Activation Mapping: Basic Concepts, Pitfalls, and Windowing

[@solitairewolff]

I cannot even imagine the amount of time and effort that goes into making such an enlightening and educational presentation. It is remarkable how much goes into making such figures and diagrams. Without a doubt, your videos are the best educational material in the field. As an EP fellow all your videos are a very valuable resource, thank you Dr. Cooper!

[@dr.joshuacooper-arrhythmia9917]

@@solitairewolff Thanks so much for your kind words! Yes indeed, my presentations take an enormous amount of time, especially this one! 😂 But it's a labor of love👍

[@dineshvoruganti5570]

Most people I know in EP have listened to your lectures and they highly recommend them. Esp for beginners, including cardiology fellows.

[@asdasdk1]

I am EP fellow. This channel should grow with more videos. is incredible. Thank you

[@doristhecoder765]

I am not a physician or medical student. I am in medical coding and compliance and I could follow much of this. You are an amazing teacher Dr. Cooper. Thank you for your valuable contributions.

[@taxidermy_12]

You have nothing to do with this material.)))

[@marvinlu1283]

I viewed this before EP fellowship and viewing it again 6 months into fellowship. This is a great talk and I think all EP fellowships should include this in their curriculum. Thank you Dr. Cooper!

[@nieuwegeljo5645]

My compliments for the clear way you explained the ins/outs of activation mapping. As a retired EP-technician I wished I had your lecture during my training.

[@ozlemkarakurt-en4hu]

Very gratefull for the simple and delicate explanation of the hard understood and basic topic of the EP.

[@3bayvillagers]

I have been using 3D mapping for more than 20 years, but I learned a lot today. You are a good teacher.

[@dr.joshuacooper-arrhythmia9917]

Thank you so much! High praise, coming from one with your experience!

[@krg9942]

I am just a normal lay person who has afib and my Dr. is 'highly suggesting' an ablation. I sat in on your lecture to learn about the many steps involved in this procedure to educate myself. Sounds like the mapping expert is extremely important. Also, it seems that there is plenty of room for errors. I did enjoy the Harry Potter "window of interest" humor. Thank you to all the people that dedicate their time trying to save other humans.

[@kyawkhant4273]

Thank you so much, Dr. Cooper. Appreciate your intricate and detailed arrhythmia modeling to educate us all.. make things so much easier to understand!!

[@ahmadhalawa7548]

Congrats on a wonderful talk. Very impressive and easy to understand. I am a general fellow and will start EP this year. You changed my understanding of activation mapping. Thank you!

[@erose7139]

Time well spent. Thanks Josh for your passion and care to educate your colleagues.

[@reginakiefer6701]

Thank you for taking the time to do this! It's a complex concept. This video helped break it down for me.

[@dr.gvenkatesh1271]

Thank you sir Dr.Cooper, your passion towards teaching and the effort you have put into this is highly appreciated.

[@richardkalman6682]

Thank you Dr. Cooper for taking the time to put this presentation together.

[@vickramvignesh]

Dear sir This is one of the amazing presentation created with so much passion. We, the budding EP fellows look forward to ur many presentations to come.

[@girijajha]

MY HUMBLE GRATITUDE AND RESPECT

[@craigmoskowitz4616]

Wow! Wish I had these videos at the start of EP Fellowship. Thank you Dr. Cooper!

[@williammak4986]

Dr. Cooper, thank you for the enlightening talk! Cardiology trainee from Hong Kong.

[@Chipchase780]

As a recipient of this treatment, well and arrhythmia free over a year later, Id like to say a huge thank you to all the doctors and technicians who make it possible. I can’t pretend to understand the problems and solutions dealt with here, but I must say my life would have been miserable in the extreme if cardiac ablation was not possible.

[@mansouralmunajem5940]

I owe you a lot of what I understand and imagine now compared to before!

[@willyfrick1664]

Incredible video. I imagine this took a ton of tedious work to make, and the illustrations you’ve included clarify the concepts wonderfully. Thank you for this, Dr. Cooper.

[@dr.joshuacooper-arrhythmia9917]

Thank you so much! Yes indeed this was an extraordinarily tedious presentation to put together, and ended up being the motivation for me to make additional educational videos thereafter. I'm so glad you enjoyed this activation mapping video and my hope is that it still remains somewhat relevant in today's era of more complex 3D mapping software capabilities.

[@mohammadpaymard792]

Thank you so much, Dr Cooper for this fantastic presentation

[@hanyabed9367]

Thank you. Very helpful. I think I’ll ask my carto techs more often about the reference and the WOI set-up.

[@Netsal1000]

Thanks a lot, this really helps me understand the limitations of activation mapping. Can't wait for the next video.

[@dr.ahmadjawadqureshi3343]

Great lecture. I appreciate your hard work ,efforts and others.

[@DrRKumthekar]

"But Hermione, how did you know where to set the left caliper of the window?" Harry asked. "I read all about it in Zipes" said Hermione.

[@maqsoodalam9129]

Thank you Dr Cooper for this excellent presentation..helped me a lot....looking forward for more presentations ..especially in context of VT ablations

[@weijiawang1571]

Thank you very much Dr. Cooper! This video is awesome and you are a superb teacher.

[@dr.joshuacooper-arrhythmia9917]

Thanks so much!!!

[@sergiocaccavale889]

terrific lecture. I watched all your videos. I'm waiting for the new onces. Thanks a lot.

[@AcostaBrunoNicolas]

Thank you! excelent video, very clear presentation!

[@kamilgulsen7262]

Thanks for sharing this highly dedicated and educational presentation

[@ahmadaljefri2753]

Thank you very much - such a great presentation please keep posting similar EP educational material

[@ThePsoasmajor]

Thank you so much, I love your passion for teaching, saw your at EP 101 in Boston years ago.

[@dr.joshuacooper-arrhythmia9917]

Thanks so much! I love the EP 101 course and am so glad you were able to attend!

[@sharathkumar8518]

Your Fellows are lucky Dr Cooper, I wish I was one ! Thank You.

[@sharathkumar8518]

Two points I would like to ask you: 1) For a stable reference can we consider alternatives to Cs like NCC or azygous or even a SVC catheter 2) Ripple maps can avoid the need to annotate EGM activation time and do not require a WOI. There is no data interpolation in the generation of the map in RM, do you consider RM as an effective strategy in the situation you discuss in the talk.

[@dr.joshuacooper-arrhythmia9917]

@@sharathkumar8518 As long as the reference catheter is recording signals in the same chamber you are mapping (i.e. atrial reference for an atrial arrhythmia) and the catheter remains physically stable throughout mapping, you could use any catheter. CS catheter just happens to be out of the way and stable, which is why it's usually used for atrial mapping. And yes, technologies that show wavefronts in motion in a looping format (Ripple, Sparkle, Rhythmia) add additional visual information that can be helpful beyond the static image. I decided not to add that additional topic to this presentation due to its 2h length already!

[@MonishaK-jc9mq]

Thank You Dr. Cooper for explaining activation mapping. It was really helpful. If possible my request is, if you could make a video on activation mapping using Systems like CARTO(OCTARAY) which I found particularly challenging to understand to someone who's new to this field.

[@dr.joshuacooper-arrhythmia9917]

All of the principals in this video are exactly the same with any multi-spline catheter. Each bipole, whether it is the only one being taken at that time, or if it is one of 50 bipoles being recorded simultaneously, is gathering location, amplitude, and relative timing data compared to a reference. More modern mapping software can use the summation of multiple bipoles, for example from the coronary sinus catheter, rather than a single bipole, for a more stable reference. But all of the principles are exactly the same, including window of interest, activation sequence, and pitfalls related to outlier points, slow conduction, and a suboptimal window of interest.

[@dineshraja2462]

I don't know how much time u have spent on making this presentation. Truly marvelous presentation.Not only activation mapping, u can make a video on how to make such slides in ppt😅

[@thabongaka2423]

You are very good at explaining. Your presentation flows. I really loved it.

[@dr.joshuacooper-arrhythmia9917]

Thanks so much!! Glad you found it helpful!

[@vaibhavvaidya2474]

Amazing talk thanks for taking the time to put this together

[@ashleymcgill4336]

As good as it gets for understanding activation mapping and window setup. Wish I would have had this to watch prior to going into my mapping training. Would be worth paying for.

[@dr.joshuacooper-arrhythmia9917]

Thanks Ashley! It's great to hear that you found my presentation useful. And it's free !! :)

[@drluckyv]

Dr Cooper this is a great lecture, thank you for sharing.

[@drluckyv]

Please include this in EP101 with your unipolar lecture. I wish I knew this last year......

[@dr.joshuacooper-arrhythmia9917]

@@drluckyv I'm certainly going to try to find a way to sneak this topic into either the EP101 or EP301 curriculum :)

[@dan1600m]

Thank you for the wonderful presentation Dr. Cooper -- truly incredible! Spending this amount of time outside of your practice for education is SO admirable. This limitation of sequential mapping was part of my catalyst to venture into non-contact mapping for global activation. Is that a fair thought, in your opinion?

[@ivancakulev2047]

This goes beyond anything one can give to educate young EPs. You deserve a prize and to be remembered for ever. I just have one comment, not an objection. In your initial tachycardia where 3D mapping did not work, you resorted to Entrainment map (7:55). You also mention entrainment from multiple areas in the right atria. Entrainment is reserved for reentry tachycardias and PPI is really not part of it. The original 4 criteria do not include PPI. For all purposes the right atrial activation behaves as focal. You can use the PPI interval (Klein has shown good approximation) instead of entrainment (as this is not a reentry tachycardia) to detect how close you are to the site of origin. In my experience this does not work all the time (scarring, different activation to and from, resetting the focus etc) the way it was originally described but I guess it can be used in challanging cases. Thanks really for your video!

[@dr.joshuacooper-arrhythmia9917]

Thank you so much for your comments and question! The initial challenging tachycardia in this case actually was most likely a reentry (small) circuit within a scarred area at the thick upper interatrial septum. The tachycardia slowed before terminating during RF ablation, reinforcing that likelihood. Had this truly been a focal (automatic/triggered) tachycardia, overdrive pacing (not true entrainment, as you point out) can also be helpful, as long as the focus isn't overly suppressed by fast/long pacing drives. As such, if the post-pacing interval after overdrive pacing is very similar to the tachycardia cycle length, that suggests that the pacing site is relatively close to the site of origin (especially if pacing at other sites shows a longer PPI). A long PPI doesn't necessarily mean one is far from the focal site of origin, given the possibility of suppression and a slight delay in tachycardia resumption.

[@ankaraeps7956]

Thank you very much for this great work, very good job. Congrats!!!

[@rushilshah7149]

Hi Dr. Joshua Cooper, I would love to meet you at one of these HRS meetings. Were you in Boston this year? I am a postdoc in Cardiac EP & CMR Imaging at Stanford University. I hope to match into a cardiology fellowship later this year.

[@dr.joshuacooper-arrhythmia9917]

Yes, i was in Boston. Congrats on a great career choice! 😉

[@selcukadabag8004]

Very well made. Congratulations and Thank you.

[@javiermogro8425]

Great !!! presentation. You are a very good teacher. Thank you very much.

[@truongquoccuong1808]

Thanks for your kind to give us the exciting lecture, thanks again.

[@ernestofonseca5092]

Excelente Dr, Mis Respetos.

[@charlesmathews36]

Wonderful presentation! Have you assessed Ripple mapping as a way of overcoming these obstacles?

[@dr.joshuacooper-arrhythmia9917]

Indeed, that is the next step - leveraging software programs that are able to show the 4th dimension (time) such as Ripple and Sparkle and Rhythmia, in a continuous loop. Presenting the data with wavefront motion included will often help further clarify what is going on. I didn't get into those technologies, given the 2 hour length of the talk already!

[@charlesmathews36]

@@dr.joshuacooper-arrhythmia9917 Great! I look forward to Part 2!

[@tbaykaner]

this is great josh, well done!

[@youhonghu173]

THANK YOU FOR EXPLANATION

[@lukyluchano2630]

Thank you very much for the video!!!

[@bantha_poodoo]

Thanks soooo much for the easy, clear explanation!

[@dr.joshuacooper-arrhythmia9917]

Thank you so very much for your kind feedback!!

[@shenle75]

excellent presentation

[@youhonghu173]

what a wonderful video

[@fernandomalpicacervantes829]

thanks for this excellent material, congratulations. where we can see more of your material?

[@dr.joshuacooper-arrhythmia9917]

I'll be posting more videos to this KZbin channel as they are created (some will be for patient education). And some of my educational videos for EPs will also be featured in the J&J educational website - I'll be posting the link on Twitter, so keep an eye out for it!

[@driedtoast12]

45:54 Instead of entrainment, why not simply change your reference to high RA and re-map? Like you previously demonstrated with focal AT#1, the color scheme would remain the same… because the earliest (ie medial to the CTI line, will still be the earliest, regardless of your reference)

[@dr.joshuacooper-arrhythmia9917]

Using a different reference point would not necessarily change the color scheme, as you say, and would thus still show an "early meets late" appearance on the RA floor due to the prior atrial flutter line of block across the cavo-tricuspid isthmus. To sort out the difference between a reentry pattern and a focal pattern, overdrive pacing on the medial and lateral sides of the line would show very different results with this atrial tach (in contrast to typical flutter, where entrainment would show PPI = TCL in both places; see my other video on entrainment for more details). Thanks so much for watching and for your question!

Thanks a lot for your great video

[@dr.joshuacooper-arrhythmia9917]

You are most welcome. So happy you found it helpful!

[@basam2018]

Thanks doc!

[@munirabdullatif2022]

Thanks so much.. İt is really fascinating

[@druo7840]

Thank you.

[@dr.joshuacooper-arrhythmia9917]

You're welcome!

[@andreabernardini7249]

thanks very much!

[@dr.joshuacooper-arrhythmia9917]

Glad it helped!

[@comedybear1193]

Can you talk about what happen to cardica arrest

[@muzzafermanzoorbhat3734]

thanks a lot

[@dr.joshuacooper-arrhythmia9917]

My pleasure!

[@anunaygupta5343]

My gratitude knows no bounds. I am learning EP and i feel jealous of your fellows.😕

[@DH-vy8hw]

Can you do a tutorial on I.C.E. images?

[@dr.joshuacooper-arrhythmia9917]

There are some great video tutorials on ICE imaging in EP on the J&J Institute Learning Website: courses.jnjinstitute.com/#/dashboard