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    • For single shot techniques like the CBA a modified

    2019-06-18

    For single-shot techniques, like the CBA, a modified spiral mapping catheter has been introduced for the identification of PVPs prior to ablation and also for monitoring purposes during the ablation process [6]. The Achieve™ Mapping Catheter (AC) is an intra-cardiac electrophysiological diagnostic catheter, which can be used for both first and second generation cryoballoon CB (Arctic Front Advance™). The distal part of the AC is a circular loop with 8 evenly spaced electrodes. Two-loop diameters are now available, one with a 15-mm and the other with a 20-mm outer diameter. The inter-electrode distance varies between 4 and 6mm (for the 15- and 20-mm diameter loops, respectively). The more number of electrodes present, the more accurately PVPs can be identified [7]. Despite the emerging technical TMC125 cost of the last two decades, the primary success rate of PVI has not exceeded 70%. Even with multiple procedures, only a maximum of approximately 80% success rate can be achieved. In this context, the development of the High Density Mesh Mapper™ (HDMM) was a rational step. The multi-electrode basket catheter fitted with a 32-pole circular mesh structure provides high-resolution recording in a closed space. The catheter can be spanned as an umbrella with a maximum diameter of 25mm. For performing a successful PVI, the use of basket catheters, such as the HDMM, have been described in the past, especially because a basket catheter allows for the sophisticated analysis of myofibrils spread throughout the PVs parallel to the longitudinal axis of a PV [8–10].
    Material and methods
    Results
    Discussion Summarizing the results, the main findings of our study are as follows: high-density mapping with the HDMM identifies more residual PV-potentials after a single-shot CBA procedure. Despite the small-sized study group, consisting of only 24 patients, the differences are significant; the HDMM was able to identify PVPs in 279 quadrants, whereas PVPs were detected in 192 quadrants by the AC (P<0.001). These underestimations of PV potential mapping with the AC, in comparison with High Density Mapping, did not lead to an improvement of the net clinical outcome after 3 and 6 months in the HDMM ablation group. Residual PV-potentials following CBA were mainly found in the upper PVs. The HDMM guided CBA procedure led to the necessity of additional freezes, which then resulted in a final 100% success rate of the acute procedure. The impact of precise mapping, both prior and subsequent to PVI, is still controversial. Von Bary et al. recommended the use of additional mapping catheters to improve the PV isolation rate when there is doubt concerning the signal quality in single-shot (stand-alone) strategies [11]. In a small study population of only 12 patients, Anter et al. were recently able to demonstrate the superiority of mini-basket catheters over circular lasso catheters for the detection of PVPs following PVI. The PV-potentials could be recorded with only the smaller and closely spaced, mini-basket electrodes [12]. The question of whether or not focus should be placed more on mapping properties to close the gap between responders and non-responders of the PVI procedure remains. The “single-shot” ablation catheters commonly used today simplify the ablation procedure by allowing new developments to be mapped and ablation to be conducted in the same session (e.g., the second generation CB with its AC as an inner lumen mapping catheter [3–7]). As recently described, the results of CBA are comparable to those of the standard point-by-point radiofrequency ablation technique, as introduced for the ablation of PAF and PersAF [13,14]. Both techniques have a primary success rate range of 70–80% with a predefined recurrence rate in the follow-up period. Revisions of primary effective isolated PVs show a reconnection of the muscle sleeves between the LA and PV in most cases, thus leading to the necessity of additional ablation efforts. The question remains as to whether these reconnections are true reconnections or completely isolated PVs from the first ablation attempt, having been caused by ignored or false-negative mapping procedures.