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Simultaneous mapping of the tricuspid and mitral valve annuli at electrophysiological study
L M Davis1, D A Richards, J B Uther
1Cardiology Unit, Westmead Hospital, New South Wales, Australia.
Insights
This study introduces a new catheter technique for mapping accessory pathways in the right free wall, improving accuracy and safety. The method facilitates the detection and ablation of these pathways and atriofascicular connections.
Area of Science:
- Electrophysiology
- Cardiovascular Medicine
- Medical Devices
Background:
- Mapping accessory pathways in the right free wall is challenging due to limitations in electrode placement compared to the left free wall.
- Existing methods like sequential roving catheters are less effective than simultaneous multi-electrode recordings around the valve annulus.
Purpose of the Study:
- To describe and evaluate a novel catheter technique for mapping the tricuspid annulus.
- To improve the accuracy and efficiency of identifying right free wall accessory pathways and atriofascicular connections.
Main Methods:
- A specially shaped 10-pole catheter was used to map the tricuspid annulus in nine patients with suspected right free wall accessory pathways or atriofascicular connections.
- Simultaneous recordings were obtained using additional catheters for the coronary sinus and His bundle activity.
- Catheter positions were confirmed by multiplane fluoroscopy and coronary angiography.
Main Results:
- The technique successfully detected seven right free wall accessory pathways, two posterior septal accessory pathways, and three atriofascicular connections.
- Locations of eight accessory pathways and three atriofascicular connections were confirmed during operative mapping.
- The tricuspid annulus catheter was consistently positioned anatomically relative to the right coronary artery.
Conclusions:
- The new catheter technique allows rapid, detailed mapping of atrial and ventricular activation around the tricuspid annulus with high resolution.
- The method demonstrated accuracy, simplicity, and safety, facilitating the detection and ablation of right free wall accessory pathways and atriofascicular connections.
Background:
Mapping of the right free wall in patients with accessory pathways is difficult compared with that of the left free wall where the coronary sinus permits stable and accurate location of the electrodes used for endocardial mapping. Furthermore, the sequential roving catheter method is less satisfactory than multiple simultaneous electrode recordings spanning the circumference of the valve annulus. A new method for mapping the tricuspid annulus is described.
Methods:
Mapping was performed in nine patients with a suspected right free wall accessory pathway or an atriofascicular connection. The tricuspid annulus was mapped using a specially shaped 1 cm interelectrode 10 pole catheter positioned in the right atrium immediately above the annulus. The coronary sinus was mapped with a 5 mm interelectrode 10 pole catheter and a 2 mm interelectrode 10 pole catheter recorded His bundle activity. Catheter positions were confirmed by multiplane fluoroscopy. Electrograms were digitised and recorded simultaneously using a custom computerised mapping system. The position of the multielectrode catheter around the tricuspid annulus relative to that of the coronary arteries was examined by coronary angiography in three patients.
Results:
Seven right free wall and two posterior septal accessory pathways, and three atriofascicular connections were detected. Ventricular activation adjacent to both valve annuli was mapped in five patients with pre-excitation. The locations of eight of the nine accessory pathways and the three atriofascicular connections were confirmed at operative mapping. One right free wall accessory pathway in a patient with Ebstein's anomaly was not detected at operative mapping. No additional accessory pathways were found at operative mapping or routine 6 month postoperative electrophysiological study, or during a mean (SD) clinical follow up of 22 (7) months. The tricuspid annulus catheter was located during coronary angiography at a mean (SD) of about 2.5 (0.7) cm above and parallel to the right coronary artery in the right atrioventricular groove.
Conclusions:
This new catheter technique permits rapid detailed mapping of atrial and ventricular activation around the tricuspid annulus with a resolution of at least < or = % 1 cm, depending on the number and spacing of electrodes in each catheter. The technique was accurate as judged by mapping at surgery. This method is simple and safe compared with that of others for mapping the right free wall via the right coronary artery. It should facilitate detection and ablation of right free wall accessory pathways and atriofascicular connections.