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The procedure guide is an education and training supplement and is not intended to be a substitute for training. For more information, please refer to the Operator’s Manual and Instructions for Use, or contact your Medtronic representative.

Brief Statement

See the device manuals for detailed information regarding indications, contraindications, warnings, precautions, and potential adverse events.

Duty-Cycled Phased RF PROCEDURAl GUIDE

EuropeMedtronic International Trading SàrlRoute du Molliau 31Case postaleCH-1131 TolochenazTel: +41 (0)21 802 70 00Fax: +41 (0)21 802 79 00

United Kingdom/IrelandMedtronic ltdBuilding 9Croxley Green Business ParkHatters laneWatfordHerts WD18 8WWUKwww.medtronic.co.uk Tel: +44 (0)1923 212213Fax: +44 (0)1923 241004

www.medtronic.euwww.ablationfrontiers.com

32

REMOTE CONTROL

GENERATOR FOR

ABLATION CATHETERS

Connect to 1 (or 2*)external monitor

Connect to RS232*

*V14 or higher GENius generator

Overview

GENius Multi-Channel RF Ablation Generator

Model #990018 PVAC

Model #990030MASC

Model #990001MAAC

Model #990000

System Setup and ComponentsMedtronic Supplied Components: 1) Catheters •PulmonaryVeinAblationCatheter(PVAC)–Model#990030 •Multi-ArraySeptalCatheter(MASC)–Model#990001 •Multi-ArrayAblationCatheter(MAAC)–Model#990000 2)GENiusMulti-ChannelRFAblationGenerator–Model#990018 3) Power cord 4)ECGInterfaceBox–Model#990028 5)ECGInterfaceBoxCable–Model#990020 6)ECGAmplifierCable–Model#990027 7)CatheterInterfaceCable–Model#990004

Required Accessories: 8) Two ValleylabTMPatientReturnElectrodes–Model#E7506 •TransseptalSheath(9.5Frorgreaterinnerdiameter)[not shown] •PV-Tracker™orequivalent(0.032”outerdiameter,200cmlength

with3mmJtipguidewire)–Model#990045[not shown]

Medtronic Optional Accessories: 9)GENiusJr.RemoteControl–Model#99002910)RemoteControlCable,15ft–Model#990041or25ft–Model#990042

EP Lab Setup

32

105

97

1

8

6

4

This guide was designed to give you a visual overview of duty-cycled phased RF ablation procedures.

Before you begin using the products:•PleasefamiliarizeyourselfwiththeOperator’sManualandInstructionsFor

Use of the–GENiusMulti-ChannelRFAblationGenerator–Model#990018–PVAC–PulmonaryVeinAblationCatheter–Model#990030–MASC–Multi-ArraySeptalCatheter–Model#990001–MAAC–Multi-ArrayAblationCatheter–Model#990000

•ConsultwithyourMedtronicAFSolutionsrepresentativetolearnabouttraining opportunities

Procedural guide scope:•Setupthecatheterablationsystem•Manageperiproceduralanticoagulation•Interpretgeneratorinterface•Strategizeangiographyapproaches•DeployandusethePVAC,MASC,andMAAC catheters•Troubleshootproceduralchallenges

Important note:•Thisguideisnotintendedtobeasubstitutefortraining•Formoreinformation,pleaserefertoOperator’sManualandInstructionsforUse,orcontactyourMedtronicrepresentative

1

54

Patient Preparation•Firmlypressalongtheentireelectrodeareaduringplacement•Avoidareaswithadiposetissue,bonyprominences,fluidinvasion,scartissue,andexcesshair(shaveareaasnecessary)•Donotattempttoreposition;replaceifnecessary• Do not reuse (single use only)•InsertblueconnectorsfirmlyintoECGbox

EP Recording System Setup

Option 1

Option 2

* Applies to V12 or earlier.

3

2

EP Lab Setup

FEATURE VALUEGain One step more than the value used for a diagnostic

circular mapping catheterHigh pass 100HzLow pass 500HzClose pacing channels, where possible and when not actively delivering pacing stimuli

GENius-ECG Box Setup

Lead Amplifier Connectivity

4

5

6

Step 1: Connect the power cord at Step 2: Connect the ECG interface box thebackoftheGENius cablefromgeneratortoECG generator box (both ends of the cable are

identical and does not matter which end is connected to which part)

Step 1: The 12-lead ECG amplifier Step 2: Plug the ECG amplifier cable connects to the ECG into the ECG interface box interface box

EP Lab Setup

Step 1: Grasp the screen handle Step 2: Pull out screen completely

GENius Screen Setup

Step 3:Pressinbothknobson Step 4: Swing screen into place side of screen*

Step 5: Switch power on

REMOTE CONTROL

GENERATOR FOR

ABLATION CATHETERS

Connect to 1 (or 2*)external monitor

Connect to RS232*

*V14 or higher GENius generator

Multi-Channel RF Ablation Generator

ECG Interface Box

Remote

STOP

Standby StartAll

Channels

CH 1

CH 5

CH 2

CH 6

CH 3

CH 7

CH 4

CH 8

Temp Up

Temp Down

DurationUp

DurationDown

Bipolar Unipolar

1:1 2:1 4:1

GENERATOR

76

Loading dose after transseptal puncture 100U/kgHeparin administered during procedure 10U/kg/hourMonitoring Interval after achieving target ACT 30 minACT target range 300-350 seconds

350-400 seconds for significant atrial enlargement

To prevent sheath-related thrombi, heparinized-saline can be continuously infused via the transseptal sheath

Periprocedural Anticoagulation

Anticoagulation Strategies

•Summaryof“Anticoagulation and Strategies to Prevent Thromboembolism”from 2007 HRS/EHRA/ECAS Expert Consensus Statement1

Fredersdorf

JCE 2009

“…systemicanticoagulationwasachievedwithintravenous heparin to maintain an activated clotting time of≥300seconds.”2

Wieczorek

JCE 2009

“…andheparinwasadministeredintravenously,startingwithabolusof10,000IUuntilanactivatedclottingtimeof300–350swasobtained.”3

Scharf

JACC 2009

“Afterfemoralvenousaccessandtransseptalpuncture,asingle10.5-Fsheathwasinsertedintotheleftatrium,andheparin was administered to maintain an activated clotting time(ACT)>300s.”4

•Summaryofanticoagulationstrategiesfromselectpeer-reviewdata on phased RF

Approach #1: Selective PV Angiography

DelivercontrasttoeachPVantrum/ostium via:

1) The transseptal sheath placed near PVtrunk

OR

2) A deflectable and/or multipurpose catheter

Approach #2: Entire Left Atrial (LA) Angiography

Delivercontrasttowholechambervia:

1) Administration of bolus (20 mg) adenosinetoinduceAVblock5,6

OR

2) Right-ventricular pacing (~ 300 ms)6-8

THEN

3) Inject ~ 20 ml contrast into LA body or near roof

Possible Approaches

Example shown: LSPV in LAO

LAO Projection

Relationship of the PVs to Catheter Positions

Example shown: Entire LA in AP

RAO Projection

Selective Angiography

CSRIPV

RSPV

LAA

LIPV

LSPV

CS

RIPV

RSPV

LAA

LIPV

LSPV

98

Guidewire compatibility: •0.032”outerdiameter•200cmlengthorgreater•3mmJtip

Transseptal sheath compatibility:

•9.5Frorgreaterinnerdiameter

CURVE REACH40 mm at 90°

CURVE RADIUS19 mm

PAIR 2

TIP

PAIR 3

PAIR 1

PAIR 4

PAIR 5

6 5

4

3

1

10

9

8

7

ELECTRODES

3 mm

25 mmSPIRAL DIAMETER

3 mm

2

Product Specifications

145 cm ± 5 cm

105 cm ± 5 cm

9 Fr

SPIRAL ARRAY

CAPTURE DEVICE

TENSIONCONTROL KNOB

SLIDECONTROL KNOB

CONNECTORDISTALLUMEN PROXIMAL

LUMENSTEERING KNOB

Capture

1 •Inserttheproximalendofthe0.032"guidewireintothedistal end of the PVAC•TheguidewiremustexittheproximalendofthePVAC

•Removethecapturedevicefromthehandle•Slideuptothespiralarray2

•Holdthecapturedeviceagainstthespiralarray•Usetheotherhandtoadvancetheslidecontrolknobforward

on the handle (approximately ¼ of the travel)

3

•Slidethecapturedeviceforwardtocapturethespiralarrayonthedistal end •Continuetoadvancetheslidecontrolforwardascapturedeviceis

advancing forwardNote: Always lead the tip of the PVAC ahead of the capture device to preventkinkingofthedistallumen

4

5 •Thespiralarrayshouldlooklikethefigurebelow•Ifnot,pullbackslightlyonthecapturedevice,advancetheslide

control fully forward while capturing the tip of the spiral array with the capture device

Refer to Appendix on page 36 for Colored Arrow Chart

PVAC PVAC

1110

Insertion

•RetracttheguidewiretothedistaltipofthePVAC

•Insertthecapturedeviceintothehemostasisvalve

•Inserttheguidewirehalfwayintothetransseptalsheath

•Advancethearrayintothesheathbeforeremovingandreplacingthe capture device onto the handle

1

2 •Advancethecatheterthroughthetransseptalsheathuntilthearray enters the atrium

•Beforefullydeployingthecatheter,verifythattheguidewireisinthe left pulmonary vein

•Toensuretheguidewireexitsthesheathcorrectly,confirmthatentrapment does not occur in any existing sideholes

Deployment

•RetractthedistalendofthetransseptalsheathintotherightatriumtoallowforfulldeflectionofthedistalsegmentofthePVAC,asneeded

•Asthefourthelectrodeexitsthedistalendofthesheath,slowlypullbackontheslidecontrolknobwhilecontinuingtoadvancethe PVAC to deploy the spiral array

1

2

PVAC PVAC

1312

Navigation

•AdvancetheguidewireintotheselectedPV

•Advancethespiralarrayontotheantrum/ostium

•Donotretractguidewiretipcompletelyintoarrayinordertopreventkinkingofthedistaltip

1

2

•DonotattempttosteerthePVACwithinthesheath3

Catheter Maneuvers to Navigate the PVAC Array at the PV Antrum/Ostium

•Usethefollowingmaneuverstoimprovetissuecontact1

Steering•Bringsthearraytodifferent

areas of the antrum/ostium

•Changestheplaneof contact

•Increasestheareaofantral/ostial ablation

Rotating•Movestheelectrodearrayto

different antral/ostial positions

Pulling or pushing•Adjustscontactpressurewith

tissue

Sliding•Improvestheelectrode-tissue

contact

•Placesthearraywithinthevein

PVAC PVAC

1514

Navigating from Left-to-Right–Sided Veins

•ToaccessrightPVs,retracttheguidewiretothetipofthePVAC

•PointandsteerthePVACinanacutecurvetowardtheLIPV•Tightenthetensionknobenoughtoholdatightcurve

•Rotateclockwisetobringthearray posteriorly toward the right PV

1

2

3

Navigating Common Ostia

•Placingguidewireintodifferentveinbranchesallowsfor approaching the antrum/ostium using different planes9

•Slightlyadvancetheslidecontrolknob•Applycounterclockwisetorquetoexpandarray•Alwaysunlockthetensioncontrolknobwhennavigatingatthe

PV antrum/ostium

1

2

PVAC PVAC

1716

Mapping inside the Veins

•RetractthePVACfromtheantrum/ostiumofthevein•Advancetheslidecontrolknobhalfwayforward

•AdvancethearrayintotheveinwhilerotatingthePVAC counterclockwise

1

2

Generator Software Default Settings4

Target Temperature 60 °CAblationDuration 60 secPower Mode 4:1 (use 2:1 if needed to achieve isolation after

trying catheter maneuvers)

Suggested Ablation Strategy2-4,9,10

•Targetelectrodepairswithmostsignals during the first 4-5 ablations per vein

•SelectthedesiredpairsforRF

•Ifpowerindicationsare<3W, suggest the operator to reduce contact pressure by slightly pulling back(“PullforPower”)orde-energizeonly those low power channels*

•Rotate45°-90°between consecutive ablations•Advancethespiralarray

onto the tissue•Performadditional

ablations to touch up on resistant fascicles

•Alwayspullbackthearrayfrom the antrum/ostium before going to the next ablation

Recommended Setting for Ablating with PVAC

(continued) * Low power channel is presumably a result of reduced cooling due to the electrode being deeply embedded in tissue. See page 33 for Managing Temperature and Power.

PVAC PVAC

1918

•PVACisdesignedtoablateatpulmonaryvein antrum/ostium

•Usefluoroscopicvisualizationtoconfirmlocation to prevent ablating the left atrial septum and posterior wall

•PVACisdesignedtoablateatpulmonaryvein antrum/ostium

•Usefluoroscopicvisualizationtoconfirmlocation to prevent ablating the left atrial wall with PVAC fully extended

•Ifitbecomesdifficulttowithdrawthetip of the PVAC into the distal end of the sheath,removethesheathwiththePVACcontained inside

Note:Donotallowelectrodes1and10 to come in contact with each other. Instead:•PerformPVACmaneuvers(sliding, rotating,steering,pushing,orpulling)

OR•Ensure electrodes 1 and 10 are separated

prior to ablating

•Usefluoroscopicvisualizationtonavigate the PVAC to different ablation location

•Prior to consecutive ablation in the samelocation,waitforappropriatetissue cooling to occur

Recommended Setting for Ablating with PVAC (continued)

PVAC

Validation of Pulmonary Vein Isolation (PVI)

Entrance Block

•WithPVACplacedatthedistalofthepresumedablationline,checkforentranceblockbymappingduringsinusrhythm,distalCSpacing(forLPVs),proximalCSpacing(forRPVs),orHighRightAtrialpacing(forRPVs)10,11

Differential Pacing

•UsedifferentialpacingorevaluatetheP-wavetoavoidmisinterpretationduetofar-fielddetection,e.g.,LAAinLSPV,RAinRSPV12

Exit Block

•PlacethePVACarraywithinthetargetedPV

•PaceathighoutputfromeachofthePVACpairs,checkingtheeffectonPVand atrial activations11,13

PVAC

2120

Removal

•EnsurethePVACisstraight•Verifyatleast5cmofguidewireisinsertedintooneoftheLPVs•Advanceslidecontrolknob¼forwardandpullbackonthePVAC

shaft to retract the array into the sheath

•Continuetoadvancetheslidecontrolwhilesimultaneously retracting the PVAC

1

2

3

Reinsertion

•Removetheguidewire from the PVAC

•Flushtheguidewirelumen using heparinizedsaline

•Cleantheguidewire and makesurethewireis free of debris

•Reinsert the guidewire into the PVAC

PVAC

•Insertthecapturedeviceintothehemostasisvalve•ContinueretractingthePVACuntilthearrayis

located in the capture device•Removethecapturedevicewiththespiralarray

and the guidewire from the valve of the sheath

Transseptal Sheath Compatibility:•9.5Frorgreaterinnerdiameter

26 mm

135 cm ± 5 cm105 cm ± 5 cm

8.5 Fr 9 Fr

ARM 1 MARKER

ARM 2 MARKERS

ELECTRODES PAIR 1

PAIR 2

12

4mm

2mm

2mm

2mm

34

PAIR 3

PAIR 4

PAIR 5PAIR 6

8

9 10 1112

76

5

6mm6mm

26 mm

135 cm ± 5 cm105 cm ± 5 cm

8.5 Fr 9 Fr

ARM 1 MARKER

ARM 2 MARKERS

ELECTRODES PAIR 1

PAIR 2

12

4mm

2mm

2mm

2mm

34

PAIR 3

PAIR 4

PAIR 5PAIR 6

8

9 10 1112

76

5

6mm6mm

Product Specifications

MASC

2322

Capture

Capture and Insertion

1

2

•Removethecapturedevicefromthehandleandslideituptothearray

•Advancetheslidecontrolknobonthehandleforwardcompletelyand hold in position

•Slidethecapturedeviceoverthedistalarray

Insertion•Insertthecapturedeviceintothehemostasisvalve

•AdvancetheMASCintothesheathapproximately15cm

•Slidethecapturedevicebackintoplaceonthehandle

MASC

•AdvancetheMASCthroughthesheathuntilthearrayenterstheleft atrium

•Thedistalportionofthearraymustexitthesheathpriortoretractionoftheslidecontrolknob

•Astheslidecontrolknobisretracted,simultaneouslyretractthesheathbackintotheRA

1

2

Deployment

MASC

Refer to Appendix on page 36 for Colored Arrow Chart

2524

Generator Software Default Settings4

Target Temperature 60 °CAblationDuration 60 secPower Mode 1:1

Navigation and Ablation

1

2

•Verifythetipofthesheathdoesnotextendintotheleftatrium

•PulltheMASCbacktoengagetheelectrodesagainsttheleftatrialseptum

MASC

•SelectthedesiredpairsforRF•Ifpowerindicationsare<3W,slightlypushforwardoradjustthecontrolknobonthehandle.(Thisisanindication that the electrode is deeply embedded in the left atrial septum.)

Navigation and Ablation (continued)

3

4Reposition the Array

MASC

Step 1: Slightly advance the controlknob

Step 3: Rotate the array to a new position

Step 2:Pushthearrayforward,away from the septum

Step 4: •Retracttheslidecontrolknobbacktodeploythearray•RetracttheMASCtoengagethe

electrodes against the septum•Ablateasnecessary•RepeatuntiltheMASChas been

rotated 360°

•Donotattempttorotatethecatheter while the array is against the septum

•Usefluoroscopicvisualizationto confirm the array arms are separated before delivering RF energy

2726

•Advancethedistalendofthesheathintotheleftatrium•FullyadvancetheslidecontrolknobandpullbackontheMASCshaft

to capture the array within the sheath•CarefullywithdrawtheMASChalfwaythroughthetransseptalsheath

1

2 •Insertthecapturedeviceintothehemostasisvalve•ContinuetowithdrawtheMASCuntilthearrayislocatedwithinthe

capture device•Removethecapturedevicefromthehemostasisvalveofthesheath

Removal

MASC

105 cm ± 5 cm9 Fr

TENSION CONTROL KNOB

CAPTURE DEVICEARRAY

CONNECTOR

135 cm ± 5 cm

STEERING KNOB

PAIR 4

PAIR 3

PAIR 2ELECTRODES

2 mm

10 mm

PAIR 1

5

6 7

8

1

234

ARM 1 MARKER ARM 2 MARKER 2 mm

CURVE REACH 50 mm at 90oCURVE RADIUS 19 mm

Product Specifications

Transseptal sheath compatibility: •9.5Frorgreaterinnerdiameter

MAAC

2928

•Removethecapturedevicefromthehandleandslideitupto the array

•Beginslidingthecapturedeviceforwardtocapturethearray

1

2

Capture and Insertion

Capture

Insertion

•Insertthecapturedeviceintothehemostasisvalve

•AdvancetheMAAC into the sheath approximately 15 cm

•Slidethecapturedevicebackintoplaceonthehandle

MAAC

•Usefluoroscopicvisualizationtoconfirmthedistalendofthe sheath is not against any structure of the heart

•AdvancetheMAAC through the sheath until the array enters the left atrium

•Asthearrayexitsthedistalendofthesheath,advancetheMAAC and retract the sheath into the right atrium to enable full deflection of the MAAC

1

2

Deployment

MAAC

Refer to Appendix on page 36 for Colored Arrow Chart

3130

Generator Software Default Settings4

Target Temperature 60 °CAblationDuration 60 sec (30 sec on thin LA walls)Power Mode 1:1

•Usingthesteeringknoblocatedonthehandle,deflectthetipinthedirection of interest within the atrium for mapping and ablation

•Tightenthetensioncontrolknobtomaintaincurveconfiguration

•DonotattempttosteertheMAAC within the sheath

Navigation and Ablation

1

2

MAAC

Navigation and Ablation (continued)

MAAC is designed for atrial navigation. If ventricular signals are detected by the MAAC:

•Rotateclockwisetowardsthepostero-lateralwallwheninthe left atrium

•Usefluoroscopicvisualizationtoensureanatomicallocation of MAAC in the left atrial body and away from the area of the mitral valve

4

MAAC

•SelectthedesiredpairsforRFdelivery.Ifpowerindicationsare<3W,pullbackslightlyoradjustthecontrolknobonthehandle.(Thisisanindication that the electrode is deeply embedded into the tissue.)

3

Pair 1

3332

•Advancethedistalendofthesheathintotheleftatrium•EnsuretheMAAC is straight•Neutralizethesteeringknobandloosenthetensioncontrolknob

•SlowlyretracttheMAAC into the sheath to capture the array•WithdrawMAAC approximately halfway through the sheath

1

2

Removal

•Insertthecapturedeviceintothehemostasisvalve•PulltheMAAC array into the capture device •Removethecapturedevicefromthehemostasisvalveofthesheath

3

MAAC

Scenario 1: EFFECTIVE Lesion Creation: Good Contact + Good Cooling•Greenbarsindicatetargettemperatureisreached(±5°C)•Powerdeliveryof5-7Wsuggestsgoodcontactandeffectiveelectrodecooling

(Max Power in 4:1 = 8 W)

Scenario 2: EFFECTIVE Lesion Creation: Low Contact/High Cooling•BluebarsindicatetargettemperaturehasNOTbeenreached,buttemperature>50°C

appropriate for lesion creation•Maxpowerdeliveryof8WsuggestshighfloworMarginal Tissue Contact•Gently INCREASING contact pressure may increase temperature to green range

(“Push for Green”)

Scenario 3: INEFFECTIVE Lesion Creation: High Contact/Low Cooling•Greenbarsindicatetargettemperatureisreached(±5 °C)•Powerdeliveryof<3Wsuggestslowfloworlimitedcooling(“Buried Electrode”)•GentlyDECREASING contact pressure may improve cooling by exposing more electrode

surface to blood and result in increased power delivery (“Pull for Power”)

Scenario 4: INEFFECTIVE Lesion Creation: Low/No Contact•Bluebars<45°Csuggesttissuecontactisminimal

•Maxpowerdeliveryof8WsuggestsLimited Tissue Contact

•GentlyINCREASING contact pressure may increase temperature to green range (“Push for Green”)

Managing Temperature and Power

General Properties of an Effective Lesion:•Power>3W•Temperature>50°C

•QuickThermalResponseatOnsetofRFdelivery•StableTemperatureafterInitial“RampUp”•StableArrayPositionduringRFapplication

3534

•Unplugandre-plugthecathetercable•PushSTOPonGENius

•Replacethecathetercable•PushSTOP

•Unplug and re-plug all of the cables from the ECG interface box and from GENius front panel

•PushSTOP on GENius

•Replacethecatheter•PushSTOP

PleaserefertotheGENiusOperator’sManualorcontactyour Medtronic representative.

1

2

3

4

General Steps

Troubleshooting

2

31

4

General Procedural Reminders Situations1 Ensure correct patient return

electrode patch model is used and placed appropriately on the body. Donotreusepatches(singleuseonly).

Inadequateadhesionandimproperplacement may cause potential for superficial lesions due to reduced unipolar current path.

2 Follow proper use of energy mode for each catheter type.

Use of non-default energy modes may increaseriskofcollateraldamageorother adverse events.

PVAC Procedural Reminders Situations3 Always use PVAC with a compatible

guidewire. Use fluoroscopic visualizationtoconfirmguidewireis NOT withdrawn past the distal tip of the PVAC.

Use of a PVAC without the guidewire mayleadtokinkinganddamagetothe guidewire lumen.

4 PVAC is designed to ablate at PV antrum/ostium. Use fluoroscopic visualizationtoconfirmlocationtoprevent ablating in the left atrial septum and posterior wall with PVAC fully extended.

Inaccurate temperature measurement mayleadtoanincreasedriskofcollateral damage or other adverse events.

5 Donotallowelectrodes1and10 to come in contact with each other.

Overlapping electrodes may increase bipolar current density and possibly “overdrive”temperatures;maytrigger“shortcircuit”or“channelfault”message.

6 Rotate the PVAC 45°-90° between RF applications.

Array rotation allows time for electrode and tissue cooling and potentially prevent ineffective lesion formation.

7 Move the array to a different location or position before continuing RF application.

PerformingrapidsequentialRFapplicationmaycauseinadequatecooling and inaccurate temperature measurements.

MASC Procedural Reminder Situation8 Confirm the 3 array arms are

separated on fluoroscopy before delivering RF energy.

Attached arms may increase current densityandpossibly“overdrive”temperatures;maytrigger“shortcircuit”or“channelfault”message.

MAAC Procedural Reminder Situation9 Toavoidentrapment,use

fluoroscopicvisualizationtosteer away from the mitral valve. Applyclockwisetorqueshouldentrapment occur.

MAACinmitralvalvemaycauserisksofentrapment.

Important Procedural Reminders

3736

Appendix

ACT Activated clotting time

AP Anterior posterior

CS Coronary sinus

LA Left atrium

LAA Left atrial appendage

LAO Leftanterioroblique

LIPV Left inferior pulmonary vein

LPV Left pulmonary vein

LSPV Left superior pulmonary vein

PV Pulmonary vein

PVI Pulmonary vein isolation

RA Right atrium

RAO Rightanterioroblique

RF Radiofrequency

RIPV Right inferior pulmonary vein

RSPV Right superior pulmonary vein

1 CalkinsH,BrugadaJ,PackerDL,etal.HRS/EHRA/ECASexpertConsensusStatementoncatheter and surgical ablation of atrial fibrillation. Heart Rhythm.June2007;4(6):816-861.

2 FredersdorfS,WeberS,JilekC,etal.Safeandrapidisolationofpulmonaryveinsusinganovel circular ablation catheter and duty-cycled RF generator. J Cardiovasc Electrophysiol. October2009;20(10):1097-1101.

3 WieczorekM,HoeltgenR,AkinE,SaliliAR,OralH,MoradyF.Resultsofshort-termandlong-term pulmonary vein isolation for paroxysmal atrial fibrillation using duty-cycled bipolar andunipolarradiofrequencyenergy.J Cardiovasc Electrophysiol.April2010;21(4):399-405.

4 ScharfC,BoersmaL,DaviesW,etal.Ablationofpersistentatrialfibrillationusingmultielectrodecathetersandduty-cycledradiofrequencyenergy.J Am Coll Cardiol. October6,2009;54(15):1450-1456.

5 TseHF,LeeKL,LauCP.Adenosinetriphosphateenhancedcontrastpulmonaryvenogramtofacilitate pulmonary vein ablation. J Cardiovasc Electrophysiol.March2002;13(3):300.

6 EctorJ,DeBuckS,NuyensD,etal.Adenosine-inducedventricularasystoleorrapidventricular pacing to enhance three-dimensional rotational imaging during cardiac ablation procedures. Europace.June2009;11(6):751-762.

7 TangM,KriatselisC,YeG,etal.Reconstructingandregisteringthree-dimensionalrotational angiogram of left atrium during ablation of atrial fibrillation. PACE. November 2009;32(11):1407-1416.

8 Gerds-LiJH,TangM,KriatselisC,etal.Rapidventricularpacingtooptimizerotationalangiography in atrial fibrillation ablation. J Interv Card Electrophysiol.November2009;26(2):101-107.

9 BoersmaLV,WijffelsMC,OralH,WeverEF,MoradyF.Pulmonaryveinisolationbyduty-cycledbipolarandunipolarradiofrequencyenergywithamultielectrodeablationcatheter.Heart Rhythm.December2008;5(12):1635-1642.

10 Asirvatham SJ. Pulmonary vein-related maneuvers: part I. Heart Rhythm.April2007;4(4):538-544.

11ShahD.Electrophysiologicalevaluationofpulmonaryveinisolation.Europace. November 2009;11(11):1423-1433.

12ShahD,BurriH,SunthornH,Gentil-BaronP.Identifyingfar-fieldsuperiorvenacavapotentialswithin the right superior pulmonary vein. Heart Rhythm.August2006;3(8):898-902.

13GerstenfeldEP,DixitS,CallansD,etal.Utilityofexitblockforidentifyingelectricalisolationof the pulmonary veins. J Cardiovasc Electrophysiol.October2002;13(10):971-979.

References

Common Abbreviations

Colored Arrow ChartThe directions and manipulations of catheter motions are indicated by the different colors of arrows

Arrow Colors DefinitionsSlidingorTension-knobturning

•Indicatesslidingmotionofcapturedeviceorslidingknobtocapturethespiralarray

Or•Indicatesturningoftensionknobtolockorunlockcurveconfiguration

Steering •Indicatessteeringofsteeringknobtonavigate the electrode array in the left atrium

Rotating •Indicatesrotatingcatheterhandletorotatethe electrode array

Pushing or Pulling •Indicatespushingorpullingofcatheterhandletoadvanceorpullbacktheshaft

Reminder •Safepracticerecommendations