Exercise 5 EnSite NavX OneMap. Objectives

Transcription

1 Exercise 5 EnSite NavX OneMap Objectives Following completion of this exercise the user will have acquired knowledge of the following: Contact Mapping Reference/Roving Source Detection Algorithms Sensitivity Low-V ID Map Displays Standard LAT Reentrant Map Propagation Map Interior Projection Exterior Projection Interpolation 3D Points, 3D Labels, Surface Points Auto Color HR/CL Indicator OneMap The text contained in these boxes is from the EnSite Velocity Instructions for Use. Please reference this document for more information.

2 1. Login to the system: a. Username: training b. Password: esi Select Past Studies. EnSite Velocity NavX OneMap Exercise 3. Select NavX Case 01 from 05/04/2009 and open the study. 4. In the catheter setup subtask change the color of the CS catheter to aqua. 5. In the model surface list, select [Edit Model] and delete all surfaces in the list. 6. Hide the DIF model using the Map Settings drop-down menu. 7. Switch to dual view and set the translucency to 50 for both viewports. Set one to RAO and the other to LAO. 8. Turn the page and read the Chapter from the EnSite Velocity IFU on Contact Mapping. (If you completed Exercise #4 Mapping move to step 9)

3 Types of Contact Maps Figure 1. The contact mapping screen. The mapping tool organizes data collected during conventional electrophysiology procedures and displays the data in three-dimensional maps. During mapping, the clinician samples various heart locations (points) in a stable rhythm using EnGuide-located conventional catheters. The 3D location of each sampled location (point) is saved along with voltage and activation data, which can be displayed on the nearest surface as color. A single set of collected data can be used to display several types of maps. Cardiac Triggered Maps Cardiac triggered maps use a surface electrocardiogram or an intra-cardiac electrogram as the reference to which collected points are measured. There are four types of cardiac triggered maps: Local Activation Time (LAT) isochronal maps display color-coded activation times for each collected location (or nearest surface). The local activation time is the difference in milliseconds between detected activation on the roving waveform and the reference waveform. Colors range from white (early) to purple (late). Peak-to-Peak (P-P) voltage maps display color-coded voltage values for each collected location (or nearest surface). The P-P voltage is the difference in millivolts between the peak positive and peak negative components of the detected activation complex on the roving waveform. Colors range from grey (low voltage) to purple (high voltage). Peak Negative (P-Neg) voltage maps display color-coded voltage values for each collected location (or nearest surface). The P-Neg voltage is the difference in millivolts between baseline and the peak negative component of the detected activation complex on the roving waveform. Colors range from grey (low voltage) to purple (high voltage). CFE Mean maps provide a fractionation index based on the cycle length between multiple, discrete, local activations in an electrogram. Collected points with a lower value are mapped toward the white end of the color spectrum. Note: At least one LAT point must be mapped and saved in order for Peak-to-Peak and Peak-Negative, and CFE Mean options to become available. Prior to this action, these options are greyed out. Non-Cardiac Triggered Maps Non-cardiac triggered maps collect points at one second intervals. CFE Mean maps provide a fractionation index based on the cycle length between multiple, discrete, local activations in an electrogram. Collected points with a lower value are mapped toward the white end of the color spectrum. CFE Standard Deviation maps provide a fractionation index based on the cycle length between multiple, discrete, local activations in an electrogram. The CFE standard deviation calculates the standard deviation between activations. Collected points with a lower value are mapped toward the white end of the color spectrum.

4 Signals Collection Reference Signal Source Cardiac triggered maps require a reference signal. The reference signal is provided by a surface electrocardiogram or an intra-cardiac electrogram. The electrodes that provide the reference signal must remain in a stable position throughout the mapping procedure. The reference signal is set once before beginning a mapping procedure, and is used for timing of the roving signals. Non-cardiac triggered maps do not use any part of the cardiac signal as a reference. Instead, the waveform window refreshes once each second. Roving Signal Source Both cardiac triggered and non-cardiac triggered maps require a roving signal. The roving signal is used for sampling local activation times and voltages from various locations in the heart. The roving signal source can be any intracardiac electrode; it can be changed during a procedure, and data can be sampled from one or from multiple electrodes. Detection Algorithm Both reference signals and roving signals require a detection algorithm. Detection algorithms locate the best point on the waveform signal to use to identify activation. The detection algorithm selected for a given map should be the one that provides the most consistent and accurate detection. -dvdt Sharpest negative slope +dv/dt Sharpest positive slope abs dvdt Sharpest slope, regardless of positive or negative Max Peak positive Min Peak negative abs Peak Largest peak (difference from baseline) regardless of positive or negative QS First deflection from baseline Figure 2. Collection tab. Note: Cardiac triggered CFE maps use the same detection algorithm as LAT, P-P, and P-Neg. Non-cardiac CFE maps use the one second window refresh signal as a trigger. The detection algorithm is not selectable. Note: Detection on the roving waveform will take place within the Roving Activation Interval ( Roving Activation Interval (RAI) on page 163). P-P Sensitivity (Applies to the map that has focus when in Split Screen mode.) The minimum peak-to-peak voltage required for the detection algorithm to operate. Incoming signal complexes must be larger in amplitude than the P-P Sensitivity in order to be considered activations by the system. While changing the P-P Sensitivity, red amplitude lines will appear on the related signal in the acquisition panel to indicate the current setting. Additional Signals Additional ECG or intracardiac signals may be selected to facilitate confirmation of rhythm stability. These signals are only for reference and are not involved in detection. Figure 3. Signals control panel.

5 Considerations Non-Cardiac Triggered CFE Maps Multiple detections are possible in a single sample. Tick marks in CFE maps are not individually adjustable. In CFE maps, some detection settings can be adjusted retrospectively and affect all points in the current map, including P-P Sensitivity, Width, Refractory, the RAI, and Segment Length. P-P Sensitivity is set independently for CFE maps and other map types. The Width slider controls the minimum complex width to consider for activation. The Refractory slider controls the minimum amount of time between detections. The Segment Length slider controls the number of seconds per sample. Reentrant Maps LAT maps present the mapping of reentrant arrhythmias and are displayed in a manner similar to activation maps. The color displayed within the map is linked to the cardiac cycle length (CL). The CL of a Reentrant LAT map is determined by the spacing between the curtains. Adjustment of the CL can be made by clicking and dragging the edge of the curtains to the desired location. The CL will not take effect until the Reentrant checkbox is turned on. Note: Adjusting the CL and then collecting points may invalidate the map. Propagation Maps These maps display areas of activation times that fall within a specific time interval. The interval, represented by a white band on a purple background, can be moved forward through one heart cycle either automatically or by user control. A button beneath the Propagation checkbox controls automatic motion of the activation interval with [Play] and [Freeze] options. These options are available in Review mode only. [Play] loops over the user-selected cycle length. Propagation maps may be played in Realtime or RealReview but recordings can only be exported in Offline Review. When Propagation is enabled, the colors of the map change to purple and white only. The leading edge of the white stripe is brighter than the trailing edge of the stripe to indicate the direction of travel activation. Using the side color bar, the stripe can be widened (increasing the interval in milliseconds [ms]), by clicking and dragging above the white stripe. This action can also be accomplished by clicking to the right of the stripe in the color bar at the top of the window.

6 Cardiac Triggered Mapping Settings Mapping Control Panel Cardiac Triggered Reference This checkbox determines which map types are available for use. Current Map These checkboxes control the type of data displayed on the map that has focus. When the checkbox is changed, the scale, values, and colors on the color bar will change in the map display. The numeric display type for the waveforms under the Points tab will also change to the current map type. The following display types are available: LAT Local Activation Time isochrone Peak-to-Peak Peak-to-Peak voltage Peak-Negative Peak-negative voltage CFE Mean Complex Fractionated Electrogram Mean activation between complexes CFE Std. Dev. Complex Fractionated Electrogram Standard Deviation between complexes. (Available only if Cardiac Triggered Reference is unchecked). Low-V ID (Applies to the map that has focus when in Split Screen mode.) Identifies low-voltage zones in LAT or CFE maps (see Figure 4). If a collected point s P-P value is lower than the specified Low-V ID value, then that point will display a grey area instead of the color-coded scale for the current map type. Grey points do not interpolate with color points. The Low-V ID control and the Color Low value of a P-P map are linked, and adjusting one will adjust the other to the same value. Figure 4. An LAT isochrone with Low-V ID Figure 5. Cardiac Triggered Mapping control panel Map Display (LAT maps only) The type of LAT map: Standard LAT, Reentrant Map, or Propagation Map. Map Appearance Includes slider controls that modify various features of the map. Interior Projection (Applies to both maps when Split Screen mode is active.) This slider controls the maximum distance that an interior 3D Point (represented as a triangle) can project to a location on the surface (represented by a square). For multiple-surface models, points will project to the nearest surface. Exterior Projection (Applies to both maps when Split Screen mode is active.) This slider controls the maximum distance that an exterior 3D Point (represented as a triangle) can project to a location on the surface (represented by a square). For multiple-surface models, points will project to the nearest surface. Interpolation (Applies to the map that has focus when in Split Screen mode.) This slider controls the minimum distance between surface points necessary for the system to interpolate color. For multiple surface models, points will interpolate between surfaces in the same group.

7 3D Points (Applies to the map that has focus when in Split Screen mode.) Enables/disables the display of collected points as triangular markers. The triangular markers are placed on the positive electrode of the roving signal channel (Figure 6). 3D Labels (Applies to the map that has focus when in Split Screen mode.) Allows data to be numerically displayed adjacent to the triangular 3D points. 3D Points must be enabled in order to show 3D labels (Figure 6). Surface Points (Applies to the map that has focus when in Split Screen mode.) Enables/disables the display of small square points on the surface. These squares represent the point on the surface closest to a collected 3D point (Figure 6). Auto Color (Applies to the map that has focus when in Split Screen mode.) Controls whether the system automatically controls the pointers on the color bar during mapping. If Auto Color is enabled, the pointers will adjust to the minimum and maximum data values for all points in the current map. Auto Color applies separately for each display type. Auto Color will be disabled if any color is manually adjusted. Show HR/CL (Applies to the map that has focus when in Split Screen mode.) Enables/disables the display of the heart rate (in beats per minute [bpm]) reference cycle length (in mm), and the measurement of the current roving point in the lower right corner of the map display. The reference rate and cycle length are computed from detections on the reference catheter. Figure 6. A collected point displayed as A: surface point; B: 3D point; C: 3D label.

8 Non-Cardiac Triggered Mapping Settings Notice that in the Mapping Settings control panel (see Figure 7) the available settings have changed slightly from those shown in Figure 141 on page 160 of the EnSite Velocity IFU. The Map Display controls have been replaced with the following slider controls: The Width slider (CFE maps only) determines the minimum complex width to consider for activation. Applies to the map that has focus when in Split Screen mode. The Refractory slider (CFE maps only) determines the minimum amount of time between detections. Applies to the map that has focus when in Split Screen mode. The Segment Length slider (CFE maps only) determines the duration of the selected segment length. Applies to the map that has focus when in Split Screen mode. Figure 7. Non Cardiac Triggered Mapping control panel.

9 Collecting Points Figure 8.The waveform display for contact maps. A. Time scale The time scale (in milliseconds) appears at the top edge of the waveform display. The detected timing reference appears at 0 msec. Right-click on the Time Scale to display a menu to set the sweep speed, font size, and waveform thickness. B. Color bar (LAT maps only) When collecting or displaying LAT isochronal data, the color bar appears above the waveform display. The function of the color bar duplicates the color bar in the map display. Dragging the pointers on the color bar will adjust the range. C. Roving Activation Interval (RAI) The Roving Activation Interval is a timing parameter that is used in the detection of roving catheter activation. The RAI is defined by the black area between the curtains. The curtains appear as shaded areas on either side of the RAI. Roving catheter activation will not be reliably detected unless the beat falls within the black-background portion of the waveform display. To adjust the RAI, click and drag the edge of the shaded background. The current RAI value appears in the lower right of the waveform display. For non-cardiac CFE maps, the RAI is equivalent to the segment length, and appears as a left curtain only. For cardiac triggered CFE maps, the RAI is set independently for CFE maps and other contact map types. D. RAI Curtain Click and drag the curtain to adjust the RAI. E. Reference Activation Caliper (Green) Reference catheter activation as defined by the selected reference detection algorithm. The reference caliper will always appear at 0 msec on the time scale. Note: If the current rhythm does not meet the reference detection settings, this caliper will be magenta. Points may still be collected and adjusted. F. Roving Activation Caliper (Yellow) Roving catheter activation as defined by the selected roving detection algorithm, within the Roving Activation Interval. When adjusting this caliper, the associated location in the map display will move to reflect the roving position at the time of the caliper measurement. Note: If the current rhythm does not meet the roving detection settings, this caliper will be magenta. Points may still be collected and adjusted. If a time is adjusted and there are error conditions in the signal and the reference caliper is not purple, the caliper will turn yellow. Note: For CFE maps, multiple tick marks may appear on the roving waveform. Activation tick marks for CFE maps are not adjustable. G. Voltage High Caliper Roving catheter high voltage. This voltage caliper is set to the highest voltage within 100 msec of detected roving activation, within the RAI. This caliper is used in determining peak-to-peak (P-P) voltage.

10 H. Voltage Low Caliper Roving catheter low voltage. This voltage caliper is set to the lowest voltage within 100 msec of detected roving activation, within the RAI. This caliper is used in determining peak-to-peak (P-P) voltage and peak-negative voltage. I. Time Interval The RAI time interval. J. [Freeze]/[Save] When data is being collected (gated to detection of the timing reference), the [Freeze] button may be used to stop the display and review data. After pressing [Freeze], the label on the button will change to [Save]. Pressing [Save] will save the current point to the map and the point display. The following data is saved with each collected beat: electrode position, current waveforms (reference, roving, signal1, signal2, signal3), buffered waveforms and related roving electrode locations, timing, and voltage. Performance may begin to slow after 1000 points. When mapping is used in Review mode, [Freeze] will also freeze the waveform display and [Save] will cause the waveform display to play. Hot key: <F11> duplicates the function of the [Freeze] and [Save] buttons. K. [Cancel]/[Resume]. When the waveform display is frozen, [Cancel] will remove the currently displayed beat and resume gated data collection without adding information to the map. [Resume] will resume gated data collection. Hot key: <F12> duplicates the function of the [Cancel] button. L. Collected point buffer. As data is collected, each detected beat is temporarily saved in a buffer. When the waveform display is frozen, buffered data can be accessed using the buffer controls below the waveform display (Figure 145 on page 163 of the EnSite Velocity IFU). The beat that was present at the time that [Freeze] was selected is represented by [0]. Previous beats may be accessed by selecting the buttons for [1], [-2], etc. The arrow keys at the sides of the buffer controls may also be used to access previous beats. When reviewing beats in the buffer, the associated location in the map display will change to reflect the roving location at each selected beat. Hot key: The left and right arrow buttons in the beat buffer are duplicated by the left and right arrow keys on the keyboard. M. Points list This is a list of the points that have been collected for the map. Waveform Shadows Shadows behind the waveform indicate morphology of previous beats. Grey Grey shadows appear for reference signals occurring after the first point is saved in a map. The morphology of these shadows begins with the first point on the map. The shadow s amplitude matches the current amplitude for the related waveform. Shadows are used to confirm rhythm stability. Note: Changing the reference signal of the waveform will remove the shadow. Dark red A dark red shadow appears behind the current waveform for the roving catheter. This waveform indicates the morphology of the previous beat for this catheter. This shadow is used to confirm beat-to-beat stability. Note: If data does not exist for the previous beat (earliest beat in the buffer, etc.), then the dark red shadow will not appear. Amplitude The amplitude for ganged waveforms may be adjusted by middle-clicking the waveform and dragging up or down. To adjust the amplitude of an individual waveform, Shift + middle-click on the waveform. Sweep Speed To adjust the sweep speed for waveforms, right-click in the waveform area and then select the sweep speed from the pop-up menu.

11 Points Display Click on the Points tab to display the collected points. The display is a combined waveform segment, synchronized in time, of every roving catheter waveform incorporated into the map. Each waveform includes a tick mark indicating the activation point and a numeric metric that is determined by the current map type. Selecting a waveform in the Points display shows the original data for that heartbeat in the waveform display including all saved waveforms, timing calipers, voltage calipers, and all buffered data. The beat of interest and voltage caliper settings may be adjusted. All changes are saved automatically. The point in the map display that is related to the highlighted waveform will flash red. A. Sort The waveforms can be sorted by order of collection, current map type, and cycle length. B. Time scale The time scale, in milliseconds (msec), appears at the top edge of the waveform display. The timing reference of all waveforms is synchronized to 0 msec. The Sweep Speed may be adjusted by right-clicking in the black background and selecting Sweep Speed. The available options are 40, 50, 100, 200, and 400 mm/sec. C. Waveform number The waveform number indicates the order of collection. When multiple points are acquired simultaneously, all of the related points will have the same waveform number. D. Electrode Polarity Shows the polarity of the electrodes on the catheter. E. Hide point checkbox When checked, this checkbox indicates that this point on the map may show. Clear the check mark to hide this point. F. Dashed line A dashed waveform line indicates that a point is not used to color the map. The following types of points are drawn as dashed: hidden points, duplicate points, points outside the projection distances, and points with no locations. G. Solid line A solid line indicates a point that is used in the map. H. Blue background A blue background indicates the selected waveform. The data for the waveform is shown in the waveform display. If the corresponding point is used in the map, the 3D point, its projection on the map surface, and its text, flash red. I. Timing caliper Indicates the roving activation time. J. Map point measurement Displays the Timing (in ms) or Voltage (in mv) of the map point. K. Number of points This is the number of points that have been collected. The list may have to be scrolled to see all of the waveforms. L. Delete To delete a waveform from the Points display and its corresponding point from the map, select the waveform and click [Delete]. Figure 9. The Points display. M. Delete last Removes the point(s) last saved. Amplitude Waveform amplitude may be adjusted by middle-clicking the waveform and dragging up or down. For the Points display, amplitudes are ganged for all waveforms. Panning The Points display will default to centering on the timing reference. The display can be panned by <Shift> + middle-clicking in the background and dragging left or right. Waveform indicators The type of line used in the waveform indicates the effect of the waveform on the map. Solid, bold with blue background The waveform is selected. The original data for this waveform is currently displayed in the waveform display. If displayed in the map display, the 3D point, 3D text, and surface point for this waveform flash red. Solid The waveform is used in the 3D points and surface isochrone. Dashed The point is a duplicate or is degraded.

12 Delete Hidden Points To delete points that were hidden using the Show checkbox, right-click in the waveform display or Points display and select Delete Hidden Points. Delete Unused Points To delete all points that are not displayed due to the current projection settings, right-click in the waveform display or Points display and select Delete Unused Points. Scroll bar Use this control to scroll through all activation points. Hot key: When the Points display is open, the up and down arrow keys select the previous or next point, respectively. When the Points display is open, [Delete] will remove the current beat in the waveform display. Interpreting Color Color interpretation of contact maps is similar to color interpretation of isopotential maps (refer to Interpreting Isopotential Maps on page 144 of the EnSite Velocity System IFU).

13 OneMap OneMap is used to simultaneously create a model and a map. By default, OneMap is disabled. To use OneMap, select the [OneMap] button at the top of the Mapping control panel. If no model surfaces have been created (most likely scenario), a default surface will be created. If model surfaces have already been created, the currently selected surface is chosen by default. To create a new map, click on the drop-down menu in the top right of the control panel. Click on [New Map]. Enter a name for the new map and click [OK]. Refer to Creating a Map on page 169. There are three tabs located above the catheter selections (Settings, Points, and Model). The Model tab is only available when [One Map] is selected. Except for Show/Hide Field Scaling, the Model tab displays the entire menu that is available under the Model task. This permits the user to easily edit the model without the need to return to the Model task. There is no need to click on the [Finish Model] button. When exiting OneMap, the model finishes automatically. Note: When [OneMap] is enabled, model surfaces may appear to be modified because intersecting surfaces are no longer being calculated. Figure 10. OneMap - Model control panel.

14 Setting up a New Map 1. Select the Mapping task from the tool bar. The Mapping screen will appear. 2. Select New Map from the drop-down menu, in the upper right of the Mapping control panel. 3. Name the map, and click [OK]. 4. Select the reference timing signal. In the Collection control panel (lower left corner) Reference section: a. Select a timing reference source from the drop-down menu. b. Select a detection algorithm from the Detection drop-down men. c. Adjust the Sensitivity to a level just outside of baseline noise. After the timing reference and detection algorithms have been selected, waveforms will begin to refresh in the waveform display, gated to detected activation on the timing reference. 5. Adjust the Roving Activation Interval by clicking and dragging the edge of the shaded boundary. Generally, the Roving Activation Interval should be set to encompass one activation sequence on the roving catheter. 6. Select an initial roving catheter signal. The roving catheter can be any intracardiac electrogram. In the Collection control panel Roving section: a. Select a roving source from the drop-down menu. The roving signal can be changed during mapping, allowing any intracardiac electrode to be used as part of the mapping process. b. Select a detection algorithm from the Detection drop-down men. c. Adjust the Sensitivity to a level just outside of baseline noise. Sensitivity is set independently for CFE and other map types. 7. (OneMap only) Select the source for collecting model points from the From drop-down menu: select Active EnGuide to use the Active EnGuide to collect points, or Active Electrode to use the active electrode to collect points. Collecting Points 1. With the patient in the clinical rhythm, place the roving catheter to collect data. When a beat of interest appears in the RAI, select [Freeze]. Note: (OneMap only) Selecting [Freeze] will automatically enable [Collect Points] when model type is set to OneModel. 2. In the frozen mapping window, review the morphology of the beat and placement of the caliper lines. If necessary, select an optimal beat from the collected point buffer and/or adjust calipers. 3. Select [Save] to save the point; otherwise, select [Cancel]. The waveform display will return to acquisition mode.

15 To Map from a Segment Figure 10. Map from Segment (example). 1. Click the Split Screen Mode button in the upper right corner of the Mapping screen. 2. Select the appropriate segment from the drop-down list at the bottom of the right display. 3. If necessary, use the Waveform control panel in the right display to set the roving catheter and electrode. 4. Reference J through M under Collecting Points on page 163. (Refer to Figure 145 on page 163 of the EnSite Velocity IFU). Note: Points can be added to either the left or right display and will be applied to both displays.

16 Managing Maps New Map New Map may be selected from the drop-down menu in the upper right corner of the Mapping control panel. Select New Map; the Map Name window comes up with a prompt to name the map. Type a name in the Name field and click [OK]. Copy Open Map - Copy Open Map may be selected from the drop-down menu in the upper right corner of the Mapping control panel. Select Copy Open Map; the Map Name window comes up with a prompt to name the map. Type a name in the Name field and click [OK]. Note: Renaming and deleting maps is not available in Mapping. To rename or delete a map, go to the Notebook in RealReview. Mapping Controls The following Mapping controls can be accessed by clicking on the eye ball icon in the upper right of the map workspace. Label Text On. Turns Label text on and off. Label Show Through. Projects the labels through surfaces that may be obscuring them. Show EnSite Model. Turns the entire model on and off during mapping. Map Transparency On. Turn the map Transparency on and off. Note: Do not turn on Transparency unless a map is currently displayed. Fixed Proximity Indicator. Turning this checkbox on sets the diameter of the Proximity Indicator to a maximum of 10mm, regardless of the current lesion size. Edge Enhancement. When turned on, provides a rendering of the model where the body is translucent but the edge remains distinctly defined.. Figure 11. Map Displays

17 9. Using the Model Task, in the waveform display, right click and adjust the sweep speed to 200 mm/sec. 10. Read the section below on how to create calipers. How to Create a Caliper In RealReview or Offline Review, while playing a segment of interest, select the [ll] pause button beneath the waveforms. Then select the [ ] caliper button and select the beat of interest in the waveform display. Using Calipers Calipers are used to measure timing between signal features in the waveform display during review mode. The caliper is a set of two vertical lines with a horizontal line between them. The time between the vertical lines is displayed above the horizontal line in milliseconds. The frequency is displayed beneath the waveform if it is greater than 1hz. Ten calipers are available. To move vertical caliper lines, click on the lines to move that side of the caliper. To move the entire caliper without changing the distance between the vertical lines, middle-click the caliper and drag left or right. To move a horizontal caliper line, left-click and drag the horizontal line up or down. To add a caliper, click the [Caliper] button, next to the [Show/Hide Wave Controls] button. To remove a caliper, left-click and drag the horizontal line past the top or the bottom of the waveform display. Calipers move with the waveform display. When a vertical line or caliper moves outside of the display area, a small arrow appears at the edge of the screen. This arrow may be middle-clicked to select the vertical caliper line then dragged to bring the caliper back into the waveform display. The relative caliper position also appears in the segment overview. 11. Pause the segment playback. Use the calipers by selecting the [ ] button in the lower left corner to measure the cycle length of the tachycardia on one of the CS catheter electrograms (Figure 12). a. Record the tachycardia cycle length (TCL) here ms 12. Move to the Mapping task to setup a Local Activation Time (LAT) map. 13. Set the sweep speed of the waveform display to 200 or 400 mm/s 14. Adjust the curtains of the Roving Activation Interval (RAI) to be no longer than the tachycardia cycle length (<100%). The measurement of each curtain from the zero reference is displayed in the bottom of the window. Set the total interval to be around 90% of the measured tachycardia cycle length. This ensures only one complex will be in the curtains at a time (see Figure 13 on next page). a. Example: RAI = 0.9 TCL, ms = 270 ms = (RAI) Figure 12. Calipers measuring cycle length of the rhythm. b. Your measured (TCL) = 0.9 = = (RAI) c. Your calculated (RAI) = / 2 = this is the number you will use for setting each side of your RAI (+/-) in front of your reference signal.

18 15. Set your RAI using the numbers from the previous page. Use the right hand number from step c and set your RAI window by clicking on the small triangle at the bottom of the waveform display and dragging the RAI curtain until its value displayed in white text in the middle of the RAI equals the number you wrote down on the previous page (Figure 13). 16. Setup the collection criteria for the Reference (Figure 14): a. Source: The reference source should be an electrode that remains in a stable position throughout the mapping procedure. This is set once at the beginning and cannot be changed. For this case, select CS-5-6. b. Detection: Choose the method that provides the most consistent and accurate detection. For this case, select Max. Figure 13. RAI adjusted to 90% of the TCL (arrows). The numbers at the bottom of the RAI indicate how wide (in ms) the RAI window is. c. Sensitivity: Adjust the slider to eliminate any baseline noise. Any signal between the red lines will not be used for time or voltage data. (0.500 for this case) Figure 14. Reference source, detection and sensitivity settings (left) red lines showing sensitivity on reference source electrogram when adjusted (right). Play the segment and ensure that the Reference signal and green caliper tracks consistently at zero. Note: You may use the HR/CL window to visualize the cycle length detected from your reference signal. 17. Setup the collection criteria for the Roving (Figure 15): a. Source: The roving source is the catheter used to move around the chamber to collect points. It can be any catheter, can be changed during the procedure, and can be one or multiple electrodes. For this case select, Spir- D-2. For more experienced users, select Spir-ALL and choose to Show All Roving Waves b. Detection: Choose dv/dt as a roving detection algorithm. Figure 15. Roving source, detection and sensitivity settings. c. Sensitivity: Adjust the roving sensitivity to eliminate any baseline noise. Use filters if needed. (0.200 for this case) 18. Uncheck the waveform shadows to hide the dark red shadow behind the current roving waveform. This is used to confirm beat-to-beat stability and is helpful when mapping PVC s by creating a snapshot of the morphology of the first beat saved for each map. 19. Use the Signals tab to add the following ECG signals to the waveform display; II and V 1. This is helpful to ensure the appropriate signal is saved (i.e. atrial signal and not ventricular). Also add the proximal and distal CS electrograms. To add, highlight signal in Available Signals column and click on the button. Figure 16. Signals Tab.

19 20. Using the Map Control Panel, set the Interior and Exterior Projection and Interpolation to Using the Map Control panel turn uncheck 3D points and check Auto Color. 22. Set Low-V ID to Figure 17. Map Control Panel Settings for Projection, Interpolation, Points/Labels and Appearance. 23. Click on OneMap to enable the model tab on the Map Control Panel. 24. Click the to add a model surface, call in RA. 25. Collect model points 26. Change the type to OneModel 27. Left mouse click on the timing tick mark and drag to the beginning of segment 09: RA Geometry. Note: For users new to mapping, adjust the waveform speed from 1:1 to 1:2 or slower. 28. Click 29. When a beat of interest appears in the RAI, select [Freeze]. 30. Review the morphology of the frozen beat. a. Are the calipers marking the signal appropriately? Examine both timing and voltage (Figure 18). Figure 18. Collected beat showing that timing (red arrow) and voltage (yellow arrows) have been appropriately marked.

20 b. Is it the appropriate signal? [A vs. V] No QRS QRS Figure 19. Collected beats comparing A vs. V signals. No QRS in RAI window (left). QRS shown on top of a fused atrial electrogram (right). The collected beat on the (left) will be saved. The collected beat on the (right) will not be saved to the map. c. If the beat is suboptimal, choose a point from the collected point buffer by clicking on the beat number or using the left and right arrow keys on the keyboard. Once a new beat is selected click [Resume]. 31. When satisfied with the frozen beat, select [Save], otherwise select [Cancel]. Hotkey: F11: Freeze/Save Mapping Point, F12: Discard Mapping Point 32. Continue to freeze and save points as the catheter moves around the chamber to create the timing map. Play through the segment multiple times if needed. Note: If it appears there is no electrogram on your ROV catheter take a look at your map to see where the catheter is in the chamber. (IVC or SVC?) Is it in close proximity to the model surface? (Figure 20). If not, increase the gain on your ROV electrograms. Middle-mouse click on the electrogram and push the mouse up. Figure 20. SPIR catheter in the IVC.

21 33. Advanced users: Set the roving source to Spir-All and check the box for Show All Roving Waves. Now each time you freeze you will have to verify the timing of five contact bipolar elecrograms instead of just one. (Figure 21). 34. After changing the roving source to All, check the box next to Show All Roving Waves to show all of the electrograms used for collection. Figure 21. Roving source electrode selection (above). Drop down menu allows for selection of ALL electrodes on Source for collection. All roving waveforms shown in RAI window (right). 35. When you feel the chamber is adequately sampled, Click Figure 22. OneMap before finishing model. 36. Click and remove any model points if necessary. Then click. 37. Turn on Auto Color in the Mapping Control Panel. This will automatically adjust the color spectrum to the earliest collected point colored white and the latest collected point colored purple. Does the color spectrum fill the RAI? (Figure 23). Figure 23. Auto Color ON, color spectrum distributed across the RAI window. 38. Move to the Points tab in the Mapping Control Panel. Use the Sort drop-down menu to sort by LAT. The earliest point collected will be shown at the top of the list. 39. Prior to making any edits, preserve the original map data set by selecting Copy Open Map from the dropdown menu in the upper right corner of the Mapping Control Panel. Name it Map Copy. Figure 24. Collected points can be sorted by LAT.

22 40. In the Points tab, right-click and Delete Unused Points. Unused points fall outside of the currently selected interior and exterior projection criteria. Figure 25. Points with a dotted line appearance fall outside the set projection values and are not displayed on the map. In this map only 1035 points are being used out of 2815 points total. 41. Click on the earliest point. The point will now be displayed in the waveform display window. If the point was collected using ALL roving electrograms the electrogram for the selected point in the list will have a blue halo on the right and left sides of the electrogram highlighted in the list (Figure 25). Figure 26. Selected point in list (left) and the electrogram shown in the waveform display (right). The selected point has a blue halo on the left and right sides of the electrogram in the waveform display. The highlighted point is not appropriately marked for timing (tick mark is on far left side of RAI). a. Are the calipers marking the signal appropriately? Review timing and voltage. b. Where is the point located? Rotate the model to find the point; it will flash red on the model. c. Adjust the point or delete as needed. d. Review a few more points with early activation times. 42. Rotate the map and locate a point with a late activation time. This will be in a purple color area. Click on the point. The point will be displayed in the waveform display window. Review the point as was done with the early points. Review a few more late points and adjust or delete as needed. Note: If you see an area of white/red in the middle of a large area of blue/purple or vice-versa, check the points in that area for correct activation timing.

23 Figure 27. Inappropriately triggered signals(left) can be identified by being surrounded by late points (if early) or vice-versa, late points surrounded by many early points. New beat selected from the buffer (right) corrects the display of the map data. 43. Scroll through all the collected points in the points and edit or delete as necessary. Click on any points on the model that display color that may not make sense and review those points for timing and voltage. 44. Adjust the interpolation slider to the maximum value of 30. Watch the effect in the color display on the map. Interpolation is the radial distance of color that projects around a map point. This should be used with caution as a full map of color does not equal a full set of map data. 45. Switch the Map Display Type to a Reentrant Map. Note the change in the map display. The reentrant map emphasizes the area where early meets late. Figure 28. Standard LAT (left), Reentrant (right).

24 46. Switch to a Propagation Map and press [Play] to view the animation of the map. Change the playback speed of the propagation map to 100. Figure 29. Propagation map controls. Animations may only be saved in review mode. 47. Bonus: Navigate to the Therapy Task and turn on the lesion markers. Is this where you expected the ablation target would be? Figure 30. Propagation Map Unless otherwise noted, indicates that the name is a trademark of, or licensed to, St. Jude Medical or one of its subsidiaries. ST. JUDE MEDICAL and the nine-squares symbol are trademarks and services marks of St. Jude Medical, Inc. and its related companies St. Jude Medical, Inc. All Rights Reserved.