A New Dimension in EP

Accurate Diagnosis and Efficient Workflow in AF Therapy

HOW IS AN INDIVIDUALIZED THERAPY POSSIBLE GIVEN HIGH PRESSURE ON WORKFLOW?

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How is an indiviualized therapy possible given high pressure on workflow?

Since the first days of electrocardiography, new forms of ventricular tachycardias as well as new observations on a variety of supraventricular arrhythmias, atrioventricular conduction disturbances, and paced rhythms have been described.

How EP workflows changed over time

In turn, catheter ablation procedures have evolved substantially and procedures and technical features have become more complex as previously not amenable complex arrhythmias became mappable and therefore treatable. The age of patients being treated has also increased. Advances in mapping/ablation technology, including new energy sources for ablation and both contact and non-contact mapping systems, have been key to extending indications and improving outcomes.

To handle the increased complexity of procedures, a close collaboration among cardiac electrophysiologists, engineers and technicians is highly needed in order to get the best from the available technology.

 

SEE PROF. DR. BOLDT'S STATEMENT:

More pressure due to COVID-19 – impact on individualized therapy?

Although ablations are always individualized, the heightened pressure, for example due to changed workflows because of COVID-19, might impact the execution of individualized therapy. While many intensive care units were overwhelmed at the start of the pandemic, most departments that provide elective procedures were closed or reduced to a minimum. Electrophysiological treatments often had to be postponed during the pandemic, as only urgent procedures could be performed. Consequently, the need for a fast and standardized workfllow increased. In recent years, novel technologies have provided electrophysiologists with possible solutions that support faster and more individualized approaches. An example would be charge density mapping systems, such as the AcQMap® platform.

  • Mapping of arrhythmia in three minutes or less: Rapid and consistent mapping creates an efficient map-ablate-remap strategy.
  • 2-minute ultrasound: The technique allows fast anatomic reconstruction of the left and right atrium by ultrasound.
  • Electrical mapping in 30 seconds: Non-contact intra-chamber electrical mapping delivers full chamber electrical activity at high resolution and within a very short time period.
  • Visualization with a single beat: Charge density mapping allows for a precise visualization of any arrhythmia characteristics, including single beat.
  • Optional possibility: contact mapping for conventional procedures.

Non-Contact Mapping

 

SuperMap

 

Contact Mapping

SEE PROF. DR. MEYER'S STATEMENT:

Personalized care in the treatment of complex arrhythmia

Individualized care is especially important in the treatment of more complex arrhythmia, such as ablation of non-pulmonary vein foci (NPVF).5 Real time visualisation of data are essential to the operator to apply effective therapeutic solutions even for the most complex arrhythmogenic substrates. Credible visualisation of areas of low-voltage/scar as a surrogate for fibrosis further impels the electrophysiologist’s ability to effectively modulate or eliminate arrhythmogenic substrates. This can improve the prognosis of patients suffering from highly symptomatic complex supraventricular and ventricular arrhythmias.

More personalized care thanks to the AcQMap system

Three-dimensional electroanatomic mapping (3D-EAM) systems offer significant advantages in the management of challenging arrhythmias, and the introduction of novel algorithms has led to improvements in patients' outcomes.3 The introduction of 3D-EAM systems has facilitated marked progress in catheter visualization, arrhythmia mapping, and the reduction and even elimination of fluoroscopy and radiation exposure in cardiac electrophysiology.4

Real-time imaging software does not only allow for faster imaging, but can help physicians to find the exact origin of an arrhythmia and deliver a more precise ablation. The key advantage of charge density (CD) mapping is the ability to globally discern both focal and rotational patterns, as well as other more complex patterns characterized by localized changes in conduction velocity, direction, and wave front pivoting (localized irregular activation, LIA).7 The process of map – ablate – remap allows EPs to do iterative mapping – combining mapping and ablating in a continuous repeatable process. Map – ablate – remap, map—ablate – remap, an iterative approach to diagnosis, treat, and re-check for ablation effectiveness.

A study using non-contact CD mapping with iterative mapping capability outside the pulmonary veins suggests that pulmonary vein isolation (PVI) plus ablation of individualized, patient-specific non-PV targets provides benefit to conventional approaches.6

Acutus Mission: Possible Webinar Series Episode 5

Sources

  1. Sommer, P., Rhythmologische Besonderheiten bei COVID-19-Patienten. Webinar at Deutsche Gesellschaft für Kardiologie, Herz- und Kreislaufforschung. dgk.meta-dcr.com/kardiovaskulaere-erkrankungen-in-den-zeiten-von-corona/crs/rhythmologische-besonderheiten-bei-covid-19-patienten, May 13 2020. (Accessed July 16 2020)
  2. Stern S. Electrocardiogram: still the cardiologist's best friend. Circulation. 2006;113(19):e753-e756. doi:10.1161/CIRCULATIONAHA.106.623934
  3. Berruezo, A. (2010). Complex ventricular arrhythmias: a therapeutic nightmare. Heart, 96(9), 723–728. doi:10.1136/hrt.2008.163337
  4. Compagnucci P, Volpato G, Falanga U, et al. Recent advances in three-dimensional electroanatomical mapping guidance for the ablation of complex atrial and ventricular arrhythmias [published online ahead of print, 2020 May 26]. J Interv Card Electrophysiol. 2020;10.1007/s10840-020-00781-3. doi:10.1007/s10840-020-00781-3
  5. Aryana A. Novel and Emerging Tools and Technologies in Cardiac Electrophysiology: What's on the Horizon in 2020? J Innov Card Rhythm Manag 2019; 10: 3944-3948.
  6. Koutalas E, Rolf S, Dinov B, et al. Contemporary Mapping Techniques of Complex Cardiac Arrhythmias - Identifying and Modifying the Arrhythmogenic Substrate. Arrhythm Electrophysiol Rev. 2015;4(1):19-27. doi:10.15420/aer.2015.4.1.19
  7. Willems S et al. Targeting Nonpulmonary Vein Sources in Persistent Atrial Fibrillation Identified by Noncontact Charge Density Mapping: UNCOVER AF Trial. Circ Arrhythm Electrophysiol 2019; 12:e007233.

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