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• W4306175075 abstract "Key Teaching Points•Although the ultra-high-resolution mapping system (Rhythmia; Boston Scientific, Marlborough, MA) is useful to identify the detailed mechanisms of complex atrial tachycardia, there is a limitation for the detection of the epicardial conduction.•A micro-mapping catheter (1.6F) can help make a diagnosis of mitral flutter via epicardial connection along the vein of Marshall (VOM) that occurs after mitral isthmus (MI) linear ablation.•It is important to correctly interpret the activation map when using an auto-annotation algorithm of an ultra-high-resolution mapping system. Differentiation between local near- and far-field potentials around the MI region can sometimes be difficult owing to the presence of epicardial connection along the VOM. We need to incorporate multiple techniques and identify epicardial structures for accurate diagnosis. •Although the ultra-high-resolution mapping system (Rhythmia; Boston Scientific, Marlborough, MA) is useful to identify the detailed mechanisms of complex atrial tachycardia, there is a limitation for the detection of the epicardial conduction.•A micro-mapping catheter (1.6F) can help make a diagnosis of mitral flutter via epicardial connection along the vein of Marshall (VOM) that occurs after mitral isthmus (MI) linear ablation.•It is important to correctly interpret the activation map when using an auto-annotation algorithm of an ultra-high-resolution mapping system. Differentiation between local near- and far-field potentials around the MI region can sometimes be difficult owing to the presence of epicardial connection along the VOM. We need to incorporate multiple techniques and identify epicardial structures for accurate diagnosis. We herein report a 53-year-old man with atrial tachycardia (AT) recurrence after atrial fibrillation ablation. In the initial procedure, pulmonary vein isolation for atrial fibrillation and a mitral isthmus (MI) line for the intraprocedural mitral flutter were successfully performed. In the second procedure for recurrent AT, an endocardial activation map with an ultra-high-resolution mapping system (RhythmiaTM; Boston Scientific, Marlborough, MA) showed clockwise mitral flutter (cycle length [CL]: 240 ms) via epicardial fiber with a breakout site 11 mm posterior from the previous MI line that simultaneously demonstrated a residual endocardial gap near the left inferior PV (Supplemental Movie). A hexapolar 1.6F catheter (EP Skinny; FMD Co, Ltd, Tokyo, Japan) advanced into the vein of Marshall (VOM) to assess the epicardial potentials clearly showed sharp epicardial potentials at the opposite site of the endocardial gap on the MI line with tiny and dull potentials (Figure 1A). The activation map of endocardial and epicardial mapping satisfied the entire AT CL, and the postpacing intervals during entrainment pacing at the septal and inferior region along the mitral annulus and the VOM were equal to AT CL, but they were much longer than AT CL at the great cardiac vein (Figure 2). These findings indicated a diagnosis of mitral flutter via VOM and the residual endocardial MI gap was considered to be bystander. After accidental AT termination by catheter stimulation, we targeted the epi-endo breakout sites along the ridge during pacing from the proximal coronary sinus, and MI was successfully established without any radiofrequency application to the previous MI line (Figure 1B). This case demonstrated a pseudo-endocardial gap at the previous MI line using the auto-annotation algorithm of the ultra-high-resolution mapping system; however, these signals were in fact far-field potentials of the epicardial signals. It is important to correctly interpret the activation map when using an auto-annotation algorithm of an ultra-high-resolution mapping system. Differentiation between local near- and far-field potentials around the MI region can sometimes be difficult owing to the presence of epicardial fibers, such as VOMs.Figure 2Postpacing intervals (PPIs) during entrainment pacing at the vein of Marshall (VOM) and at the great cardiac vein (GCV). PPI during entrainment pacing at the VOM was equal to AT CL (PPI-AT CL = 0 ms), while PPI at the GCV was much longer than AT-CL (PPI-AT CL = +70 ms). AP = anteroposterior view; CS = coronary sinus; GCVd and CSp = distal electrode of GCV and proximal electrode of CS; LAO = left anterior oblique view; VOMd = distal electrode of VOM; VOMp = proximal electrode of VOM.View Large Image Figure ViewerDownload Hi-res image Download (PPT) eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxM2ZmYzAzNjU5OTg1ZTBjMjgxM2RlMDZiZTZhNTMxOCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2NjY5NTE3fQ.R6MVATrnm8g5Jxmcb96G4kuf8dtF-gOTuwcatqT4Ua1PxlhYQeS8-DiHs5vxPrvtEgP9WJXp-bwydkW739qu-TV7JKbuEsFHjanSONDL7nAXcZcxSx6VTtuRcyWpvu6m6YBdGOurZOu-8pqxbkHSItwtYngFKDK0Moi1fy5neWZZetE3vjVQimp7dAiO4EBySUB57RPDI0Ze9pu5rVrUGJdi07uhVUfbeY5Qk51OmuzaQjB2Gg12xp6dCFMW2NjGzAudOQXFnWm7-fQPdbrYhykx3wElAyg45BXkVRpf_7jJ7DZbuEUq8D4OnMkpv_RXHxg1IRoWWWYi8wStrP0llg Download .mp4 (3.08 MB) Help with .mp4 files Supplemental MovieThe activation map during atrial tachycardia (AT) with an ultra-high-resolution mapping system. AT (CL 240 ms) propagated clockwise around the mitral annulus via epicardial fiber with a breakout site 11 mm posterior from the previous MI line; however, a residual endocardial gap was simultaneously demonstrated near the left inferior PV. These two activations immediately collided with each other." @default.
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• W4306175075 date "2023-02-01" @default.
• W4306175075 modified "2023-09-27" @default.
• W4306175075 title "A case of pseudo-endocardial gap during mitral flutter: Pitfalls of the auto-annotation algorithm on the ultra-high-resolution mapping system" @default.
• W4306175075 doi "https://doi.org/10.1016/j.hrcr.2022.10.010" @default.
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