Identification of Circumferential Pulmonary Vein Isolation Gaps and Critical Atrial Substrate From HD Grid Maps in Atrial Fibrillation Patients: Insights From Omnipolar Technology

Abstract

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 15, No. 1Identification of Circumferential Pulmonary Vein Isolation Gaps and Critical Atrial Substrate From HD Grid Maps in Atrial Fibrillation Patients: Insights From Omnipolar Technology Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBIdentification of Circumferential Pulmonary Vein Isolation Gaps and Critical Atrial Substrate From HD Grid Maps in Atrial Fibrillation Patients: Insights From Omnipolar Technology Wen-Han Cheng, MD, Li-Wei Lo, MD, Yenn-Jiang Lin, MD, Shih-Lin Chang, MD, Yu-Feng Hu, MD, Fa-Po Chung, MD, Ta-Chuan Tuan, MD, Tze-Fan Chao, MD, Jo-Nan Liao, MD, Ting-Yung Chang, MD, Chin-Yu Lin, MD, Ling Kuo, MD, Shin-Huei Liu, MD, Jennifer Jeanne Vicera, MD, Isaiah C. Lugtu, MD, Steven Kim, MSEE and Shih-Ann Chen, MD Wen-Han ChengWen-Han Cheng Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Li-Wei LoLi-Wei Lo Li-Wei Lo, MD, Division of Cardiology, Taipei Veterans General Hospital, 201, Sec.2, Shih-Pai Rd, Taipei, Taiwan, Email E-mail Address: [email protected] https://orcid.org/0000-0002-8672-4274 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Yenn-Jiang LinYenn-Jiang Lin Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Shih-Lin ChangShih-Lin Chang https://orcid.org/0000-0001-7030-8471 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Yu-Feng HuYu-Feng Hu https://orcid.org/0000-0001-5715-2070 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Fa-Po ChungFa-Po Chung https://orcid.org/0000-0001-8960-1301 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Ta-Chuan TuanTa-Chuan Tuan Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Tze-Fan ChaoTze-Fan Chao https://orcid.org/0000-0002-6587-3094 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Jo-Nan LiaoJo-Nan Liao Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Ting-Yung ChangTing-Yung Chang https://orcid.org/0000-0002-2612-0057 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Chin-Yu LinChin-Yu Lin https://orcid.org/0000-0003-3282-7523 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Ling KuoLing Kuo https://orcid.org/0000-0002-8604-6151 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Shin-Huei LiuShin-Huei Liu Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Search for more papers by this author , Jennifer Jeanne ViceraJennifer Jeanne Vicera https://orcid.org/0000-0001-6722-1826 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Search for more papers by this author , Isaiah C. LugtuIsaiah C. Lugtu https://orcid.org/0000-0003-1635-1625 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Search for more papers by this author , Steven KimSteven Kim Abbott, Advanced Applications Department, MN (S.K.). Search for more papers by this author and Shih-Ann ChenShih-Ann Chen Correspondence to: Shih-Ann Chen, MD, Cardiovascular Center, Taichung Veterans General Hospital, 1650 Taiwan Blvd Sect. 4, Taichung, Taiwan, Email E-mail Address: [email protected] https://orcid.org/0000-0001-9085-0823 Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., J.J.V., I.C.L., S.-A.C.). Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan (W.-H.C., L.-W.L., Y.-J.L., S.-L.C., Y.-F.H., F.-P.C., T.-C.T., T.-F.C., J.-N.L., T.-Y.C., C.-Y.L., L.K., S.-H.L., S.-A.C.). Cardiovascular Center, Taichung Veterans General Hospital, Taiwan (S.-A.C.). Search for more papers by this author Originally published23 Dec 2021https://doi.org/10.1161/CIRCEP.121.010424Circulation: Arrhythmia and Electrophysiology. 2022;15:e010424Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 23, 2021: Ahead of Print In patients with drug-refractory and symptomatic atrial fibrillation (AF), pulmonary vein isolation (PVI) remains an important intervention. Reconnections of left atrial-pulmonary vein (LA-PV) conduction constitute the main cause of recurrences.1 Abnormal atrial substrate is also considered in AF recurrences.2 Kalman’s group proposed the concept of dynamic atrial substrate, showing that variation in cycle length and directions of wavefront caused significant changes in substrate maps,3 which raises concerns for the accuracy of targeting static low voltage zones (LVZs). Multiple maps acquired during sinus rhythm (SR) and pacing rhythms from different sites with various cycle lengths would be required to identify the active substrates. Omnipolar voltage map (OT Vmax) provides a potential solution to this problem.4 In the present study, we aimed to identify circumferential PVI gaps and atrial substrate efficiently and accurately with OT Vmax.This was a retrospective study recruiting 51 patients (45 patients [88%] with paroxysmal AF) receiving catheter ablation between June 2019 and December 2019. The study was approved by the institutional review board (IRB-TPEVGH number: 2020-06-015BC). All supporting data are available within the article.Post-ablation LA mapping was reconstructed during SR and different pacing rhythms (proximal and distal coronary sinus [CS] pacings) following first-pass PVI. Data were exported and retrospectively analyzed using OT Vmax to identify LA-PV gaps (defined as areas on ablation lines with residual voltages associated with activation conducting into the PVs) or critical atrial substrate and compared with bipolar voltage. LA global peak-to-peak bipolar electrogram voltage was measured during SR and CS pacing (proximal and distal). In areas where maximal bipolar or omnipolar voltage <0.5 mV were defined as LVZs.The anatomic distribution of LA-PV conduction gaps is shown in the Figure [A]. Using bipolar voltage, a significantly greater number of conduction gaps were noted during CS pacing (proximal and distal, respectively), as compared to SR (18.40±3.72 versus 13.00±4.00, P=0.006 and 18.30±3.02 versus 13.00±4.00, P=0.004, respectively). Compared with bipolar voltage, OT Vmax detected significantly more conduction gaps across all rhythms (Figure [B]). A representative conduction gap example can be identified with the OT Vmax but not with bipolar voltage (Figure [C]).Download figureDownload PowerPointFigure. Application of omnipolar technology for gaps and atrial substrate identification.A, Regional distribution of postpulmonary vein (PV) isolation conduction gaps detected on both bipolar and omnipolar voltage map (OT Vmax) during sinus rhythm (SR) and from different pacing sites. B, Conduction gap identification by bipolar vs omnipolar voltage. Compared with bipolar voltage, OT Vmax detected significantly more conduction gaps across all rhythms (during SR and from different pacing sites). C, A representative case of the identified right PV carina conduction gap with OT Vmax, which was obscured on bipolar voltage. Areas of the conduction gap were 28 mm2 on bipolar voltage and 44 mm2 on OT Vmax. Corresponding activation map during SR revealed a residual conduction gap (white arrow indicates residual conduction and black lines indicate block lines created by PV isolation). D, Low voltage zones (LVZs) percentage by bipolar vs omnipolar voltage. Compared with bipolar voltage, OT Vmax could detect significantly less left atrial substrate abnormalities during SR and from different pacing sites. DCSP indicates distal coronary sinus pacing; LIPV, left inferior pulmonary vein; LPV, left pulmonary vein; PCSP, proximal coronary sinus pacing; RIPV, right inferior pulmonary vein; RPV, right pulmonary vein; RSPV, right superior pulmonary vein. *The use of OT Vmax.Using bipolar voltage, compared with SR, there were more discrete LVZs during proximal CS pacing (13.1±4.7% versus 21.2±4.8%, P<0.001) or distal CS pacing (13.1±4.7% versus 21.5±5.1%, P<0.001). Across all rhythms, independent of rate and wavefront direction, OT Vmax detected significantly less LVZs, compared with those in bipolar voltage (Figure [D]). Among these 51 patients, there were 14 (27%) patients (12 paroxysmal and 2 nonparoxysmal AFs at the index procedures) with atrial tachyarrhythmia recurrences (10 with AF, 3 with atrial flutter, and 1 with atrial tachycardia) after a mean follow-up period of 10.92±2.24 months. No procedural complications were observed in all patients.The main findings of this study included (1) during proximal or distal CS pacing, significantly more PV conduction gaps and more discrete LVZs were noted compared with SR; (2) across a variety of functional rhythms (controlled for rate and wavefront direction), OT Vmax exhibited a higher degree of sensitivity to detection of conduction gaps; and (3) OT Vmax yielded a higher degree of specificity for detection of low voltage LA substrate abnormalities.Omnipolar technology enables optimization of bipole orientation for sensitive and specific detection of highest voltage amplitude,5 with better discrimination of low amplitude residual pathways of LA-PV gaps on scars of PVI lines. For the purposes of this study, the inclusion criteria for gap determination was not limited to a strict gold standard, in which causality (eg, minimal lesions to create PVI) was documented. Instead, the definition of gap in this study was based upon the observational criteria of relative voltage amplitude, activation timing, and visual confirmation of localized activity in the electrograms. Those observations yielded in a higher change to identify gaps before a durable PVI.In addition, optimization according to maximum voltage accounted for significantly reduced LVZs, given different rates and pacing sites. Wong et al3 showed that the degree and anatomic distribution of LA abnormal substrate proved to be important factors underscoring the dynamic nature of LA abnormal substrate. The vulnerability of substrate to functional dynamics suggests the potential limitation of LVZ-targeted substrate modification.The concept of the directional-independence has been validated by Wong et al3 and Haldar et al,4 who illustrated that omnipolar electrograms can obtain the highest voltage by automatically computing and resolving numerous activation wavefronts into a net activation direction. Because omnipolar technology permits directional-independence and real-time analysis of vector fields; this feature can serve to be a more consistent finding of abnormal LA substrate, with the potential for identification of more reliable targets for AF substrate ablation.In conclusion, variations of rate and wavefront direction produce changes of electrogram voltage. By controlling electrogram orientation, OT Vmax can unmask potential conduction LA-PV gaps and identify specific regions in atrial substrate with functional independence, possibly increasing the long-term efficacy of PVI and substrate modification.Article InformationSources of FundingThe present work was supported by Abbott Research Grant.DisclosuresNone.Nonstandard Abbreviations and AcronymsAFatrial fibrillationCScoronary sinusLAleft atriumLA-PVleft atrial-pulmonary veinLVZlow voltage zoneOT Vmaxomnipolar voltage mapPCSPproximal coronary sinus pacingPVpulmonary veinPVIpulmonary vein isolationSRsinus rhythmFootnotesFor Sources of Funding and Disclosures, see page 65.Correspondence to: Shih-Ann Chen, MD, Cardiovascular Center, Taichung Veterans General Hospital, 1650 Taiwan Blvd Sect. 4, Taichung, Taiwan, Email [email protected]hinet.netLi-Wei Lo, MD, Division of Cardiology, Taipei Veterans General Hospital, 201, Sec.2, Shih-Pai Rd, Taipei, Taiwan, Email [email protected]hinet.net