Abstract
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.
Learning objective
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.
Keywords
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References
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Article info
Publication history
Published online: November 15, 2022
Accepted:
October 24,
2022
Received in revised form:
October 6,
2022
Received:
July 6,
2022
Identification
Copyright
© 2022 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. All rights reserved.
