Case Report| Volume 27, ISSUE 3, P97-100, March 2023

The pitfalls of automatic point acquisition with high-resolution mapping

Published:November 15, 2022DOI:


      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.


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        • Mantziari L.
        • Butcher C.
        • Kontogeorgis A.
        • Panikker S.
        • Roy K.
        • Markides V.
        • Wong T.
        Utility of a novel rapid high-resolution mapping system in the catheter ablation of arrhythmias: an initial human experience of mapping the atria and the left ventricle.
        JACC Clin Electrophysiol. 2015; 1: 411-420
        • Lackermair K.
        • Kellner S.
        • Kellnar A.
        • Riesinger L.M.
        • Wakili R.
        • Sinner M.F.
        • Rizas K.D.
        • Fichtner S.
        • Estner H.L.
        Initial single Centre experience with the novel Rhythmia© high density mapping system in an all comer collective of 400 electrophysiological patients.
        Int J Cardiol. 2018; 272: 168-174
        • Takigawa M.
        • Takagi T.
        • Martin C.A.
        • Derval N.
        • Denis A.
        • Vlachos K.
        • Cheniti G.
        • Duchateau J.
        • Pambrun T.
        • Shirai Y.
        • Tao S.
        • Takahashi Y.
        • Goya M.
        • Sacher F.
        • Cochet H.
        • et al.
        Differentiating atrial tachycardias with centrifugal activation: lessons from high-resolution mapping.
        Heart Rhythm. 2021; 18: 1122-1131
        • Barkagan M.
        • Shapira-Daniels A.
        • Leshem E.
        • Shen C.
        • Anter E.
        Pseudoblock of the posterior mitral line with epicardial bridging connections is a frequent cause of complex perimitral tachycardias.
        Circ Arrhythm Electrophysiol. 2019; 12e006933
        • Pambrun T.
        • Derval N.
        • Duchateau J.
        • Denis A.
        • Chauvel R.
        • Tixier R.
        • Welte N.
        • André C.
        • Nakashima T.
        • Nakatani Y.
        • Kamakura T.
        • Takagi T.
        • Ramirez F.D.
        • Krisai P.
        • Goujeau C.
        • et al.
        Epicardial course of the musculature related to the great cardiac vein: anatomical considerations and clinical implications for mitral isthmus block after vein of Marshall ethanol infusion.
        Heart Rhythm. 2021; 18: 1951-1958
        • Nakagawa H.
        • Ikeda A.
        • Sharma T.
        • Lazzara R.
        • Jackman W.M.
        Rapid high resolution electroanatomic mapping: evaluation of a new system in a canine atrial linear lesion model.
        Circ Arrhythm Electrophysiol. 2012; 5: 417-424
        • Sakamoto Y.
        • Lockwood D.
        • Yamaguchi R.
        • Yoshimoto D.
        • Suzuki T.
        • Ho S.Y.
        • Nakagawa H.
        Systematic evaluation of high-resolution activation mapping to identify residual endocardial and epicardial conduction across the mitral isthmus.
        JACC Clin Electrophysiol. 2021; 7: 292-304