Takashi Nitta, MD, Masataka Mitsuno, MD, Chris K

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Cryoablation of ventricular tachycardia guided by return cycle mapping after entrainment Takashi Nitta, MD, Masataka Mitsuno, MD, Chris K. Rokkas, MD, Richard Lee, MD, Richard B. Schuessler, PhD, John P. Boineau, MD The Journal of Thoracic and Cardiovascular Surgery Volume 121, Issue 2, Pages 249-258 (February 2001) DOI: 10.1067/mtc.2001.111052 Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Difference between the CCP ablation and the EAS ablation. The upper panel illustrates the figure-of-8 reentry model. The CCP is a narrow isthmus between the lines of conduction block that are depicted as bold lines. The EAS locates at the exit from the pathway. The arrows indicate activation wave fronts. Each shaded region indicates the region to be ablated required to terminate reentry. The lower panel shows the electrocardiogram and the electrograms recorded at the CCP and at the EAS during VT in an animal in this study. Note that the electrograms at the CCP are low voltage and polyphasic, whereas the electrograms at the EAS have monophasic potentials with higher voltage and steep deflection. See text for detailed explanation. CCP, Central common pathway; EAS, earliest activation site. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 249-258DOI: (10.1067/mtc.2001.111052) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Mechanism of return cycle mapping after entrainment. Panel 1 illustrates the figure-of-8 reentry circuit and the activation pattern during entrainment from a region proximal to the CCP. The pacing site is denoted as a rectangle and the lines of block are denoted as bold lines. Arrows indicate the activation sequence. The antidromic activation of the Nth pacing collides with the orthodromic activation of the (N-1)th pacing. The fine lines connected to the lines of block are the lines of collision and the transition from Nth to (N-1)th activation. Panel 2 represents the activation sequence and the return cycle after entrainment at sites A, B, and C in panel 1. Panel 3 illustrates that the return cycle isochrone equal to the VTCL shifts as the stimulation site changes, but always converges on the lines of block irrespective of the stimulation site. Panel 4 shows that the potentials from the CCP are not necessarily required to have the return cycle isochrones converge on the lines of block. See text for detailed explanation. CCP, Central common pathway; VTCL, ventricular tachycardia cycle length; PCL, pacing cycle length. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 249-258DOI: (10.1067/mtc.2001.111052) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 Location of 61 unipolar electrodes over the epicardium. The schema represents the polar view of the ventricles as if they are observed from the apex. Nineteen electrodes are distributed over the right ventricular epicardium, and 31 over the left. Eleven electrodes are located at the interventricular groove along the LAD. AO, Aorta; PA, pulmonary artery; RA, right atrium; LAA, left atrial appendage; IVC, inferior vena cava. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 249-258DOI: (10.1067/mtc.2001.111052) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 An example of return cycle mapping. The upper panel shows the electrocardiogram during cessation of entrainment of a VT induced in a 4-day-old canine infarct. The activation maps during the first and second activation after cessation of entrainment are shown in the middle panels. Boxed areas on the electrocardiogram are the data window analyzed to construct the activation maps. The VT was entrained from the right ventricular outflow tract (denoted as a rectangle ) at a pacing cycle length of 160 ms. After cessation of pacing, the VT resumed at a cycle length of 168 ms with the EAS located at the inferior left ventricle near the apex (denoted as an asterisk ). The activation times are represented as color codes with 20-ms increments. The left lower panel shows the return cycle map constructed from these activation maps, by subtracting the first activation time from the second activation time after cessation pacing. The return cycle was also represented as color codes with 10-ms increments. The return cycle was longest at the region around the pacing site and was shorter at the region near the earliest activation site. The blue indicates the region where the return cycle equaled the pacing cycle length, suggesting orthodromic activation by the preceding stimulus. The red line indicates the return cycle isochrone equal to the VTCL. As we changed the pacing site from the red to the blue rectangle, this isochrone shifted from the red to the blue line as shown in the right lower panel. These lines converged on a region 20 mm away from the earliest activation site and formed intersections. The VT was terminated by a cryothermia to the region between the intersections. ECG, Electrocardiogram; AO, aorta; PA, pulmonary artery; RA, right atrium; LAA, left atrial appendage; IVC, inferior vena cava; VTCL, ventricular tachycardia cycle length. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 249-258DOI: (10.1067/mtc.2001.111052) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Another example of return cycle mapping. The cycle length of the VT was 153 ms and the earliest activation site was at the anterior left ventricle adjacent to the LAD (denoted as an asterisk ). The VT was entrained at a pacing cycle length of 140 ms. The left panel represents the return cycle map after entrainment from a site at the anterior left ventricle. The site of stimulation is denoted as a rectangle. The return cycle is represented as color codes with 10-ms increments, and the red line indicates the return cycle isochrone equal to the VTCL. The right lower panel shows the return cycle isochrone equal to the VTCL in the return cycle maps after entrainment from two different pacing sites that were denoted as blue and red rectangles. The VT was terminated by a cryothermia applied to the region between the intersections of these isochrones. For abbreviations, see Fig 4. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 249-258DOI: (10.1067/mtc.2001.111052) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 6 Electrocardiograms and activation maps of the anterior left ventricle during cryoablation guided by return cycle mapping. A total of 253 unipolar electrodes were distributed over the anterior left ventricle. The electrode patch was located from the basal left ventricle 1 to 2 cm away from the left atrioventricular groove to the inferior apex of the left ventricle. The left margin of the electrode array was adjacent to the LAD. The right margin was located at the obtuse margin. Boxed areas on the electrocardiogram are the data window analyzed to construct the activation maps. Panel 1 shows the baseline activation map during VT before the application of cryothermia. The cycle length of the VT was 153 ms. Cryothermia was applied at the region localized by return cycle mapping with 61 electrodes as shown in Fig 5. The mapped region was the entrance of the CCP between the lines of conduction block. Panels 2 and 3 show the activation maps 5 and 10 seconds after the start of cryothermia, respectively. As the diameter of the cryolesion became larger, the cycle length of the VT prolonged by degrees. Panel 4 shows the activation map during the last VT cycle before its termination after 20 seconds of cryothermia. The cryolesion connected the lines of block, blocked the rotating wave front, and resulted in termination of the VT. For abbreviations, see Fig 4. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 249-258DOI: (10.1067/mtc.2001.111052) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 7 Distance between the earliest activation site and the sites where cryothermia successfully terminated the VT guided by return cycle mapping. The distance was plotted as a function of the cycle length of the VT (VTCL). The Journal of Thoracic and Cardiovascular Surgery 2001 121, 249-258DOI: (10.1067/mtc.2001.111052) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions