Abstract
The three-dimensional (3D) mapping of cardiac arrhythmias has evolved in recent years to an important and extremely useful tool, providing important insights into arrhythmia mechanisms and thus improving ablation success rates, especially in complex arrhythmias. In atrial fibrillation (AF), the most common but also one of the most complex cardiac arrhythmias, progress in mapping technology has been focusing on several aspects according to the type of AF.
In paroxysmal AF, important progress in the exact anatomic reconstruction of the main ablation target, i.e., the pulmonary veins (PV), has been achieved. Perhaps even more importantly, new insights into conduction patterns, such as deceleration at the PV ostia, spiral conduction more distally into the PV, and PV cross-talk have been detected and enable faster and more sustainable PV isolation.
In persistent AF, the basic understanding of ongoing AF is perhaps the electrophysiological challenge of the 21st century. Since AF is instable in its course, mapping tools that assess statistically returning patterns or deal with so-called AF “rotors” or “drivers” have been developed, offering unique insights into possible AF mechanisms. Refined high-density bi-atrial voltage maps make it possible to further characterize the arrhythmogenic substrate and scar zones, while new and innovative mapping algorithms enable automated, fast, and reliable annotation of up to thousands of electrograms.
This improved understanding of AF mechanisms has led to the development of promising new ablation strategies, some of which are already in use in clinical routine.
Zusammenfassung
Das dreidimensionale (3-D) Mapping von Herzrhythmusstörungen hat sich in jüngeren Jahren zu einem bedeutsamen und äußerst nützlichen Verfahren entwickelt. Es bietet wichtige Einblicke in die Mechanismen von Arrhythmien und erhöht so die Erfolgsraten der Ablation, insbesondere bei komplexen Arrhythmien. Beim Vorhofflimmern (AF), der häufigsten, aber auch einer der komplexesten Arrhythmien, konzentriert sich der Fortschritt in der Mapping-Technik in Abhängigkeit vom AF-Typ auf mehrere Aspekte.
Bei paroxysmalem AF wurden erhebliche Verbesserungen in der genauen anatomischen Darstellung des Hauptablationsziels, genauer der Pulmonalvenen (PV), erreicht. Vielleicht von noch größerer Bedeutung sind die neuen Einblicke in Leitungsphänomene wie die Leitungsverzögerung an den PV-Ostien, die spiralförmige Leitung weiter distal in die PV und den „PV cross-talk“, was eine schnellere und gleichzeitig nachhaltigere PV-Isolation ermöglicht.
Die wesentliche elektrophysiologische Herausforderung des 21. Jahrhunderts besteht vielleicht darin, die Abläufe bei persistierendem AF grundlegend zu entschlüsseln. Da der Verlauf des AF unbeständig ist, wurden Mapping-Instrumente entwickelt, mit denen statistisch wiederkehrende Muster geprüft und sogenannte AF-Rotoren bzw. -Driver untersucht werden. Die Instrumente bieten einzigartige Einblicke in mögliche AF-Mechanismen. Detaillierte „voltage maps“ beider Vorhöfe ermöglichen eine genauere Beschreibung des arrhythmogenen Substrats und der Narbenbereiche, während neue, innovative Mapping-Algorithmen die schnelle und zuverlässige automatische Annotation Tausender Elektrogramme erlauben.
Das verbesserte Verständnis der AF-Mechanismen hat die Entwicklung vielversprechender neuer Ablationsstrategien ermöglicht, die zum Teil auch schon Eingang in die klinische Praxis gefunden haben.
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I. Deisenhofer declares that she has no competing interests.
This article does not contain any studies with human participants or animals performed by any of the authors.
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Deisenhofer, I. Mapping of atrial fibrillation: strategies to understand an enigmatic arrhythmia. Herzschr Elektrophys 29, 307–314 (2018). https://doi.org/10.1007/s00399-018-0586-7
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DOI: https://doi.org/10.1007/s00399-018-0586-7
Keywords
- Atrial fibrillation
- Catheter ablation
- 3D mapping systems
- Atrial fibrillation substrate
- Electrogram analysis