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Interpretation of Unipolar Electrograms for
Noncontact Mapping
Yenn-Jiang Lin, MD; Shih-Ann Chen, MD.
Taiwan HRS Meeting and St. Jude Medical
Taipei, 10/16, 2011 Division of Cardiology, Taipei Veterans General Hospital
and National Yang-Ming University, Taipei, Taiwan
Non-contact Mapping System
The differences between unipolar and
bipolar electrograms
Unipolar electrogram voltage
Unipolar electrogram morphology
Electronic filtering of unipolar recordings
Topics
Differences Between Unipolar and Bipolar Electrograms
Differences Between Unipolar and Bipolar Electrograms
Unipolar
Electrogram
Bipolar
Electrogram
AAB
B
A
B
A
B
IndifferentElectrode
A
B
Unipolar Bipolar
•Subtract Far-field signal
•Morphology indicates direction of WF
•WF direction affects amplitude
Differences Between Unipolar and Bipolar Electrograms
1Uniformly Isotropic Substrate
(HRA epicardial stimulation – RL view of RA)
A
C
B
A
B
C
1Uniformly Isotropic Substrate
(HRA epicardial stimulation – RL view of RA)
A
C
B
A
B
C
QS
1Uniformly Isotropic Substrate
(HRA epicardial stimulation – RL view of RA)
A
C
B
A
B
C
QS
RS
1Uniformly Isotropic Substrate
(HRA epicardial stimulation – RL view of RA)
A
C
B
A
B
C
QS
RS
R
A
B
C
Smaller R wave
Smaller S wave
A
B
C
QS
RS
R
A
B
C
A
B
C
Amplitude ofUnipolar Vol.
Less negative deflection indicated abnormal substratePNV of unipolar Eg for the dynamic substrate mapping
Peak Negative Unipolar Voltage
P = 0.01 P = 0.004
Fig 5
Voltage and conduction velocity Voltage and conduction velocity within the conduction isthmuswithin the conduction isthmus
Huang JL and Lin YJ et al JACC 2006
Conduction Velocity Along the Circuit
0 20 40 60 80 100
100-Specificity (%)
100
80
60
40
20
0
Se
nsi
tivity
(%
)
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Inside isthmus
<=0.38Sens: 92.3
Spec: 85.7
A: ROC Curve Analysis
B: Ratiometric voltage
Ra
tiom
etr
ic V
olg
ate
Outside isthmus
Prediction of slow conduction Prediction of slow conduction using ratiometric PNV unipolar Egusing ratiometric PNV unipolar Eg
38% of the maximal PNV predicted slow conductionAreas (less than 37% of PNV indicated slow
conduction area) and could be arrhythmogenic
Huang JL and Lin YJ et al JACC 2006
Appropriate Orientation of the Anatomic model and Unipolar Eg
Right
Right atrial septum
From LA?
Unipolar electrograms at the earliest sites were associated with substrate property
and wavefront dynamics
R wave morphologiesClinical Implications
QS MorphologiesClinical Implications
Slow QS Concealed R Wave
1. Subendocardial or epicardial focus 2. Anisotropic conduction3. Poor contact of catheter
Isotropic conduction
Anisotropic conduction
Non-uniformed anisotropic conduction
Slow conduction in reentry circuits
Conduction block
Specific Unipolar Eg
1. Isotropic ConductionSingle Compact Site
• Activation typically proceeds concentrically away from a single “spot” of early activation
20
½ vel
norm vel
AB
C
A
B
C
2. Uniformed Anisotropic Substrate
21
7
½ vel
norm vel
AB
C
A
B
C
Uniformed Anisotropic Substrate
Seidl, Munger, Binder, Guzman
1
2
3
1
1: Initial onset of depolarization
2
2: Breakout
3
3: Wrap around effect
3. Non-Uniformed Anisotropic conductionOrigin, preferential pathway, and exit site
Earliest Activation from Bipolar mapping
Single-morphology from channel
Ventricular Channel
++
**
EndocardiumEndocardium
EpicardiumEpicardium
4. Epicardial in Origin
5. Reentry Circuits5. Reentry Circuits
6. Slow Conduction6. Slow Conduction
Lin YJ and Chen SA et al Heart Rhythm 2009
4
Line of Block
B
C
D
B
C
D
A
A
7. Lines of Conduction Block7. Lines of Conduction Block
Low Amplitude <30-37% of maxim
< 1.0 mV (PNV)
Fibrosis, marked anisotropic property, far away from array
Fractionated, continuous Eg
> 70 ms, multiple baseline crossing
Slow conduction, anisotropic conduction, noise
Split potentials > 50 ms, seperated by isoelectric line
Local conduction block
Low frequency Low dV/dt Preferential conduction,
far-field (not near field)
Late component
After QRS or P wave
Delay activation, lines of block, slow conduction, bystander
Summery of Unipolar Eg InterpretationSummery of Unipolar Eg Interpretation
Combined = Bandpass Filter (passes depolarization)
V
f
Baseline noise
depol
physiologic environmental
Highpasscutoff freq
(0.5 - 32 Hz)
Lowpasscutoff freq
(250 - 500 Hz)
Low pass and High pass filtering of Low pass and High pass filtering of Unipolar ElectrogramsUnipolar Electrograms
V
f~16 Hz ~64 Hz
approximates the derivative
High-pass unipole: d(Vol)/d(time) vs.
Bipole: d(Dis)/d(time)
depol
High pass filtered unipolar Eg was compatible to conventional bipolar recordings (without far-fields)
Biophysics of Unipolar EgBiophysics of Unipolar Eg
Soejima, et al., JCE 2005
High pass filtered Eg eliminates the far-field unipolar signal; however, limits the Eg Morphology
Earliest activation site of VT
SLOW & FAST FAST ONLY
WAVEFRONT POSITION-VELOCITY WAVEFRONT “POSITION” BLEND “VELOCITY”
Scar
Flutter
AF
EAT
VT exit Ischm Circuit Idio Circuit
WPW & AVNRT
H P F R E Q U E N C Y (Hz)
Equivalent CL (ms) – and – HR (bpm)
0.5 1 2 4 8 12 16 32 2000 1000 500 250 125 83.3 62.5 31.3 30 60 120 240 480 720 960 1920
Application of High Pass Filtering in Unipolar Electrograms
Take home message: What Take home message: What information could be obtained from information could be obtained from
single site unipolar recordingsingle site unipolar recording
PNV: for the substrate mapping, <30-38% to the maximal PNV indicates abnormal
Accurate timing for very wide-band activation (0.5-300), with onset negative voltage
Approaching wavefronts (mass, speed)
Local activation (dV/dt)
High-pass filtering (4-16 Hz)
1. X slow conduction
2. X far-field signals
3. X morphology
THANK YOU