supplemental data:
supplemental methods:
ablation procedures:
typical flutter (AFL): The electrophysiological study was performed under sedation utilizing
midazolam and fentanyl. One quadripolar diagnostic catheter (Biosense Webster, California, USA)
was advanced into right ventricular apex and one decapolar catheter (Webster® CS uni-directional
catheter, Biosense Webster, California, USA) into the coronary sinus under fluoroscopic guidance.
Subsequently, in the CARTO-3 group (c3) the infero-septal and infero-lateral tricuspid annulus as well
as the junction between the inferior vena cava and the right atrium were marked in the EAM (electroanatomical map) as anatomical landmarks of the cavo-tricuspid isthmus (CTI) under fluoroscopic
guidance. Afterwards, if tachycardia was present, an entrainment mapping was performed at the CTI
to confirm typical flutter. Now an point by point ablation line at the CTI was created under guidance
of the EAM and active fluoroscopy if necessary (Thermocool® SF catheter, Biosense Webster,
California, USA; ablation settings: 40W at an irrigation rate of 15ml/min with a maximum
temperature of 43°C). Finally the bidirectional block of the line was confirmed with differential pacing
under guidance of the EAM and active fluoroscopy if necessary. In the CARTO-UNIVU group (cU)
after positioning of the diagnostic catheters the UNIVU module was registered and one X-ray image in
RAO 20-30° and one X-ray image in LAO 50-60° were recorded. Then, the infero-septal and inferolateral tricuspid annulus as well as the junction between the inferior vena cava and the right atrium
were marked in the EAM as anatomical landmarks of the cavo-tricuspid isthmus (CTI) under active
catheter tracking in the pre recorded X-ray images and only if necessary under fluoroscopic guidance.
Afterwards, if tachycardia was present, an entrainment mapping was performed at the CTI to confirm
typical flutter. Now an point by point ablation line at the CTI was created under guidance of the EAM,
active catheter tracking in pre recorded X-ray images and active fluoroscopy only if necessary
(ablation settings: 40W at an irrigation rate of 15ml/min with a maximum temperature of 43°C).
Finally the bidirectional block of the line was confirmed with differential pacing under guidance of the
EAM, active catheter tracking in pre recorded X-ray images and active fluoroscopy only if necessary.
atrial fibrillation (AF): The electrophysiological study was performed under sedation utilizing
midazolam fentanyl and propofol. One quadripolar diagnostic catheter (Biosense Webster, California,
California, USA) was advanced into right ventricular apex and one decapolar catheter (Webster® CS
uni-directional catheter, Biosense Webster, California, USA) into the coronary sinus under
fluoroscopic guidance. A single trans-septal puncture was performed with a steerable intra-cardiac
sheath (Agilis™ NxT, St. Jude Medical, Inc., Minnesota, USA) under fluoroscopy guidance. Upon left
atrial access, a bolus of unfractionated Heparin (100 IU/kg) was administered and repeated
intermittently to maintain an activated clotting time between 300 and 350 ms. If atrial fibrillation was
present during the procedure an electrical cardioversion was performed. In the CARTO-3 group (c3)
an EAM including substrate-mapping (voltage values higher than 0.5 mV were defined as healthy
myocardium. Voltage values below 0.2 mV were defined as total scar) of the left atrium and the
pulmonary veins was acquired under fluoroscopic guidance with a multipolar mapping catheter
(Lasso® eco NAV catheter, Biosense Webster, California, USA). During the EAM acquisition
selective angiographies of the pulmonary veins were done for fluoroscopic confirmation of catheter
position throughout PVI. Now the acquired EAM was merged to the reconstructed CT with a visual
alignment technique and well defined anatomical landmarks, followed by registration of the surface.
Subsequently, in all atrial fibrillation procedures a point by point pulmonary vein isolation was
performed with pace and ablate technique under guidance of EAM and if necessary under active
fluoroscopy (ablation settings: 40W at an irrigation rate of 15ml/min with a maximum temperature of
43°C, reduction of the RF energy to 30W at the left atrial posterior wall, intra-oesophageal
temperature monitoring with RF stop cut off of 39°C). In case of additional low voltage areas within
the left atrium these areas were isolated by point by point creation of additional ablation lines. Finally
the conformation of PVI and bidirectional block of all additional lines was performed under EAM and
if necessary fluoroscopic guidance. In the CARTO-UNIVU group (cU) after trans-septal puncture the
UNIVU module was registered and angiographies of the left atrium and the pulmonary veins were
recorded in RAO (20-30°) and LAO (50-60°) views. The further procedure was done like in the
CARTO-3 group but under active catheter tracking in the angiographies and active fluoroscopy only if
necessary.
ectopic atrial tachycardia (EAT): One quadripolar diagnostic catheter was advanced into right
ventricular apex and one decapolar catheter into the coronary sinus under fluoroscopic guidance. If
patient were under sinus rhythm the EAT was triggered with programmed atrial stimulation. If the
origin of the tachycardia was supposed in the left atrium a single trans-septal puncture was performed
with a steerable intra-cardiac sheath (Agilis™ NxT, St. Jude Medical, Inc., Minnesota, USA) under
fluoroscopy guidance. In the CARTO-3 group (c3) an EAM including activation-mapping of the right
or left atrium were acquired under fluoroscopic guidance. Subsequently, the ectopic focus was ablated
under guidance of the EAM and if necessary under active fluoroscopy (ablation settings: 30-40W at an
irrigation rate of 15ml/min with a maximum temperature of 43°C). In the CARTO-UNIVU group (cU)
after positioning of the diagnostic catheters and optional trans-septal puncture the UNIVU module was
registered and one X-ray image in RAO 20-30° and one X-ray image in LAO 50-60° were recorded.
The further procedure was done like in the CARTO-3 group but under active catheter tracking in the
pre recorded X-ray images and active fluoroscopy only if necessary. In all patients an observational
time of 15 minutes was kept after the last ablation to rule out an early recurrence.
accessory pathyway (AP): One quadripolar diagnostic catheter was advanced into right ventricular
apex and one decapolar catheter into the coronary sinus under fluoroscopic guidance. If the AP was
supposed in the left atrium a single transseptal puncture was performed with a steerable intra-cardiac
sheath (Agilis™ NxT, St. Jude Medical, Inc., Minnesota, USA) under fluoroscopy guidance. In the
CARTO-3 group (c3) an EAM including activation-mapping of the mitral or tricuspid annulus were
acquired under fluoroscopic guidance. Subsequently, the AP was ablated under guidance of the EAM
and if necessary under active fluoroscopy (ablation settings: 30-40W at an irrigation rate of 15ml/min
with a maximum temperature of 43°C). In the CARTO-UNIVU group (cU) after positioning of the
diagnostic catheters and optional transseptal puncture the UNIVU module was registered and one X-
ray image in RAO 20-30° and one X-ray image in LAO 50-60° were recorded. The further procedure
was done like in the CARTO-3 group but under active catheter tracking in the pre recorded X-ray
images and active fluoroscopy only if necessary. In all patients an observational time of 15 minutes
was kept after the last ablation to rule out an early recurrence.
premature ventricular complexes (PVCs) One quadripolar diagnostic catheter was advanced into right
ventricular apex and one decapolar catheter into the coronary sinus under fluoroscopic guidance. If the
PVC was supposed in the left ventricle a single trans-septal puncture was performed with a steerable
intra-cardiac sheath (Agilis™ NxT, St. Jude Medical, Inc., Minnesota, USA) under fluoroscopy
guidance. In case the origin of the PVC was supposed in the aortic valve or in the left ventricular
outflow tract, a retrograde trans-aortic access of the ablation catheter was chosen. In the CARTO-3
group (c3) EAMs including activation- or pace-mapping of the supposed cardiac chambers were
acquired under fluoroscopic guidance. Subsequently, the PVC was ablated under guidance of the
EAM and if necessary under active fluoroscopy (ablation settings: 30-50W at an irrigation rate of 1530ml/min with a maximum temperature of 43°C). In the CARTO-UNIVU group (cU) after positioning
of the diagnostic catheters and optional trans-septal puncture or trans-aortic access the UNIVU module
was registered and one X-ray image in RAO 20-30° and one X-ray image in LAO 50-60° were
recorded. The further procedure was done like in the CARTO-3 group but under active catheter
tracking in the pre recorded X-ray images and active fluoroscopy only if necessary. In all patients an
observational time of 15 minutes was kept after the last ablation to rule out an early recurrence.
ventricular tachycardia (VT): One quadripolar diagnostic catheter was advanced into right ventricular
apex and one decapolar catheter into the coronary sinus under fluoroscopic guidance. If patient were
under sinus rhythm the VT was tried to trigger with programmed ventricular stimulation. The
triggered VT was recorded and terminated with anti-tachycardia pacing or electrical cardioversion. In
case the an epicardial origin of the tachycardia was supposed, an epicardial puncture was performed
under fluoroscopic guidance and an steerable sheath (Agilis™ EPI, St. Jude Medical, Inc., Minnesota,
USA) was advanced into the pericardial space. If the origin of the tachycardia was supposed in the left
ventricle a single trans-septal puncture was performed with a steerable intra-cardiac sheath (Agilis™
NxT, St. Jude Medical, Inc., Minnesota, USA) under fluoroscopy guidance. In the CARTO-3 group
(c3) angiographies of the ventricles in RAO 20-30° and in LAO 50-60° were recorded (in case von
severe renal dysfunction or hemodynamic instability only X-ray images were recorded). Then EAM
including substrate-, pace- and activation-mapping of the right or left ventricle (endo- and epicardial)
were acquired under fluoroscopic guidance. Subsequently, a substrate modification due to ablation of
the low voltage areas under guidance of the EAMs and if necessary under active fluoroscopy (ablation
settings: 40-50W at an irrigation rate of 15ml/min with a maximum temperature of 43°C) was
performed. In the CARTO-UNIVU group (cU) after positioning of the diagnostic catheters and
optional epicardial and trans-septal puncture the UNIVU module was registered and angiographies of
the ventricles in RAO 20-30° and in LAO 50-60° were recorded (in case von severe renal dysfunction
or hemodynamic instability only X-ray images were recorded). The further procedure was done like in
the CARTO-3 group but under active catheter tracking in the pre recorded angiographies and active
fluoroscopy only if necessary.
supplemental figures:
fluoroscopy time in min
20
p < 0.001
p = 0.001
15
10
5
0
15.7
5.2
PVI only
16.2
7.8
PVI +
ablation lines
carto univu
fluoroscopy dose in cGycm2
carto 3
10000
p < 0.001
p = 0.06
8000
6000
4000
2000
0
8068
3049
PVI only
6836
4498
PVI +
ablation lines
supplemental figure 1: fluoroscopy time and fluoroscopy dose in AF procedures (c3 vs. cU)
subgroup analyses of fluoroscopy time and dose used for the AFablation procedures CARTO-3 vs. CARTOUNIVU: in PVI only subgroup only an PVI was performed, in the PVI+ablation lines group a PVI and additional
ablation lines were necessary during procedure. data presented as mean±SEM, p<0.05 was defined as significant
supplemental figure 2: RF time and RF dose in different ablation procedures (c3 vs. cU)
RF (radiofrequency) application time in seconds [sec] and RF application dose in Ws of the different ablation
procedures CARTO-3 vs. CARTO-UNIVU, AFL: ablation of typical flutter, AF: atrial fibrillation, EAT: ectopic
atrial tachycardia, AP accessory pathway, PVC: premature ventricular contractions, VT: ventricular tachycardia.
RF: radio frequency, data presented as mean±SEM, p<0.05 was defined as significant