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The impact of novel technologies on ablation therapy in scar-related tachycardia

Abstract : Recent improvement in ablation such as irrigation catheter and contact force has been dramatically raised a safety and efficacy, and several balloon technologies such as cryoballoon has significantly shorten the procedure time. Electroporation may remarkably decrease complications with maintaining a lesion durability and transmurality. However, not only such developments in ablation technologies but also those in mapping technologies are mandatory for the best outcome of an arrhythmia treatment. A circuit of atrial tachycardia (AT) and ventricular tachycardia (VT) normally has a critical isthmus to maintain the tachycardia. Successful detection of this isthmus as well as a durable lesion formation can be a limiting factor in the efficacy of ablation therapy for these tachyarrhythmias. In addition to some ablation technologies, several mapping technologies for guiding ablation therapy have recently emerged. In particular, the remarkable improvement of mapping catheters and imaging technologies may have an impact on diagnosing a tachycardia mechanism and identifying substrates and circuits of tachycardias, leading to a procedural efficacy. Multipolar mapping catheters are increasingly utilized for substrate delineation. However, the clinical impact of inter-electrode spacing and size of the electrode on the local electrograms has not been systematically examined. Additionally, the clinical efficacy of using an ultra high resolution/high-density mapping system and multipolar catheters with small electrodes and spacing has not been fully examined. Imaging information from Cardia Magnetic Resonance (CMR) and computerized tomography (CT) scan (e.g. scar area, wall thickness) can be combined with the elecroanatomical information from the 3 dimensional mapping system by a novel computational tool ‘MUSIC’ system. However, the true clinical impact of this technology has not been reported. Therefore, the aims of this research project are to (1) clarify how the signals are affected by the difference of electrode length and interelectrode spacing, and demonstrate the characteristics of each multipolar catheter in an animal model (2) to observe a clinical advantage of using an ultra high resolution/high-density mapping system and multipolar catheters with small electrodes and spacing in identifying a practical strategy to detect the isthmus of the tachycardia circuit and treat it based on these technologies, (3) to evaluate the relation between the information from imaging and voltages in each multipolar catheter, and (4) to elucidate the clinical impact of an imaging guided-VT ablation therapy with the MUSIC system. To elucidate these points, we conducted three main studies including one series of animal experiments and two series of clinical studies. The first series of 4 animal experiments demonstrated the effect of electrode size, inter-electrode spacing, and activation orientation on the local electrograms and voltage threshold determining scars. The clinical parts composed of two main studies. First, we elucidated the efficacy of using the novel ultra highresolution/high-density mapping system, 'RhtymiaTM', with the Orion TM multipolar catheter with small electrodes and inter-elecotrode spacing catheter, in diagnosing several forms of complex post-AF ATs. The second part of the clinical study describes the relationship between wall thickness distribution on CT imaging and substrate mapping on the electroanatomical mapping system in patients with ventricular tachycardias based on ischemic cardiomyopathy. [...]
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Masateru Takigawa. The impact of novel technologies on ablation therapy in scar-related tachycardia. Human health and pathology. Université de Bordeaux, 2019. English. ⟨NNT : 2019BORD0180⟩. ⟨tel-02877559⟩

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