Editorial comment
Catheter ablation of atrial flutter: Critical isthmus identification and localization
Ablação por cateter de flutter auricular: identificação e localização de istmo crítico
Alireza Sepehri Shamloo, Gerhard Hindricks
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Department of Electrophysiology, Leipzig Heart Center at University of Leipzig and Leipzig Heart Institute (LHI), Leipzig, Germany
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A: The identified mutation p.C57W is located in the muscle LIM protein and titin interacting domain. All published mutations associated with cardiomyopathies are displayed. Red arrows indicate mutations in HCM patients and blue arrows mutations in dilated cardiomyopathy patients. Orange arrows denote three variations, which were initially described as mutations, but seem to be actually benign rather than disease-associated because of their frequency. The known interaction partners of titin-cap are shown below the bar representing the protein. B: Titin-cap interacts with a variety of different proteins in the Z-disk. In addition to the N-terminus of two titin molecules, it binds the potassium channel subunit minK, muscle LIM protein (MLP), and all three members of the calsarcin protein family (according to Frank et al.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">53</span></a>). 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radiofrequency application stopped the atrial flutter (blue tag).</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AFL: atrial flutter; LAT: local activation time; RF: radiofrequency.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Adragão, Daniel Matos, Francisco Moscoso Costa, Pedro Carmo, Diogo Cavaco, Gustavo Rodrigues, João Carmo, Francisco Morgado, Miguel Mendes" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Pedro" "apellidos" => "Adragão" ] 1 => array:2 [ "nombre" => "Daniel" "apellidos" => "Matos" ] 2 => array:2 [ "nombre" => "Francisco Moscoso" "apellidos" => "Costa" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Carmo" ] 4 => array:2 [ "nombre" => "Diogo" "apellidos" => "Cavaco" ] 5 => array:2 [ "nombre" => "Gustavo" "apellidos" => "Rodrigues" ] 6 => array:2 [ "nombre" => "João" "apellidos" => "Carmo" ] 7 => array:2 [ "nombre" => "Francisco" "apellidos" => "Morgado" ] 8 => array:2 [ "nombre" => "Miguel" "apellidos" => "Mendes" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204920302518" "doi" => "10.1016/j.repce.2020.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920302518?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255120302754?idApp=UINPBA00004E" "url" => "/08702551/0000003900000006/v2_202007190644/S0870255120302754/v2_202007190644/en/main.assets" ] "asociados" => array:1 [ 0 => array:20 [ "pii" => "S0870255120302754" "issn" => "08702551" "doi" => "10.1016/j.repc.2020.06.009" "estado" => "S300" "fechaPublicacion" => "2020-06-01" "aid" => "1567" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2020;39:309-14" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "A new electrophysiologic triad for identification and localization of the critical isthmus in atrial flutter" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309" "paginaFinal" => "314" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Uma nova tríade eletrofisiológica para identificação e localização do istmo crítico no <span class="elsevierStyleItalic">flutter</span> auricular" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 783 "Ancho" => 1874 "Tamanyo" => 200435 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Flutter around an anterior wall scar and a corresponding local activation time-valley (blue, purple, red and orange bars); 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A significant number of patients with AFL will develop atrial fibrillation (AF) afterwards.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Moreover, a sizable proportion of patients who undergo AF ablation will develop AFL (atrial macroreentrant tachycardia is a more accurate term) as a secondary arrhythmia after the ablation procedure. Approaches to the management and use of anticoagulation therapy are considered equivalent for AFL and AF and the same stroke prevention strategies are therefore recommended.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Appropriate management of AFL is not only important due the symptoms, but also to the increased risk of complications, such as thromboembolism and stroke, which may lead to permanent disability or death.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> So far, different therapeutic strategies have been introduced for AFL, including rate control, cardioversion to sinus rhythm (principally electrical cardioversion or high-rate stimulation), and catheter ablation.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4–6</span></a> Due to the low success rate of pharmacological antiarrhythmic approaches in AFL, long-term drug therapy is less acceptable nowadays, and is recommended when ablation is not feasible.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Catheter ablation is a promising treatment method to maintain sinus rhythm, especially in the case of cavotricuspid isthmus-dependent AFLs.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Catheter ablation for typical right atrial isthmus-dependent AFL has yielded a high success rate of 90-98% and a low recurrence rate of only 2-15%; however, successful ablation depends on the correct identification of the reentrant circuit responsible for the arrythmia and its critical isthmus.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7,8</span></a> For non-isthmus-dependent right or left atrial macroreentrant tachycardia (so-called atypical AFL), the precise identification of the critical isthmuses for successful catheter ablation procedures is certainly more complex as multiple re-entrant pathways in the right and/or left atrium may be involved.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9,10</span></a> Fast and accurate identification and understanding of the re-entrant pathway and the critical conduction zone are crucial for the development and performance of a successful ablation strategy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The recent study by Adragão et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> sought to help us better understand how to identify and localize the critical isthmus in left AFL and introduced a stepwise approach. They took advantage of a new feature of an electroanatomical mapping (EAM) system, which produces a histogram of local activation times (LAT), in addition to the activation and voltage maps.</p><p id="par0015" class="elsevierStylePara elsevierViewall">An LAT histogram is actually a graphical illustration of the LAT values of all the points that contribute to the LAT coloring on active maps and provides a visual representation of the activation throughout the tachycardia cycle length (TCL). This tool helps electrophysiologists to identify the part of the cycle which needs to be mapped further. In principle, the range of the LAT histogram is determined based on the window of interest (WOI) and when a point is edited to be outside of the WOI, the range is expanded accordingly. The height of the histogram shows the number of points that fall within the bin range; while each bin is color coded based on the LAT values of the points associated with it. In Figures 2 and 3 of Adragão's article,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> an example of an LAT histogram is presented.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to identify the critical isthmus in left AFL, Adragão et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> proposed a very logical stepwise approach. After identifying the LAT-valleys (defined as zones in the LAT histogram with 20% or less points relative to the highest bar [maximum LAT value]); they checked whether the identified LAT-valleys corresponded to slow conduction areas and heterogeneous low-voltage zones. They then quantified the LAT-valley atrial surface with the Carto® area measurements feature to identify whether the regions corresponded to the successful ablation site or not. Their initial findings showed that that all these areas corresponded to the primary LAT-valley identified in the global histogram analysis, which confirmed the accuracy of their method. In fact, they introduced a new electrophysiologic triad for identification and localization of the left critical isthmus in AFL which encompasses: (1) areas of low- voltage (0.05 to 0.3 mV); (2) sites of deep histogram valleys (LAT-valleys) with less than 20% density points relative to the highest density zone; and (3) a prolonged LAT-valley duration which included 10% or more of the TCL. Although it was a retrospective study in a small group of patients, their results may open new windows toward a new less complex approach that is less reliant on extensive ablation lesions. Their findings also helped us to gain a better understanding of the utility of three-dimension electroanatomic mapping in the identification of the critical isthmus and potential ablation sites in patients with left AFL. Is this new strategy powerful enough to replace all other mapping strategies for successful ablation of non-isthmus-dependent atrial macro re-entrant tachycardia? No, because some limitations related to the different modes of activation mapping remain. One is that these methods are not able to define precisely the active or leading re-entrant circuit. This can only be achieved with application of elegant classical electrophysiological strategies such as entrainment mapping.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> Overall, the introduction of the new LAT histogram strategy is a useful additional tool to improve the fast recognition of critical isthmus sites in patients with complex atrial macroreentrant tachycardia.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">A.S.S has no conflicts of interest to declare. G.H. has received scientific grants and research & development grants through the University Leipzig / Heart Center from Volkswagen Foundation, German Innovation Fund, and the European Commission.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of new-onset atrial fibrillation after cavotricuspid isthmus ablation for atrial flutter" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "U. Celikyurt" 1 => "S. Knecht" 2 => "M. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 10 | 8 | 18 |
| 2024 Outubro | 61 | 38 | 99 |
| 2024 Setembro | 76 | 30 | 106 |
| 2024 Agosto | 69 | 45 | 114 |
| 2024 Julho | 61 | 48 | 109 |
| 2024 Junho | 46 | 37 | 83 |
| 2024 Maio | 39 | 26 | 65 |
| 2024 Abril | 42 | 32 | 74 |
| 2024 Maro | 37 | 22 | 59 |
| 2024 Fevereiro | 34 | 24 | 58 |
| 2024 Janeiro | 33 | 25 | 58 |
| 2023 Dezembro | 37 | 28 | 65 |
| 2023 Novembro | 49 | 29 | 78 |
| 2023 Outubro | 34 | 22 | 56 |
| 2023 Setembro | 31 | 26 | 57 |
| 2023 Agosto | 39 | 15 | 54 |
| 2023 Julho | 48 | 13 | 61 |
| 2023 Junho | 46 | 20 | 66 |
| 2023 Maio | 49 | 32 | 81 |
| 2023 Abril | 31 | 6 | 37 |
| 2023 Maro | 55 | 29 | 84 |
| 2023 Fevereiro | 68 | 15 | 83 |
| 2023 Janeiro | 69 | 20 | 89 |
| 2022 Dezembro | 62 | 22 | 84 |
| 2022 Novembro | 91 | 28 | 119 |
| 2022 Outubro | 75 | 25 | 100 |
| 2022 Setembro | 58 | 34 | 92 |
| 2022 Agosto | 55 | 33 | 88 |
| 2022 Julho | 55 | 42 | 97 |
| 2022 Junho | 39 | 27 | 66 |
| 2022 Maio | 46 | 37 | 83 |
| 2022 Abril | 31 | 40 | 71 |
| 2022 Maro | 51 | 54 | 105 |
| 2022 Fevereiro | 35 | 27 | 62 |
| 2022 Janeiro | 23 | 33 | 56 |
| 2021 Dezembro | 28 | 42 | 70 |
| 2021 Novembro | 35 | 41 | 76 |
| 2021 Outubro | 43 | 45 | 88 |
| 2021 Setembro | 31 | 30 | 61 |
| 2021 Agosto | 35 | 35 | 70 |
| 2021 Julho | 18 | 20 | 38 |
| 2021 Junho | 25 | 20 | 45 |
| 2021 Maio | 39 | 43 | 82 |
| 2021 Abril | 57 | 41 | 98 |
| 2021 Maro | 90 | 21 | 111 |
| 2021 Fevereiro | 52 | 18 | 70 |
| 2021 Janeiro | 62 | 18 | 80 |
| 2020 Dezembro | 74 | 24 | 98 |
| 2020 Novembro | 34 | 28 | 62 |
| 2020 Outubro | 61 | 19 | 80 |
| 2020 Setembro | 46 | 30 | 76 |
| 2020 Agosto | 52 | 22 | 74 |
| 2020 Julho | 128 | 63 | 191 |
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