Presentation is loading. Please wait.

Presentation is loading. Please wait.

For Internal Use Only How to Select a Reference Channel, Set a WOI and Annotate EGMs of the Mapping Catheter with.

Similar presentations


Presentation on theme: "For Internal Use Only How to Select a Reference Channel, Set a WOI and Annotate EGMs of the Mapping Catheter with."— Presentation transcript:

1 For Internal Use Only How to Select a Reference Channel, Set a WOI and Annotate EGMs of the Mapping Catheter with

2 For Internal Use Only Selecting a Reference Channel

3 For Internal Use Only What is the Reference Channel The Reference channel (REF) is a signal which is the fiduciary point in which all EA points are measured against Window of Interest (WOI) will be built around the REF channel Used as the Zero point for LAT maps Used to visually Gate Map Catheter location Generally speaking the REF channel should reflect the chamber being mapped Atrium should reference an Atrial signal Ventricle should reference a Ventricular signal

4 For Internal Use Only What is the Reference Channel In the Map Setup, select a REF channel from the drop down Select a REF channel that is appropriate to the chamber you are mapping Atrium = CS Atrial electrogram Ventricle = BS QRS

5 For Internal Use Only What is the Reference Channel Atrial Reference (CS A) Maps of Atria –Atrial Tach, Atrial Flutter, PV Tach, Sinus Tach, Normal Sinus Rhythm Ventricular Reference (QRS) Maps of Ventricles –LAT, Bipolar Maps –Anatomical Maps –Afib, AVNRT, Isthmus lines –AVRT may use the QRS as a REF channel, because the ventricle is part of the circuit and there is a fixed AV or VA ratio

6 For Internal Use Only Atrial Reference Atrial Reference Options Coronary Sinus Catheter Best choice as CS is stable, unlikely to be dislodged Choose a Reference that is physically close to the chamber being mapped –CS 7-8 or 9-10 for Right Atrium –CS 1-2 for Left Atrium –Choose an REF channel in which the A waves are larger that the V waves High RA Quad Catheter –Use only if CS not accessible Stability is an issue – position in RAA Snapshot location Lasso ® Catheter pair occasionally used, positioned in LAA V A

7 For Internal Use Only Ventricular Reference A body surface QRS will provide the most stable reference for any Ventricular Rhythm You may consider BS QRS for: Anatomical Maps in which EA information is not acquired Anatomical Maps of Afib AV Nodal Reentry Tachycardia (AVNRT) Anatomical ablations such as Caval Tricuspid Isthmus lines Atrial Ventricular Reentry Tachycardia(AVRT), as there is constant 1:1 AV or VA ratio

8 For Internal Use Only REF Channel Criterion Once you have selected a REF channel, you will have to determine where you would like the system to annotate the waveform Choices are: –Maximum Value –Minimum Value –Up Slope –Down Slope MAXIMUM VALUE

9 For Internal Use Only Maximum Value Annotation on the highest amplitude of the ECG Animate: 1 of 4. See original for timing of the waveform.

10 For Internal Use Only Minimum Value Annotation on the lowest amplitude of the ECG Animate: 2 of 4. See original for timing of the waveform.

11 For Internal Use Only Up Slope Annotation on the most positive slope of the ECG Animate: 3 of 4. See original for timing of the waveform. Slope is an option only if choosing pacing artifact as the reference

12 For Internal Use Only Down Slope Annotation on the most negative slope of the ECG Animate: 4 of 4. See original for timing of the waveform. Slope is an option only if choosing pacing artifact as the reference

13 For Internal Use Only REF Annotation Criterion When selecting an annotation criterion, it is important to visualize the EGM of the REF channel on the Carto ® 3 System to determine the annotation criterion In this tracing, there are two positive deflections of equal amplitude and one large negative deflection on the REF 9-10 Maximum Value good choice Maximum Value poor choice

14 For Internal Use Only REF Annotation Criterion If we were to select REF 9-10, maximum value, the system may have difficulty in determining which positive deflection to annotate from beat to beat. Minimum value would be a better choice for CS 9-10 But in this example, we decide to choose another electrogram, REF 3-4, Maximum value as the REF channel, as there is only 1 positive component to the electrogram Maximum Value good choice Maximum Value poor choice

15 For Internal Use Only Verify REF in Monitor Window After selecting a Reference channel, visually verify in the monitor window that your reference annotation is consistent and reproducible Notice that the REF annotation is marking each and every Atrial signal at it’s maximum peak, but ignoring all Ventricular signals. This is a reliable choice.

16 For Internal Use Only Verify REF in Monitor Window This is an example of a poor choice for a REF channel selection Notice that the REF annotation is identifying both atrial and ventricular signals on the CS catheter Another pair of electrodes should be selected

17 For Internal Use Only Beware of Wandering Reference Pick your reference carefully Surface ECG Reference Designation

18 For Internal Use Only Pacing Artifact as Reference Pacing artifact can be used as a reference It is reliable, reproducible, stable Identify a QRS or EGM that has a prominent pacing spike (Ld II in the example) Select Up/Down Slope for REF Criterion - or - Minimum/Maximum Value Set WOI From: +10 ms to exclude pace spike Pacing Spike (Select a REF channel with a prominent spike). +10

19 For Internal Use Only Recap Pick your reference correctly Correct reference – easy for system to recognize –Reliable and Reproducible –Clean, sharp signal that will remain stable –No far-field signals from other chambers Incorrect reference – can distort map –V signals annotated instead of A signals in CS –Changing deflections of BS QRS in VT –Changing deflections of CS A with respiration

20 For Internal Use Only Window Of Interest

21 For Internal Use Only What is Window of Interest? Time window is defined relative to the reference annotation - From and To Margins User determines values of WOI based on the chamber, mechanism and CL Time frame within the cardiac cycle during which the system is looking for the mapping annotation criterion Reference ECG LAT= +71 Time 0 From To From To Mapping Channel

22 For Internal Use Only What is Window of Interest? Annotation Viewer Window “From” Line –i.e., -250 (relative to REF channel) “To” Line –i.e., +100 (relative to REF channel) Reference Annotation –Zero Point Mapping Annotation –Local Activation Time (LAT) is relative time to reference zero –Left of REF = negative number –Right of REF = positive number

23 For Internal Use Only What is Window of Interest? Annotation Viewer Window “From” Line –i.e., -250 (relative to REF channel) “To” Line –i.e., +100 (relative to REF channel) Reference Annotation –Zero Point Mapping Annotation –Local Activation Time (LAT) is relative time to reference zero –Left of REF = negative number –Right of REF = positive number

24 For Internal Use Only What is Window of Interest? Annotation Viewer Window “From” Line –i.e., -250 (relative to REF channel) “To” Line –i.e., +100 (relative to REF channel) Reference Annotation –Zero Point Mapping Annotation –Local Activation Time (LAT) is relative time to reference zero –Left of REF = negative number –Right of REF = positive number

25 For Internal Use Only What is Window of Interest? Annotation Viewer Window “From” Line –i.e., -250 (relative to REF channel) “To” Line –i.e., +100 (relative to REF channel) Reference Annotation –Zero Point Mapping Annotation –Local Activation Time (LAT) is relative time to reference zero –Left of REF = negative number –Right of REF = positive number

26 For Internal Use Only What is Window of Interest? Annotation Viewer Window “From” Line –i.e., -250 (relative to REF channel) “To” Line –i.e., +100 (relative to REF channel) Reference Annotation –Zero Point Mapping Annotation –Local Activation Time (LAT) is relative time to reference zero –Left of REF = negative number –Right of REF = positive number

27 For Internal Use Only What is Window of Interest? Annotation Viewer Window “From” Line –i.e., -250 (relative to REF channel) “To” Line –i.e., +100 (relative to REF channel) Reference Annotation –Zero Point Mapping Annotation –Local Activation Time (LAT) is relative time to reference zero –Left of REF = negative number –Right of REF = positive number

28 For Internal Use Only How to Set the WOI Determine mechanism of tachycardia – Focal or Reentry? Rules of Thumb: –If Reentry, set WOI to % of TCL – 3 formulas to choose from: Split WOI 50/50: i.e., TCL = 300 = 300/2 From: -150 To: /3-1/3 method: i.e., TCL = 300, 300/3=100 From: -200 To:+100 DePonti Method: % of TCL, WOI adjusted so that P wave falls in middle of window –Atrial Focus From: Pre P wave onset by msec To: onset of QRS Ventricular Focus –From: Pre QRS onset by ms To: beyond end of QRS

29 For Internal Use Only Recap Set the Window of Interest (WOI) correctly: Avoid erroneous data from signals outside window For focal arrhythmias, set window to ms pre-P (AT) or QRS (VT) onset Helps exclude artifact, signals from wrong chamber For macroreentry, set window width to 95% of TCL All sites will appear only once within window of interest <90% of TCL: some sites will fall outside window >100% of TCL: some sites will be in window twice

30 For Internal Use Only Annotating the Mapping Signal

31 For Internal Use Only Selecting a Map Channel In the Map Setup, select a Mapping Channel from the drop down menu. Options are: –MAP 1-2 (Default) Recommended –MAP 3-4 –M1 –M2 Options to Select a Mapping Criterion –Maximum Value –Minimum Value –Up Slope –Down Slope As Map signals are collected from a roving catheter, it is important to annotate every time, thus default map criterion (maximum value) is acceptable MAXIMUM

32 For Internal Use Only How to Annotate LAT Maps What chamber are we mapping? If it lines up with QRS, it is probably a V Beat Buffer to previous beat if unclear

33 For Internal Use Only How to Annotate LAT Maps What chamber are we mapping? If it lines up with QRS, it is probably a V Beat Buffer to previous beat if unclear What signal should you annotate?

34 For Internal Use Only How to Annotate LAT Maps What chamber are we mapping? If it lines up with QRS, it is probably a V Beat Buffer to previous beat if unclear What signal should you annotate? What channel are we referencing?

35 For Internal Use Only How to Annotate LAT Maps What chamber are we mapping? If it lines up with QRS, it is probably a V Beat Buffer to previous beat if unclear What signal should you annotate? What channel are we referencing? CS

36 For Internal Use Only How to Annotate LAT Maps What chamber are we mapping? Atrium If it lines up with QRS, it is probably a V Beat Buffer to previous beat if unclear What signal should you annotate? What channel are we referencing? What signal is this? CS

37 For Internal Use Only How to Annotate LAT Maps What chamber are we mapping? Atrium If it lines up with QRS, it is probably a V Beat Buffer to previous beat if unclear What signal should you annotate? What channel are we referencing? What signal is this? CS

38 For Internal Use Only LAT Map Annotation The system will automatically assign an annotation based upon the Map Annotation Criterion Many physician will ask you to annotate the signal to the earliest deflection from baseline on the M1-M2 signal Earliest Annotation

39 For Internal Use Only LAT Map Annotation The system will automatically assign an annotation based upon the Map Annotation Criterion Many physician will ask you to annotate the signal to the earliest deflection from baseline on the M1-M2 signal Earliest Annotation

40 For Internal Use Only LAT Map Annotation The system will automatically assign an annotation based upon the Map Annotation Criterion Many physician will ask you to annotate the signal to the earliest deflection from baseline on the M1-M2 signal Others will prefer annotation to earliest sharp deflection on M1-M2 that correlates with the sharpest down slope of the unipolar (M1) Earliest Sharp Annotation Earliest Annotation

41 For Internal Use Only How to Annotate LAT Maps Annotation is clear when you have sharp, distinctive electrograms

42 For Internal Use Only How to Annotate LAT Maps Annotation is clear when you have sharp, distinctive electrograms

43 For Internal Use Only How to Annotate LAT Maps Annotation is clear when you have sharp, distinctive electrograms Annotation is not so clear if there is slowed conduction in scar, double potentials or Early meets Late in the WOI. Be consistent

44 For Internal Use Only How to Annotate LAT Maps Annotation is clear when you have sharp, distinctive electrograms Annotation is not so clear if there is slowed conduction in scar, double potentials or Early meets Late in the WOI. Be consistent

45 For Internal Use Only How to Annotate LAT Maps Annotation is clear when you have sharp, distinctive electrograms Annotation is not so clear if there is slowed conduction in scar, double potentials or Early meets Late in the WOI. Be consistent

46 For Internal Use Only How to Annotate LAT Maps Annotation is clear when you have sharp, distinctive electrograms Annotation is not so clear if there is slowed conduction in scar, double potentials or Early meets Late in the WOI. Be consistent DP

47 For Internal Use Only How to Annotate LAT Maps Annotation is clear when you have sharp, distinctive electrograms Annotation is not so clear if there is slowed conduction in scar, double potentials or Early meets Late in the WOI. Be consistent DP

48 For Internal Use Only How to Annotate Signals Early Meets Late Signals Set WOI to % of TCL to avoid having 2 beats in window Take another point or use beat buffer if unsure Copy of RA FINAL.CSZ-3 rd map

49 For Internal Use Only How to Annotate Signals Early Meets Late Signals Set WOI to % of TCL to avoid having 2 beats in window Take another point or use beat buffer if unsure Be consistent as to where you mark Copy of RA FINAL.CSZ-3 rd map Earliest deflection is inside window Earliest deflection is outside window

50 For Internal Use Only Earlys should be marked late Set WOI to 95%-100% of TCL Annotate by Location Images courtesy of Dr. Abrar Shah, University of Rochester Medical Center

51 For Internal Use Only Early Meets Late Annotation

52 For Internal Use Only How to Annotate by Location Late based on neighboring points Late based upon distance from circuit Counterclockwise Type I Flutter

53 For Internal Use Only Annotation Not clear if EGC on M1-M2 is A or V or both – use the Beat Buffer to scroll back to another beat for clarification

54 For Internal Use Only Annotation Not clear if EGC on M1-M2 is A or V or both – use the Beat Buffer to scroll back to another beat for clarification

55 For Internal Use Only Annotation Not clear if EGC on M1-M2 is A or V or both – use the Beat Buffer to scroll back to another beat for clarification Annotate a signal Beat buffered

56 For Internal Use Only Annotation Not clear if EGC on M1-M2 is A or V or both – use the Beat Buffer to scroll back to another beat for clarification V signal aligns with QRS Annotate a signal Beat buffered

57 For Internal Use Only Annotation Not clear if EGC on M1-M2 is A or V or both – use the Beat Buffer to scroll back to another beat for clarification V signal aligns with QRS Annotate a signal Beat buffered

58 For Internal Use Only Annotation Not clear if EGC on M1-M2 is A or V or both – use the Beat Buffer to scroll back to another beat for clarification V signal aligns with QRS Annotate a signal Beat buffered

59 For Internal Use Only LAT Annotation in Slow/Scar Border System automatic annotationUser defined annotation

60 For Internal Use Only WOI and Annotation during Bipolar Map Bi (mv) is the average peak to peak voltage measure on M1-M2 in the WOI Avoid pacing artifact in WOI in voltage mapping as this artificially elevates voltages in map Normal voltage 3.86mv

61 For Internal Use Only WOI and Annotation during Bipolar Map Bi (mv) is the average peak to peak voltage measure on M1-M2 in the WOI Avoid pacing artifact in WOI in voltage mapping as this artificially elevates voltages in map No need to annotate EGM in Bipolar maps Normal voltage 3.86mv

62 For Internal Use Only Map Annotation in Bipolar Map Voltage is measured as the average peak to peak voltage on the M1-M2 signal that falls within the WOI With low voltages, it is important to confirm catheter contact Annotation not necessary in Voltage maps

63 For Internal Use Only Map Annotation in Bipolar Map Voltage is measured as the average peak to peak voltage on the M1-M2 signal that falls within the WOI With low voltages, it is important to confirm catheter contact Annotation not necessary in Voltage maps

64 For Internal Use Only Test Your Knowledge Default WOI CS 1-2 M1-M2 Which Chamber was intended to be mapped? Ref is CS, however only V electrogram is visible – select another channel that displays prominent A signal

65 For Internal Use Only Test Your Knowledge Default WOI CS 1-2 M1-M2 Which Chamber was intended to be mapped? Ref is CS, however only V electrogram is visible – select another channel that displays prominent A signal Which signal should be annotated on M1-M2 ? Atrial

66 For Internal Use Only Test Your Knowledge Which Chamber was intended to be mapped? Ref is CS, however only V electrogram is visible – select another channel that displays prominent A signal Which signal should be annotated on M1-M2 ? Atrial Was WOI set correctly? No, this is the default WOI and includes both A and V Default WOI CS 1-2 M1-M2

67 For Internal Use Only Annotating Accessory Pathways Manifest (WPW) can map in: Sinus Rhythm A pacing V pacing Tachycardia (Orthodromic or Antidromic) Concealed can map in: V pacing Tachycardia (Orthodromic)

68 For Internal Use Only Accessory Pathways with V Pacing REF – CS 5-6 Max Value WOI adjusted to exclude pacing artifact from WOI Mapping along annulus should result in a VA signal Move annotation to earliest A Annotate to earliest A REF CS 5-6, Maximum Value V & A fusedV A Early site -33 ms

69 For Internal Use Only Accessory Pathways with Atrial Pacing Can only use with a Manifest pathway Atrial pacing slows AV node conduction with increasing paced rates, causing greater preexcitation though AP (Delta wave becomes more pronounced) Annotate to earliest V on M1-M2, correlate with M1 if unclear A pacing spike Delta wave Antegrade A Antegrade V M1

70 For Internal Use Only Recap Annotate Map activation times correctly The system will always pick an activation time All activation points acquired must have operator oversight Problematic situations: Complex electrograms (scar-based AT or VT) Sites on annulus with both A and V signals It only takes 1 or 2 points with incorrect activation times to mangle a map

71 For Internal Use Only How to Build A Map Verify CL is consistent with TCL AA V

72 For Internal Use Only How to Build A Map Verify CL is consistent with TCL AA V

73 For Internal Use Only How to Build A Map Verify CL is consistent with TCL Verify REF channel is annotating correctly AA V

74 For Internal Use Only How to Build A Map Verify CL is consistent with TCL Verify REF channel is annotating correctly Verify WOI is set correctly AA V

75 For Internal Use Only How to Build A Map Verify CL is consistent with TCL Verify REF channel is annotating correctly Verify WOI is set correctly Identify the waveforms AA V QRS

76 For Internal Use Only How to Build A Map Verify CL is consistent with TCL Verify REF channel is annotating correctly Verify WOI is set correctly Identify the waveforms Verify or move annotation to correct location AA V QRS

77 For Internal Use Only How to Build A Map Verify CL is consistent with TCL Verify REF channel is annotating correctly Verify WOI is set correctly Identify the waveforms Verify or move annotation to correct location Visualize color progression on map – It should make sense AA V QRS

78 For Internal Use Only How to Build A Map Verify CL is consistent with TCL Verify REF channel is annotating correctly Verify WOI is set correctly Identify the waveforms Verify or move annotation to correct location Visualize color progression on map – It should make sense Do these steps for every point acquired AA V QRS

79 For Internal Use Only Happy Mapping! Authored by:


Download ppt "For Internal Use Only How to Select a Reference Channel, Set a WOI and Annotate EGMs of the Mapping Catheter with."

Similar presentations


Ads by Google