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• W3000326306 abstract "Microreentrant atrial tachycardias (AT) can be defined as atrial arrhythmias with a cycle length (CL) coverage greater than 85% in a small area (arbitrarily set as a circuit with a diameter <2–3 cm) and a centrifugal activation to the rest of the atrial chamber.1Frontera A. Mahajan R. Dallet C. et al.Characterizing localized reentry with high-resolution mapping: evidence for multiple slow conducting isthmuses within the circuit.Heart Rhythm. 2019; 16: 679-685Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Although debate is still ongoing in the literature as to the precise definition of microreentry,2Laţcu D.G. Bun S.S. Viera F. et al.Selection of critical isthmus in scar-related atrial tachycardia using a new automated ultrahigh resolution mapping system.Circ Arrhythm Electrophysiol. 2017; 10Crossref PubMed Scopus (94) Google Scholar it is common practice to refer to the phenomenon in terms of the more general concept of localized reentry, since the size of the reentrant circuit is presumed to be in the order of centimeters.1Frontera A. Mahajan R. Dallet C. et al.Characterizing localized reentry with high-resolution mapping: evidence for multiple slow conducting isthmuses within the circuit.Heart Rhythm. 2019; 16: 679-685Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar This is the first description of a reentrant AT whose CL was entirely detected by a few bipolar pairs of a high-density mapping catheter whose recording field of view is in the order of a few millimeters. A 72-year-old woman presented for radiofrequency ablation of an atypical atrial flutter after she had already undergone 2 previous pulmonary vein isolation procedures and 1 ablation procedure for the treatment of a perimitral atrial flutter. Some months after the previous ablation procedure, she had developed a different atypical atrial flutter. Owing to the distal-to-proximal activation of the coronary sinus catheter, this AT was mapped in the left atrium by means of the Rhythmia mapping system and the mini-basket Orion catheter (Boston Scientific, Marlborough, MA). The activation map (Figure 1) showed a centrifugal pattern of activation starting from the anterior antrum of the left inferior pulmonary vein, where a crowding of isochronal lines was noted. The propagation map (Supplementary Video) showed a localized reentry at this location, from which an anterior and a posterior front spread centrifugally and collided septally. Despite the apparent existence of a localized reentry whose critical size was in the order of centimeters, interrogation of bipolar electrograms (EGMs) in that region showed that the electrical activity spanning the whole CL was detected by a few pairs of close bipoles of the Orion catheter, whose interelectrode spacing is 2.5 mm (Figure 2). Particularly, only 1 pair of bipoles showed a continuous highly fractionated potential spanning the entire CL of the tachycardia, indicating clearly that the microreentry was actually confined to a region whose size was in the order of millimeters (Figure 2, bipole F3–4). This finding was in line with our preliminary speculation by looking at the propagation maps that clearly showed a very small area of reentry at this spot (Supplementary Video). Overdrive pacing and entrainment maneuvers were attempted but no capture was obtained. When the ablation catheter (IntellaNAV Mifi OI [Boston Scientific, Marlborough, MA], equipped with 3 mini-electrodes at the tip) was positioned at the corresponding spot of bipolar pair F3–4 in Figure 2, no EGM was detected by the conventional ablation traces (Figure 3). The mini-electrode pairs detected only a part of the very long fragmented EGM previously recorded by the Orion catheter. Since the field of view of the ablation mini-electrodes is similar to that of the Orion bipoles, we hypothesize that the difference in the signal displayed was due to the difference in electrode technology and surface, and the catheter tip was very close (but not completely overlapped) to the precise ablation target point identified by the bipolar pair of the Orion catheter. After 7 seconds of radiofrequency ablation (35 W, 40°C) at this spot, the arrhythmia stopped (Supplementary Figure). After a follow-up of 8 months, no AT recurrence was reported by the patient. Microreentrant tachycardias are well defined and are thought to be responsible for a small percentage of the AT usually seen after atrial fibrillation ablation or in the presence of spontaneous atrial scarring.3Jaïs P. Matsuo S. Knecht S. et al.A deductive mapping strategy for atrial tachycardia following atrial fibrillation ablation: importance of localised reentry.J Cardiovasc Electrophysiol. 2009; 20: 480-491Crossref PubMed Scopus (199) Google Scholar Effective ablation of microreentrant ATs is usually achieved at sites with highly fractionated, low-amplitude EGMs. These EGM characteristics are highly sensitive, but not specific to microreentrant circuits.4Markowitz S.M. Thomas G. Liu C.F. et al.Atrial tachycardias and atypical atrial flutters: mechanisms and approaches to ablation.Arrhythm Electrophysiol Rev. 2019; 8: 131-137Crossref PubMed Scopus (26) Google Scholar Indeed, low-amplitude and long-duration EGMs could be present at bystander sites that do not actively participate in the circuit.4Markowitz S.M. Thomas G. Liu C.F. et al.Atrial tachycardias and atypical atrial flutters: mechanisms and approaches to ablation.Arrhythm Electrophysiol Rev. 2019; 8: 131-137Crossref PubMed Scopus (26) Google Scholar Mapping local activation within these regions of slow conduction has been limited by the resolution of EGM signals recorded by conventional mapping catheters. Furthermore, limited point density on previous mapping systems resulted in large areas of activation interpolation, and localized reentrant circuits often appeared as focal.5Takahashi Y. Takahashi A. Miyazaki S. et al.Electrophysiological characteristics of localized reentrant atrial tachycardia occurring after catheter ablation of long-lasting persistent atrial fibrillation.J Cardiovasc Electrophysiol. 2009; 20: 623-629Crossref PubMed Scopus (46) Google Scholar,6Luther V. Sikkel M. Bennett N. et al.Visualizing localized reentry with ultra–high density mapping in iatrogenic atrial tachycardia: beware pseudo-reentry.Circ Arrhythm Electrophysiol. 2017; 10e004724Crossref PubMed Scopus (49) Google Scholar By using a 224-site grid array with an interelectrode distance of 2 mm, in an in vitro superfused preparation of infarcted canine left ventricular epicardium, Zuanetti and colleagues7Zuanetti G. Hoyt R.H. Corr P.B. ß-Adrenergic-mediated influences on microscopic conduction in epicardial regions overlying infarcted myocardium.Circ Res. 1990; 67: 284-302Crossref PubMed Scopus (28) Google Scholar detected a small reentrant circuit at recording sites more than 1–2 cm from the center of the reentrant circuit; in this way, the reentrant loops were no longer hidden, but could be detected by a mapping resolution of 2–4 mm.7Zuanetti G. Hoyt R.H. Corr P.B. ß-Adrenergic-mediated influences on microscopic conduction in epicardial regions overlying infarcted myocardium.Circ Res. 1990; 67: 284-302Crossref PubMed Scopus (28) Google Scholar Although this spacing is feasible in basic experimental studies, it may not always be so during the clinical mapping of arrhythmias. The wide adoption of high-resolution mapping systems provides improved EGM and spatial resolution and could potentially shed additional light on the nature of arrhythmias of this kind. Using the Orion basket catheter with narrow interelectrode spacing, Luther and colleagues6Luther V. Sikkel M. Bennett N. et al.Visualizing localized reentry with ultra–high density mapping in iatrogenic atrial tachycardia: beware pseudo-reentry.Circ Arrhythm Electrophysiol. 2017; 10e004724Crossref PubMed Scopus (49) Google Scholar were able to fully characterize the activation pattern of most localized reentry circuits, in their experience, as small rotatory activations around scars ∼1 cm in diameter. The case described here is the first report of a reentrant circuit of a localized circuit confined to a region size of a couple of millimeters, ie, >5-fold smaller than that reported in the literature on clinical mapping1Frontera A. Mahajan R. Dallet C. et al.Characterizing localized reentry with high-resolution mapping: evidence for multiple slow conducting isthmuses within the circuit.Heart Rhythm. 2019; 16: 679-685Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,2Laţcu D.G. Bun S.S. Viera F. et al.Selection of critical isthmus in scar-related atrial tachycardia using a new automated ultrahigh resolution mapping system.Circ Arrhythm Electrophysiol. 2017; 10Crossref PubMed Scopus (94) Google Scholar,6Luther V. Sikkel M. Bennett N. et al.Visualizing localized reentry with ultra–high density mapping in iatrogenic atrial tachycardia: beware pseudo-reentry.Circ Arrhythm Electrophysiol. 2017; 10e004724Crossref PubMed Scopus (49) Google Scholar and comparable with the results from experimental mapping with electrical or optical sensors.7Zuanetti G. Hoyt R.H. Corr P.B. ß-Adrenergic-mediated influences on microscopic conduction in epicardial regions overlying infarcted myocardium.Circ Res. 1990; 67: 284-302Crossref PubMed Scopus (28) Google Scholar,8Ideker R.E. Rogers J.M. Fast V. et al.Can mapping differentiate microreentry from a focus in the ventricle?.Heart Rhythm. 2009; 6: 1666-1669Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The small surface of the electronically printed Orion electrodes (0.4 mm2) and the reduced center-to-center interelectrode spacing (2.5 mm) allowed a very small reentrant circuit to be fully detected by just a few bipolar pairs, where a continuous activity spanning the entire CL could be identified. Using this system, we have been able to fully characterize the activation pattern and clearly identify through visual impression the targeted spot that matched the area of EGM fractionation captured by the Orion catheter. Another important point to emerge from this case is the evidence that EGMs in the microreentrant circuit can be completely filtered out by the larger field of view of the conventional ablation traces. This is due to the lower spatial resolution achievable with larger electrodes and spacing. Thus, without high-resolution catheters, microreentrant circuits may be completely missed and misdiagnosed as areas of scarring. Microreentrant atrial activity may be localized in very small areas, in the order of millimeters, and its electrical activity may be filtered out by conventional catheters with larger electrodes and spacing.Key Teaching Points•This is the first description of a reentrant atrial tachycardia whose cycle length was entirely detected by a few bipolar pairs of a high-density mapping catheter whose recording field of view is in the order of a few millimeters.•Using the ultra-high-density Rhythmia mapping system (Boston Scientific, Marlborough, MA), we have been able to fully characterize the activation pattern and clearly identify through visual impression the targeted spot that matched the area of electrogram fractionation captured by the basket catheter.•Electrograms in the microreentrant circuit can be completely filtered out by the larger field of view of the conventional ablation traces. Thus, without high-resolution catheters, microreentrant circuits may be completely missed and misdiagnosed as areas of scarring." @default.
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• W3000326306 title "How small could a detectable reentrant circuit be in a localized microreentrant tachycardia?" @default.
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