Unipolar and Bipolar Electrogram Characteristics Predict Exit Block during Pulmonary Vein Antral Isolation

Authors

  • YOAV MICHOWITZ M.D.,

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • ERIC BUCH M.D.,

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • TARA BOURKE M.D.,

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • RODERICK TUNG M.D.,

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • JASON BRADFIELD M.D.,

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • NILESH MATHURIA M.D.,

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • NOEL G. BOYLE M.D., Ph.D.,

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • KALYANAM SHIVKUMAR M.D., Ph.D.

    1. From UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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  • Disclosures: None.

Address for reprints: Yoav Michowitz, M.D., UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, A2-237 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095. Fax: 310-825-2092; e-mail: ymichowitz@gmail.com

Abstract

Introduction: The usefulness of unipolar electrograms (EGMs) has been reported in assessing lesion transmurality and conduction block along ablation lines. It is unknown whether unipolar and bipolar EGM characteristics predict exit block during pulmonary vein isolation (PVI) procedures.

Methods and Results: Twenty patients (63 ± 7 years; 14 males [70%]) undergoing PVI with a circular mapping catheter (CMC) placed outside each PV ostium were retrospectively studied. After entrance block was achieved, pacing at each bipole around the CMC was performed to assess for absence of atrial capture (exit block). Bipolar EGMs recorded before pacing were examined for voltage, duration, fractionation, and monophasic morphology. Unipolar EGMs were examined for positive and negative amplitude, PQ segment elevation, fractionation, and monophasic morphology. The association of these parameters with atrial capture (absence of exit block) at each site was analyzed.

After achievement of entrance block, only 23 of 64 PV antra (36%) exhibited exit block. Unipolar EGMs at sites with persistent capture were more likely to be fractionated and had larger negative deflections. Bipolar EGMs at sites with persistent capture showed higher amplitude, longer duration, were more likely to be fractionated, and were less likely to be monophasic. In a multivariate logistic regression model, bipolar and unipolar fractionation, bipolar duration, and lack of bipolar monophasic morphology were independently associated with persistent atrial capture.

Conclusion: Specific unipolar and bipolar EGM characteristics are associated with left atrium capture after PV antral isolation. These parameters might be useful in predicting the need for further ablation to achieve exit block. (PACE 2012; 35:1294–1301)

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