Catheter Ablation of Cardiac Arrhythmias: Expert Consult - Online and Print, 2nd Edition

Cover......Page 1
Front Matter......Page 2
ISBN    9781437713688......Page 3
Copyright......Page 4
Dedication......Page 5
Contributors......Page 7
Preface......Page 14
Acknowledgments......Page 16
Resistive Heating......Page 18
Thermal Conduction......Page 19
Convective Cooling......Page 21
Electrical Current Distribution......Page 23
Dispersive Electrode......Page 24
Edge Effect......Page 25
Radiofrequency Lesion Ultrastructure......Page 26
Radiofrequency Ablation and Arterial Perfusion......Page 27
Plasma Membrane......Page 28
Calcium Overload and Cellular Injury......Page 29
Conduction Velocity......Page 30
Electrode Size......Page 31
Electrode Material......Page 32
References......Page 33
Videos......Page 35
Assessment of Catheter-Tissue Contact......Page 36
Coagulum Formation......Page 37
Cardiac Perforation......Page 38
Impedance-Titrated Energy Delivery......Page 39
Electrogram Amplitude-Titrated Energy Delivery......Page 40
Differences between Irrigated 
and Conventional Ablation Catheters......Page 41
Factors Affecting Lesion Size during Irrigated Radiofrequency Ablation......Page 42
Titrating Energy Delivery in Unusual Anatomic Sites......Page 43
Power Titration during Epicardial Ablation......Page 44
References......Page 45
Videos......Page 47
Biophysics of Cooled Radiofrequency Ablation......Page 48
Results of Animal Studies......Page 51
Cooled Radiofrequency Ablation 
for Nonidiopathic Ventricular Tachycardia......Page 54
Cooled Radiofrequency Ablation for Atrial Flutter......Page 55
Conclusion......Page 56
References......Page 57
History of Cryothermal Energy Use in Cardiovascular Medicine......Page 59
Biophysics and Mechanisms of Cryothermal Energy Tissue Injury......Page 60
Console and Catheters......Page 61
Determinants of Cryoablation 
Lesion Size......Page 63
Cryomapping and Cryoablation Delivery......Page 65
Minimal Risk for Thromboembolism......Page 67
Visualization by Ultrasound......Page 68
Clinical Applications......Page 69
Atrial Flutter......Page 70
Cryoablation in the Young......Page 71
References......Page 72
Basic Principles......Page 74
Microwave System Design......Page 75
Ablation of Ventricular Myocardium......Page 76
Basic Principles......Page 77
Diode Laser......Page 78
Laser Balloon Catheter Design......Page 79
Lessons from Experimental Studies......Page 81
Ultrasound Balloon Catheters......Page 82
Alternative Ablative Techniques......Page 83
References......Page 84
Video......Page 87
Sources of Cardiac Imaging Used in Mapping and Ablation Procedures......Page 90
Radiation Protection Recommendations......Page 92
Cardiac Fluoroscopic Projections and Nomenclature......Page 94
Region of the Sinus Node......Page 96
Junction between the Superior Caval Vein and Right Atrium......Page 98
Eustachian Valve, Eustachian Ridge, and Tendon of Todaro......Page 99
Inferior (Cavotricuspid) Right Atrial Isthmus......Page 100
Triangle of Koch......Page 101
Interatrial Groove (Septum) and Oval Fossa......Page 103
Coronary Sinus and Pyramidal Space......Page 105
Right Atrioventricular Groove......Page 106
Right Ventricular Outflow Tract 
and Its Relation to the Aortic Leaflets and the Epicardial Superior Left Ventricle......Page 108
Left Atrium and Pulmonary Veins......Page 110
Pulmonary Veins and Venoatrial Junctions......Page 111
Left Atrial Appendage and Lateral Ridge......Page 112
Relations of the Left Atrium 
with the Esophagus and Phrenic Nerves......Page 114
Left Ventricle......Page 115
References......Page 116
Underlying Basis for the Extracellular Electrogram......Page 119
Unipolar and Bipolar Signals......Page 120
Recording Artifacts......Page 122
Electrical Abnormalities in the Absence of Structural Heart Disease......Page 123
Electrogram Abnormalities 
in the Presence of Structural Heart Disease......Page 125
Activation Sequence Mapping......Page 126
Pace Mapping......Page 128
Entrainment Mapping......Page 130
Response to Atrial or Ventricular Pacing......Page 132
Electrogram Morphology in Response to Pacing......Page 135
Activation Sequence during Pacing Maneuvers......Page 137
Parahisian Pacing......Page 138
References......Page 142
Carto Advanced Mapping System......Page 143
How to Begin Mapping......Page 144
Activation Map......Page 145
Image Merge......Page 146
EnSite NavX Mapping System......Page 147
Diagnostic Landmark Mapping Tool......Page 148
Voltage Map......Page 149
Ensite Array Mapping System......Page 150
References......Page 151
Clinical Experience Using 
the Electromechanical System......Page 153
Basic Concepts......Page 156
Advantages and Disadvantages of Remote Navigation Systems......Page 158
References......Page 160
Videos......Page 161
Intracardiac Echocardiography Catheter Design......Page 162
Guidance of Radiofrequency Ablation Catheter......Page 164
Role in Atrial Fibrillation Ablation Procedures......Page 165
Accurate Positioning of the Lasso Catheter 
at the Venous Ostium......Page 166
Avoidance of Atrioesophageal Fistula......Page 168
Intracardiac Echocardiography–Guided Ablation in the Left Ventricle......Page 170
Transseptal Puncture......Page 172
Suggested Imaging Protocol for Phased-Array Intracardiac Echocardiography......Page 173
References......Page 174
Pathophysiology......Page 180
Diagnosis and Differential Diagnosis......Page 181
Mapping......Page 185
Ablation......Page 187
Troubleshooting the Difficult Case......Page 189
References......Page 190
Atrial Flutter Terminology......Page 192
Anatomy and Pathophysiology......Page 193
Surface Electrocardiography......Page 195
Electrophysiologic Diagnosis......Page 197
Ablation......Page 200
Overcoming Difficult Cavotricuspid Isthmus Anatomy......Page 203
End Points for Ablation......Page 205
Troubleshooting 
the Difficult Case......Page 213
References......Page 215
Pathophysiology......Page 218
Macro-Reentrant versus Focal Atrial Tachycardia......Page 219
Localization of Reentry to the Right or Left Atrium......Page 221
Activation Mapping......Page 222
Electroanatomic Mapping......Page 223
Ablation......Page 225
Left Atrial Macro-Reentry......Page 226
Atrial Macro-Reentry after Mitral Valve Surgery......Page 228
Atrial Macro-Reentry after Catheter Ablation for Atrial Fibrillation......Page 229
Left Septal Flutter......Page 230
References......Page 231
Anatomic Considerations......Page 233
Pathophysiology......Page 235
Anatomic Detail......Page 237
Conventional Electrogram Mapping......Page 238
Three-Dimensional Mapping......Page 242
Ablation......Page 244
References......Page 246
Mechanisms of 
Atrial Fibrillation: Interplay 
of Trigger and Substrate......Page 250
Arrhythmogenicity of Pulmonary Veins......Page 251
Pulmonary Vein Anatomy Relevant to Ablation......Page 253
Electrophysiologic Properties of Pulmonary Veins and Mechanism 
of Arrhythmogenesis......Page 255
Isolation of Pulmonary Veins......Page 256
Fluoroscopy......Page 260
Intracardiac Echocardiography......Page 261
Ablation......Page 264
Cryogenic Energy......Page 267
End Points for Ablation......Page 268
Results of Ablation......Page 270
Troubleshooting 
the Difficult Case......Page 275
Conclusion......Page 276
References......Page 277
Videos......Page 280
Pathophysiology of Non–Pulmonary Vein Atrial Fibrillation Initiators......Page 281
Atrial Fibrillation Initiators from the Right Atrium.......Page 283
Atrial Fibrillation Initiators from the Left Atrium.......Page 285
Ablation Techniques......Page 286
Superior Vena Cava......Page 288
Left Atrial Wall......Page 290
Avoiding Complications......Page 291
References......Page 294
Pathophysiology......Page 296
Problems and Limitations......Page 297
Pathophysiology......Page 298
Left Atrial Roof Line......Page 299
Assessment of Conduction Block.......Page 301
Mitral Isthmus Line......Page 302
Anterior Left Atrial Line......Page 303
Assessing Conduction Block.......Page 304
Outcomes......Page 305
Pathophysiology......Page 306
Mapping and Ablation......Page 307
Outcomes......Page 310
Ablation of Intrinsic Cardiac Autonomics......Page 311
Ligament of Marshall......Page 313
Outcomes......Page 314
End Points for the Substrate-Based Approach to Atrial Fibrillation Ablation......Page 316
Troubleshooting the Difficult Case......Page 317
References......Page 318
Stepwise Approach for Ablation of Persistent Atrial Fibrillation......Page 320
Atrial Fibrillation Cycle Length: 
A Real-Time Guide to Ablation......Page 321
Step 2: Electrogram-Based Ablation......Page 323
Procedural End Point for Stepwise Ablation......Page 326
Mapping Atrial Tachycardias......Page 327
References......Page 329
Anatomy of the Atrioventricular Node and Its Inputs......Page 334
Pathophysiology......Page 335
Diagnosis......Page 337
Slow-Fast Variant......Page 340
Slow-Slow Variant......Page 343
Fast-Slow Variant......Page 345
Left-Sided Variant......Page 346
Differential Diagnosis......Page 347
Atrioventricular Nodal Reentry and Other Arrhythmias......Page 348
Anatomic Approach......Page 349
Application of Radiofrequency Current.......Page 352
Cryoablation......Page 353
Slow-Slow and Fast-Slow Variants......Page 355
Left-Sided Variant......Page 358
Preventing Atrioventricular Block During Catheter Ablation......Page 359
Ablation of Atrioventricular Nodal Reentry in Patients with Impaired Atrioventricular Conduction......Page 360
Troubleshooting 
the Difficult Case......Page 361
References......Page 364
Complete Atrioventricular Junction Ablation......Page 367
Mapping and Ablation......Page 368
Troubleshooting the Difficult Case......Page 371
Atrioventricular Junction Modification......Page 372
References......Page 373
Anatomy......Page 376
Diagnosis......Page 378
Mapping......Page 381
Left Free Wall Accessory Pathways......Page 382
Right Free Wall Accessory Pathways......Page 387
Ablation......Page 388
Left Free Wall Accessory Pathways......Page 391
Troubleshooting 
the Difficult Case......Page 393
References......Page 397
Anatomy......Page 399
Diagnosis and Differential Diagnosis......Page 401
Mapping......Page 403
Troubleshooting the Difficult Case......Page 408
References......Page 410
Video......Page 411
Catheter Ablation of Superoparaseptal (“Anteroseptal”) and Mid-Septal Accessory Pathways......Page 412
Superoparaseptal Accessory Pathways......Page 413
Electrophysiologic Testing......Page 414
Superoparaseptal Accessory Pathways......Page 416
Troubleshooting 
the Difficult Case......Page 419
Mid-Septal Accessory Pathways......Page 421
References......Page 422
Atriofascicular Pathway Anatomy......Page 424
Pathophysiology......Page 425
Electrophysiologic Findings......Page 426
Intracardiac Recordings......Page 427
Differential Diagnosis......Page 429
Mapping......Page 431
Ablation......Page 433
Troubleshooting 
the Difficult Case......Page 436
Other Accessory Pathway Variants......Page 437
Nodofascicular and Nodoventricular Accessory Pathways......Page 438
References......Page 439
Inability to Heat......Page 441
Misdiagnosis......Page 442
Other Factors......Page 443
Coronary Sinus and Epicardial Accessory Pathways......Page 444
Atrial Appendage-to-Ventricular Accessory Pathways......Page 445
Ebstein Anomaly......Page 447
Persistent Left Superior Vena Cava......Page 448
Multiple Accessory Pathways......Page 449
Oblique Accessory Pathways......Page 450
Atypical Accessory Pathways......Page 451
Cryothermal Ablation......Page 454
Impact of Location on Ablation 
of Accessory Pathways......Page 455
Approach to the Patient Requiring Repeat Ablation......Page 456
References......Page 457
Clinical Presentation......Page 462
Anatomy......Page 463
Clinical Arrhythmias 
from Right Ventricular Outflow Tract......Page 464
Clinical Arrhythmias 
from Basal Left Ventricle......Page 467
Clinical Arrhythmias from the Aortic Cusps and Surrounding Epicardium......Page 468
Mapping Technique......Page 470
Morphology......Page 471
Mapping......Page 472
Ablation......Page 474
Troubleshooting 
the Difficult Case......Page 475
References......Page 477
Classification......Page 479
Substrate and Anatomy......Page 480
Mechanism......Page 481
Surface Electrocardiogram......Page 486
Intracardiac Electrograms......Page 487
Left Posterior Fascicular Ventricular Tachycardia......Page 490
Left Anterior Fascicular Ventricular Tachycardia......Page 492
Radiofrequency Energy Delivery 
and the End Point of Ablation......Page 493
Complications......Page 494
Troubleshooting 
the Difficult Case......Page 495
Clinical and Electrophysiologic Characteristics......Page 498
Mapping and Ablation......Page 499
Success and Recurrence Rates......Page 502
References......Page 503
Pathophysiology......Page 504
Decision-Making Process 
for Ablation......Page 507
Entrainment Mapping......Page 510
Substrate Mapping......Page 515
Ablation......Page 518
Complications......Page 520
Conclusion......Page 521
References......Page 522
Anatomy......Page 524
Surface Electrocardiogram......Page 526
Electrophysiologic Testing......Page 527
Automatic Fascicular Tachycardia......Page 530
Ablation......Page 532
Complications......Page 533
Right Ventricular Dysplasia (Cardiomyopathy)......Page 534
Mapping and Ablation......Page 536
Mapping and Ablation......Page 538
Chagas Disease......Page 541
Papillary Muscle Ventricular Tachycardia......Page 542
Sarcoidosis......Page 543
Miscellaneous......Page 544
References......Page 546
Mechanism of Post–Myocardial Infarction Ventricular Tachycardia......Page 548
Surgical Experience with Post–Myocardial 
Infarction Ventricular Tachycardia......Page 549
Mapping and Ablation......Page 552
Substrate-Based Ablation 
of Ventricular Tachycardia......Page 553
Identification and Ablation 
of the Ventricular Tachycardia Exit Sites......Page 556
Targeting the Myocardial Channels......Page 558
Radiofrequency Ablation Catheter Technology......Page 562
Rapid Single-Beat Activation Mapping......Page 564
Other Scar-Related Ventricular Tachycardias......Page 566
Are All Scar-Related Ventricular Tachycardias 
Located at the Subendocardium?......Page 567
Future of Unstable Ventricular Tachycardia Ablation......Page 568
Minimizing Complications......Page 569
Ventricular Fibrillation......Page 571
Conclusion......Page 572
References......Page 573
Epicardial Approach to Catheter Ablation of Ventricular Tachycardia......Page 576
Subxiphoid Percutaneous Approach......Page 577
Avoiding Coronary Artery Damage......Page 579
Pericardial Adhesions......Page 580
Electroanatomic Mapping......Page 581
Conclusion......Page 586
References......Page 589
Pertinent Anatomy......Page 590
Mechanism......Page 591
Strategies for Basic Mapping......Page 592
Targets for Ablation......Page 593
Success and Recurrence Rates......Page 594
Troubleshooting 
the Difficult Case......Page 595
References......Page 596
Prior Studies of Complications during Catheter Ablation Procedures......Page 598
Types and Classification of Complications......Page 600
Radiation Exposure......Page 601
Accessory Pathways......Page 603
Atrioventricular Junction......Page 604
Atrial Flutter......Page 605
Atrial Fibrillation......Page 606
Nonidiopathic Ventricular Tachycardia......Page 607
References......Page 608
Anatomy......Page 610
Protamine Sulfate......Page 611
Transseptal Sheaths and Dilators......Page 612
Transseptal Catheterization......Page 613
Double Transseptal Technique......Page 618
Troubleshooting the Difficult Case......Page 620
Acknowledgments......Page 621
Videos......Page 622
Special Considerations for Ablation in Pediatric Patients......Page 623
The Decision to Ablate: Safety Versus Efficacy......Page 624
Atrioventricular Nodal Reentrant Tachycardia in Children......Page 625
Coronary Artery Damage......Page 626
Summary and Recommendations......Page 627
Preexcitation Syndromes in Infants......Page 628
Pathophysiology......Page 629
Atrioventricular Discordance......Page 631
Double Atrioventricular Nodes......Page 632
Summary......Page 634
Atrial Flutter or Fibrillation 
in the Absence of Other Heart Disease......Page 635
Therapy......Page 636
Mapping......Page 639
Therapy......Page 640
Mapping and Ablation......Page 641
Permanent Form of Junctional Reciprocating Tachycardia......Page 642
Complications and Recommendations......Page 643
Sedation and Anesthesia......Page 644
References......Page 646
A......Page 651
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X......Page 666