title: Burning the Gap: Electrical and Anatomical Basis of the Incremental Pacing Maneuver for Cavotricuspid Isthmus Block Assessment.
abstract: The incremental pacing (IP) maneuver is a highly specific technique that improves the ability to confirm complete CTI conduction block during typical atrial flutter (AFL) ablation, and reduces long-term AFL recurrences. The purpose of this study is to assess the performance of new catheters equipped with additional high precision bipoles (AHPB) to allow the visualization of the cavotricuspid isthmus (CTI) conduction gap and to compare them with the IP maneuver.
  
  
  
  Twenty consecutive patients undergoing catheter ablation of the CTI for AFL were included. The IP maneuver confirmed functional versus complete CTI block. Local electrogram analysis using AHPB was then used to assess the presence or absence of gaps across the CTI line. Mean age was 67 years and 80% were male. At the end of the procedure CTI block was achieved in all patients. A transient stage of functional CTI block was observed in 40%. In all cases a continuous fragmented electrogram was present between the double potentials in the CTI in the AHPB channels. In contrast, no electrogram was observed between the CTI double potentials in any of the 20 patients once complete block was confirmed by the IP maneuver. When both techniques were compared a significant association and correlation were observed (chi-square <0.01, Spearman's rho = 1, P < 0.01).
  
  
  
  Catheters equipped with AHPB can aid in the assessment of complete CTI block during AFL ablation procedures by detecting conduction gaps that correlate with incomplete functional block diagnosed by the IP maneuver.
authors.affiliation: Electrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Ermengol
authors.initials: E
authors.lastname: Vallès
authors.affiliation: Electrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Sandra
authors.initials: S
authors.lastname: Cabrera
authors.affiliation: Electrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Begoña
authors.initials: B
authors.lastname: Benito
authors.affiliation: Electrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Oscar
authors.initials: O
authors.lastname: Alcalde
authors.affiliation: Electrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Jesús
authors.initials: J
authors.lastname: Jiménez
authors.affiliation: Electrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Julio
authors.initials: J
authors.lastname: Martí-Almor
mesh_terms: D000200:Action Potentials; D000368:Aged; D001282:Atrial Flutter / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D062906:Cardiac Catheters; D002304:Cardiac Pacing, Artificial; D017115:Catheter Ablation / Q000009:adverse effects; D022062:Electrophysiologic Techniques, Cardiac / Q000295:instrumentation*; D004867:Equipment Design; D005260:Female; D006339:Heart Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D011237:Predictive Value of Tests; D012008:Recurrence; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000503:physiopathology / Q000601:surgery*
keywords: catheter ablation; electrogram; incremental pacing; typical atrial flutter