no slide title chpt 6... · 2019. 12. 20. · fem-cs p fem-cs d 260 260 ... ps-ap or slow/slow or...

Figure 6.1A.

Figure 6.1B.

Figure 6.1C.

III

V1

RAA

HBp

HBD

CSp

CSD

RV

CTd

CTP

200 ms

H H H H H H

200 ms

III

V1

RAA

HBp

HBD

CSp

CSD

RV

CTd

CTP

H H H H

Figure 6.1D.

Figure 6.2A.

Figure 6.2B. 100 ms

RV

RAA

V1

II

HBp

HBd

CSd

CSp

I

H

Figure 6.2C

RV

RAA

V1

II

HBp

HBd

CSd

CSp

I

100 ms

Figure 6.2D 100 ms

RV

RAAV1

II

HBp

HBd

CSd

CSp

I

MAPp

MAPd

UNI-1

UNI-2

Figure 6.3A

H

100 ms

RV

RAA

V1

II

HBp

HBd

CSd

CSp

I

Figure 6.3B100 ms

RAA

V1

II

HBp

HBd

CSd

CSp

I

RV

MAPP

MAPd

UNId

UNIP

A

Figure 6.3C200 MS

RAA

V1

II

HBp

HBd

CSd

CSp

I

RV

MAPP

MAPd

UNId

UNIP

Figure 6.3D100 MS

RAA

V1

II

HBp

HBd

CSd

CSp

I

RV

MAPP

MAPd

UNId

UNIP

H

Figure 6.3E 300 MS

RAA

V1

II

HBp

HBd

I

RV

MAPP

MAPd

UNI-1

UNI-2

Figure 6.3F

RAA

V1

II

HBp

HBd

CSd

CSp

I

RV

MAPP

MAPd

H

100 MS

Figure 6.4A

H

CSP

RV

HBd

RAA

V1

I

CSD

HBp

Crista p

Crista d

100 MS

Figure 6.4B 100 ms

Anteroseptal Pacing Anterolateral Pacing

* *V

A

RV

RAA

V1

II

HBp

HBd

CSd

CSp

I

MAPP

MAPd

UNI-1

UNI-2

A A

A A

V V

Figure 6.4C100 MS

RV

RAA

V1

II

HBp

HBd

CSd

CSp

I

CS Pacing RAA Pacing

*

*

A

V

A V VA

Figure 6.4D

RH

RAA

V1

II

HBp

HBd

CSd

CSp

I

MAPP

MAPd

UniD

UniP

100 MS

RAA Pacing

*

*

A

VA

V

H

CS Pacing

AV

Aorta

HB

Mitral AnnulusTricuspidAnnulus

CentralFibrous Body

LAO Projection

Figure 6.5A

HBHB

RAARAA

CS CS

ABLABL

RAO LAO

Subclavian or internal jugular approach:

Figure 6.5B

Figure 6.5C

Ablation Catheter

Ablation Catheter

RAARAA

HB

CS

RAO Projection LAO Projection

100 ms

RAA

V3

V1

HBp

HBd

CSd

CSp

I

A A

Figure 6.6A

Figure 6.6B

CSP

RV

HBd

RAA

V1

I

CSD

HBp

MAPd

MAPp

UNI-1

UNI-2

CSP

RV

HBd

RAA

V1

II

CSD

HBp

MAPP

UNID

MAPD

UNIP

I

Figure 6.6C

Figure 6.6D100 ms

RAA

HBp

HBd

CSd

CSp

V1 V1

A2

A A’V V

V3

V1

I

Figure 6.6E

Figure 6.7A

CSP

RV

HBd

RAA

V1

I

CSD

HBp

ABLd

ABLp

UNI-1

UNI-2

100 ms

A A

Figure 6.7B

CSP

RV

HBd

RAA

V1

I

CSD

HBp

ABLd

ABLp

RF

UNI-1

UNI-2

Figure 6.7C

H

CSP

RV

HBd

RAA

V1

I

CSD

HBp

ABLd

ABLp

UNI-1

UNI-2

100 ms

AVN

HB

Figure 6.8A

Figure 6.8B

Figure 6.8C

RAA

V1

II

HBp

Cristad

CSd

CSp

I

HBp

Cristad

H H

100 ms

Figure 6.8D

RAA

V1

II

HBp

HBd

CSd

CSp

I

V5

100 ms

RV

A

V V

Hr

Hr

Figure. 6.9A

Figure 6.9B

CSP

RV

HBd

RAA

V1

I

CSD

HBp

MAPd

MAPp

UNI-1

UNI-2

Figure 6.9C

CSP

RV

HBd

RAA

V1

I

CSD

HBp

MAPd

MAPp

SCS SCS

SRV

V V’

UNI-1

UNI-2

Figure 6.9D

CSP

RH

HBd

RAA

V1

I

CSD

HBp

MAPd

MAPp

UNI-1

UNI-2

CSP

RV

HBd

RAA

V1

I

CSD

HBp

MAPd

MAPp A

APPUNI-1

UNI-2

Figure 6.9E

CSP

HBd

RAA

V1

II

I

CSD

HBp

CRYOP

CRYOD

UNI-2

UNI-1

Figure 6.9F

Figure 6.10A

Figure 6.10B

CSP

HBd

RAA

V1

CSD

HBp

I

HB

AP

100 ms

CSP

HBd

RAA

V1

I

CSD

HBp

MAPp

MAPd

II

RV

CS Roof

RAA

RV

HB

LAO

MS-MA

Fig. 6.10C

CSP

RV

HBd

RAA

V1

II

CSD

HBp

MAd

MAp

TAd

TAp

I

Fig. 6.10D

100 ms

CSP

HBd

RAA

V1

I

CSD

HBp

TAd

TAp

II

CSP

HBd

RAA

V1

I

CSD

HBp

MAd

MAp

II

Fig. 6.10E

10 W

34 V

0.3 A

1 secRF On

Fig. 6.10F

Figure 6.11A

A

A

HA

H

V

S

I

II

V1

RAA

LVp

LVd

RV

III

S

Anteroseptal LV Noncoronary Cusp

AP-P

Late LocalVentricularActivation

Figure 6.11B

RA

LAO Projection

RVHB

RV

RA

HB

Non-Coronary Cusp

Pullback from LV to Aortic CuspAortogram

Non-Coronary Cusp

Figure 6.11C

S1

HBp

HBd

AoVp

AoVd

RV

III

I

II

V1

RAA

A

V

S1

VX

V1-V2 = 510

X

S2

S1-S1 = 580

X-X = 580

A-A = 580

Figure 6.11D

A-A = 580

RV

III

I

II

V1

RAA

A A

“X” Advanced by 20 ms

AoVp

AoVd

HBp

HBd

S1 S1

S2

XXX-X = 560

S1-S1 = 580

Figure 6.11E

Figure 6.11F

A V

AP

AP

HBp

HBd

I

II

V1

RAA

HBm

UNI-2

UNI-1

Aorta pH

AA

A

Far-field AP

Loss AP

Aorta d

Preexcitation Pattern Suggesting Anteroseptal AP

Figure. 6.12A

Figure 6.12B

Catheter below the Right Coronary Cusp

ABL

ABL

HB

HB HBp

HBd

I

II

V1

RAA

HBm

LVp

LVd

UNI-2

UNI-1

CSp

CSd

RV

CSFigure 6.12C

Retrograde Conduction over

Slow Pathway:

(Right Inferior Extension)

Retrograde Conduction over

an Epicarida PS-AP

Figure 6.13A

Figure 6,13B SVT-1

Figure 6.13C SVT-2

Figure 6.13D

CSP

RV

HBd

RAA

I

CSD

HBp

II

V1

SVT-1

Figure 6.13E

RV

CSd

CSp

RAA

V1

II

HBp

HBd

I

SVT-2

HB

CentralFibrousBody

SVT1

SVT2

Figure 6.13F

Figure 6.14A

RV

CSd

CSp

RAA

V1

II

HBp

HBd

I

H

H

100 ms

RV

SUB-CSp

RAA

V1

II

HBp

HBd

I

SUB-CSd

FEM-CSp

FEM-CSd

260 260 260

H H H H H

V V V V’260 260 260

Figure 6.14B

100 ms

RV

SUB-CSp

RAA

V1

II

HBp

HBd

I

SUB-CSd

FEM-CSp

FEM-CSd

H H H H H’

260 260 230

V V V V’260 260 225

260 260 260 250

Figure 6.14C

Figure 6.15A

SmallCardiac

Vein

MiddleCardiacVein

GreatCardiac

Vein

MarshallVein

RA

CoronarySinus

Ostium

LA

LAO Projection

Epicardial PS-AP: Antegrade Conduction

CSE

Coronary SinusMyocardial Extension

(CSE)

PosteriorCoronary

Vein

Early EpicardialVentricular Activation

and CS-E Potential (AP-P)In MCV

Posterior Coronary Vein

Figure 6.15B

LV

LA

GreatCardiacVein

PosteriorCoronary

Vein

SmallCardiac

Vein

MiddleCardiacVein

CSE

LAO Projection

CoronarySinus

Ostium

EarliestAtrial

Activation

LADelay in Reversing

Direction of Activation

Epicardial PSAP: Retrograde Conduction

Figure 6.15C

Atrial-CSE

connections

Ventricular-CSE

connections

Atrium

Ventricle

CSE in MCV

Figure 6.15D

Figure 6.16A

III

V1

RAA

HBp

HBD

CSp

CSD

RV

V3

100 ms

III

V1

RAA

HBp

HBD

CSp

CSD

RV

V3

PL Coronary

Vein

Lateral

LV

Posteroseptal

RV

Anteroseptal

RV

Figure 6.16B

Pace from Lateral Coronary Vein

RAO LAO

RAA

HB

RAA

HB

Figure 6.16C

Pace from Lateral Left Ventricle

RAO LAO

RAA

HB

RAA

HB

Figure 6.16D

Figure 6.17A

I

V1

RAA

HBP

CSP

CSD

RV

II

HBD

MAPP

MAPd

RV Apex PL Coronary Vein AVRT

100 ms

PS-AP or Slow/slow or Fast/slow AVNRT:

CS catheter comes from subclavian or internal jugular vein

Figure 6.17B

Figure 6.17C 100 ms

I

V1RAAHBP

SC-CSP

RV

II

HBD

MAPP

MAPd

UNIdUNIP

SC-CSd

FEM-CSP

FEM-CSd

MAPP

MAPd

UNId

UNIP

I

V1

RAA

HBP

CSP

CSD

RV

II

HBD

Anteroseptal RV Posteroseptal RVPosterolateral

Coronary Vein

Figure 6.17D

Figure 6.18A

RAA

MCVPCV

LV Map

HB

HB

LVMap

CS

RAA

MCV PCV

CS

LAO

RAO

LV Endocardial Mapping -Antegrade AP Conduction

1.2 cm

30

Figure 6.18B

CS

RV Map

RV

HB

CS

RV MapRV

RAA

RAA

LAO

RAO

RV Endocardial Mapping -Antegrade AP Conduction

1.5cm

Courtesy of Dr. Jackman

Figure 6.18C

CSRV

MCV

RV

LAO

RAO

CS Extension – AP Potential (CSE-AP)Deep in Middle Cardiac Vein

RAAHB

RAA

HB

MCV

2.0 cm

Courtesy of Dr. Jackman

Validation of Antegrade CSE-AP Potential

465

520

Figure 6.18D

Validation of Antegrade CSE-AP Potential

495

520

Figure 6.18E

LV

LA

GreatCardiacVein

PosteriorCoronary

Vein

SmallCardiacVein

MiddleCardiacVein

CSE

LAO Projection

CoronarySinus

Ostium

EarliestAtrialActiv

LA

RetrogradeConduction

Delay in Reversing Direction of Activation

Figure 6.19A

35

A1

495

520

Figure 6.19B

440

490

520

Figure 6.19C

520

Figure 6.19D

2 mm

2 mm

Figure 6.20A

LAO RAO

Ideal Ablation

Site in MCV

Figure 6.20B

Figure 6.20C LAO

PL branch

of RCA

Ablation Site

Deep MCV

Floor of CS

LAO

Figure 6.20D

Figure 6.21A

Figure 6.21B

LV

RAA

V1

II

HBp

HBd

CSd

CSp

I

MAPP

MAPD

UNI-1

UNI-2

100 ms

Figure 6.21C

LV

RAAV1

II

HBp

HBd

CSd

CSp

I

MAPP

MAPD

UniD

UniP

100 ms

RV

RAA

V1

II

HBp

HBd

CSd

CSp

I

CryoP

Cryod

UNI-1

UNI-2

Figure 6.21D

MCV

Figure 6.22A

Figure 6.22B

Small Cardiac

Vein