Ikenouchi Takashi, Takigawa Masateru, Martin Claire, Miyazaki Shinsuke, Goya Masahiko, Sasano Tetsuo
Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan.
Royal Papworth Hospital, Cambridge, UK.
J Cardiol Cases. 2022 Nov 16;27(3):97-100. doi: 10.1016/j.jccase.2022.10.014. eCollection 2023 Mar.
An 81-year-old man with a typical atrial flutter underwent cavo-tricuspid isthmus (CTI) ablation. After the creation of wide planar lesion at the CTI, a high-resolution activation map with Rhythmia™ (Boston Scientific, Cambridge, MA, USA) was acquired during lateral right atrium pacing, which demonstrated a centrifugal activation at the septal side of ablation line. A review of points acquired at the earliest activation site demonstrated that perivalvular premature ventricular contractions (PVCs) at tricuspid annulus had been inappropriately acquired as atrial electrograms. This mis-acquisition was explained by the following: (i) no change in the beat acceptance criteria of the propagation reference in the coronary sinus due to the absence of ventriculoatrial conduction of mechanical PVCs, and (ii) failure to reject beats overlapping the PVCs because those voltages did not reach the threshold of 0.64 mV. When the mapping system shows centrifugal activation over the linear lesion, passive activation from the epicardial structures or the other chamber is an important differential diagnosis; however, mis-annotation due to automated acquisition must be also ruled out. It is important to understand the automated point-acquisition criteria in each mapping system and to be familiar with the pitfalls of the criteria.
The evolution of ultra-high-resolution mapping technology enables us to understand the details of tachycardia circuit with much fewer manual reannotations. The criteria for automatic point acquisition installed in the mapping system usually works effectively, resulting in a demonstration of a precise tachycardia circuit. However, the present case logically showed how we noticed the mis-annotation of the high-resolution activation map and explained the pitfall of the function of automatic beat acquisition.
一名患有典型心房扑动的81岁男性接受了腔静脉-三尖瓣峡部（CTI）消融术。在CTI处创建宽平面病变后，在右心房外侧起搏期间使用Rhythmia™（美国波士顿科学公司，马萨诸塞州剑桥）获取了高分辨率激活图，该图显示消融线间隔侧存在离心性激活。对最早激活部位采集的点进行回顾发现，三尖瓣环处的瓣周室性早搏（PVC）被误采集为心房电图。这种误采集可通过以下原因解释：（i）由于机械性PVC不存在室房传导，冠状窦中传播参考的搏动接受标准未改变；（ii）未能排除与PVC重叠的搏动，因为这些电压未达到0.64 mV的阈值。当映射系统显示线性病变上的离心性激活时，来自心外膜结构或另一腔室的被动激活是一个重要的鉴别诊断；然而，也必须排除由于自动采集导致的错误标注。了解每个映射系统中的自动点采集标准并熟悉这些标准的陷阱很重要。
超高分辨率映射技术的发展使我们能够以更少的手动重新标注来了解心动过速回路的细节。映射系统中安装的自动点采集标准通常有效工作，从而能够展示精确的心动过速回路。然而，本病例从逻辑上展示了我们如何注意到高分辨率激活图的错误标注，并解释了自动搏动采集功能的陷阱。
