Total activation mapping in a patient with an epicardial accessory pathway

Abstract

A 42‐year‐old man was admitted for recurrent atrioventricular reciprocating tachycardia. We performed a total activation mapping, which included a range from the ventricular to atrial waves during right ventricular pacing. The mapping revealed a delayed ventriculoatrial conduction on the left lateral wall. We performed ablation within the coronary sinus, and the ventriculoatrial conduction was lost. By widening the range, we could easily visualize the ventriculoatrial conduction through the accessory pathway. This mapping showed that the conduction in the area of the accessory pathway was delayed, and it was easy to estimate that the conduction pathway included the coronary sinus.

Both Figures A and B showed the same earliest atrial site during right ventricular stimulation, although the coloring of the total activation mapping in Figure B suggested conduction delay at the site. The conduction pathway of this case included the coronary sinus (Figure C).

A 42‐year‐old man was admitted for a recurrent atrioventricular reciprocating tachycardia (AVRT). We used a CARTO system (Biosense Webster) with the Pentaray catheter (Biosense Webster), and an electrophysiological study was performed. The earliest site of the atrial excitation during right ventricular pacing was on the left lateral wall as previous. When a supraventricular tachycardia was induced under an isoproterenol infusion, an AVRT was confirmed by the classic resetting criteria and ventricular pacing maneuvers during the tachycardia. Although the earliest areas that appeared to be faster than the catheter placed in the coronary sinus (CS) were ablated from the left atrium, it took about 10 s for the ventriculoatrial conduction to disappear, and reconnections reoccurred. We performed total activation mapping, which included a range from the ventricular to atrial waves during right ventricular pacing. Although the mapping revealed ventriculoatrial conduction in the 3 o'clock direction on the mitral annulus (Figure 1a, Video S1), the ventriculoatrial conduction took 40 ms to pass through the annulus. Therefore, we approached it from within the CS, and additional mapping revealed that the conduction was transmitted to the left atrium through the CS (Figure 1b, Video S2). We performed ablation at a site in the CS that was opposite the left atrial ablation sites (Figure 1c), and the ventriculoatrial conduction was lost within 3 s of starting the ablation (Figure 2). The patient has had no recurrences of arrhythmias.

FIGURE 1.

(a) Activation mapping of the left atrium during right ventricular pacing. (b) Total activation mapping during right ventricular pacing. (c) The right panel shows the temporary successful sites in the left atrium and successful ablation points within the coronary sinus

FIGURE 2.

Intracardiac electrocardiogram during the successful ablation from within the coronary sinus

By widening the range of the window, we could easily visualize the ventriculoatrial conduction through the accessory pathway more clearly. This mapping showed that the conduction in the area of the accessory pathway was delayed, and it was easy to estimate that the conduction pathway included the CS.

CONFLICT OF INTEREST

None declared.

ETHICAL APPROVAL

Written informed consent was obtained from the patient.

AUTHOR CONTRIBUTIONS

YF drafted the manuscript and performed the catheter ablation. YY collected the data. YI and WS helped draft the manuscript. KY collected the data and performed the catheter ablation.

Supporting information

Video S1

Video S2

Fujimoto, Y. , Yamaguchi, Y. , Iwasaki, Y‐k , Yodogawa, K. & Shimizu, W. (2022). Total activation mapping in a patient with an epicardial accessory pathway. Annals of Noninvasive Electrocardiology, 27, e12961. 10.1111/anec.12961

DATA AVAILABILITY STATEMENT

Data available on request due to privacy/ethical restrictions