from tamponade from a pre-existing temporary pacing wire, and four from causes unrelated to the procedure.
CONCLUSION—The non-contact system can safely be used to map and ablate haemodynamically stable VT with low VT recurrence rates. It is yet to be established whether this system may be applied with equal success to patients with haemodynamically unstable VT.


Keywords: ventricular tachycardia; mapping; ablation

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Figure 1  .

Figure 1  

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The non-contact mapping catheter with 9 French shaft (left), deployed 7.5 ml balloon with braided microelectrode array (centre), and micrograph of 0.025 inch long electrode created by removing a spot of insulation with a laser (right).

Figure 2  .

Figure 2  

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A contoured model of the chamber geometry is created by tracing the endocardial surface with a conventional roving catheter while the system tracks its position. The geometry is partially defined midway through the process in the left panel, completed and smoothed in the centre panel, and rendered in the right panel as an anatomically-contoured, wire-frame three dimensional model.

Figure 3  .

Figure 3  

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Timing difference between conventional contact electrograms and non-contact reconstructed electrograms recorded during sinus rhythm. A mean timing difference of −0.9 ms and a mean morphology cross correlation of 0.83 was demonstrated over a population of 31 487 recorded cardiac cycles. One half of the time differences were within 2 ms and 77% were within 10 ms.

Figure 4  .

Figure 4  

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A posterio-anterior radiograph showing the non-contact mapping catheter with 7.5 ml of contrast medium/saline in the balloon, deployed in the left ventricle(A). Also seen in the left ventricle is a transeptal mapping catheter (B) and a retrograde transaortic mapping catheter (C). Other catheters are positioned in the right ventricular apex and coronary sinus. This patient also has an implantable defibrillator lead (D).

Figure 5  .

Figure 5  

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Activation maps recorded during VT in a patient with two VT morphologies using the same re-entry circuit in contrarotation. The virtual endocardium has been opened along the anterior septum so that the two edges are in continuity. Labels have been placed on sites identified using fluoroscopy as follows: Basal, left ventricle base; Apex, left ventricle apex; Septal, septum; Lat, lateral. Activation is indicated by white areas. The successful radiofrequency site is shown with a green dot. Activation reaches the exit of the diastolic component of the re-entry circuit (frame 1) before systolic activation of the left ventricle is seen (frames 2 to 4); note the sparing of the region of the diastolic pathway. The lines of conduction block that define this diastolic pathway are shown as green lines. The wavefront re-enters the diastolic pathway (frames 5 to 8) and progresses from the apicoseptum to exit at the basal-lateral end (frame 1).

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