Catheter ablation of atypical flutter using new 3-dimensional electroanatomic mapping software focusing on areas of conduction block Camilla Asferg,

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Catheter ablation of atypical flutter using new 3-dimensional electroanatomic mapping software focusing on areas of conduction block Camilla Asferg, MD, Xu Chen, MD, Steen Pehrson, MD, Peter Karl Jacobsen, MD HeartRhythm Case Reports Volume 5, Issue 4, Pages 225-228 (April 2019) DOI: 10.1016/j.hrcr.2019.01.003 Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 1 The 12-lead electrocardiogram shows a 2:1 flutter with flutter wave morphology positive in V1, no visible F waves in lead I, and inverted P wave in leads II, III, and augmented vector foot (AVF) and a right bundle branch block pattern. HeartRhythm Case Reports 2019 5, 225-228DOI: (10.1016/j.hrcr.2019.01.003) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 2 Three-dimensional electroanatomic map of the right atrium performed with the PENTARAY catheter (Biosense Webster, Diamond Bar, CA) used with the CARTO 3 Multi-Electrode-Mapping technology (Biosense Webster). A: Local activation time (LAT) map. The earliest LAT point is -174 ms (red) and the latest LAT point is 120 ms (purple), thereby covering the entire tachycardia cycle length. B: Signals from the PENTARAY catheter that is placed in the region with conduction block and reentry, showing both late (eg, PR 15–16) and early (eg, PR 9–10) potentials. Local double potentials with a shift in near field and a far-field component and fractionation in between on PR 11–12 and PR 19–20 suggest that these poles are straddling the isthmus. The coronary sinus (CS) signals indicate a proximal-to-distal activation. Right lateral (RL) view. HeartRhythm Case Reports 2019 5, 225-228DOI: (10.1016/j.hrcr.2019.01.003) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 3 Electroanatomic mapping of the right atrium performed with the PENTARAY catheter (Biosense Webster, Diamond Bar, CA). Top row with the CARTO 3 high definition (HD) coloring feature (Biosense Webster). A: Local activation time (LAT) map showing conduction block (brown line) and reentry path (red line and arrow). B: The bipolar voltage map (lower threshold: 0.2 mV, upper threshold: 0.5 mV) shows that regions with scar tissue correlate with the areas of conduction block in the LAT map. Moreover, the region of healthy tissue between scars correlates with the reentry in the LAT map in panel A. The propagating wavefront is passing through the narrow path between the 2 regions of scar tissue and thereby facilitating a reentry. Bottom row shows same map as top, but without HD coloring. C: LAT map showing reentry (red line – early meets late at 80%). D: Bipolar voltage map (lower threshold: 0.2 mV, upper threshold: 0.5 mV). HeartRhythm Case Reports 2019 5, 225-228DOI: (10.1016/j.hrcr.2019.01.003) Copyright © 2019 Heart Rhythm Society Terms and Conditions