Three-Dimensional Mapping, Antalya | Prof. Dr. Umuttan Doğan

Three-dimensional ablation means finding the source of a rhythm disorder on a digital map of the heart built by computer, and applying energy to that point. In the conventional method the cardiologist follows the catheters on an X-ray picture alone. With three-dimensional mapping, the real shape of the heart is modelled on screen, the electrical character of every point is shown in colour, and the position of the catheter is followed to the millimetre. The aim is to deliver the right amount of energy to the right point.

When Should Palpitations Be Looked Into?

Everybody feels palpitations from time to time. Excitement, coffee, a bad night’s sleep or a feverish illness can speed the heart up. These do not call for investigation.

Some features, though, point towards a rhythm disorder coming from the heart itself:

If it starts suddenly and stops suddenly. Palpitations that begin as though a switch had been thrown, and end the same way, are a typical warning.
If the pulse is very fast. Rates above 150 a minute are not expected at rest.
If fainting, or nearly fainting, goes with it. This should be assessed without delay.
If there is chest pain or breathlessness as well.
If the episodes are becoming more frequent or lasting longer.
If there is a family history of sudden death at a young age.

An ECG recorded during the palpitations is the most valuable part of the diagnosis. If you can get to an emergency department while it is happening, ask for that recording to be made; every assessment afterwards is built on it. Where episodes are infrequent, a Holter monitor or a recorder worn for longer is used.

What Is an Electrophysiology Study?

The step that comes before ablation is the electrophysiology study, often shortened to EPS.

An EPS examines the electrical system of the heart from inside, with catheters. Fine catheters passed in through the vein in the groin are placed at particular points in the heart. They both listen to the heart’s own electrical signals and can deliver controlled impulses.

There is an important distinction here: EPS is the diagnosis, ablation is the treatment. In some patients only an EPS is done, the source is found and it is decided that ablation is not needed. Most of the time the two follow one another in the same session.

Why Are the Palpitations Brought On Deliberately?

This is a detail patients are surprised to hear beforehand, and knowing it in advance reduces the worry.

To find the source of a rhythm disorder, that rhythm has to be seen. Palpitations that will not appear by themselves in the clinic are brought on during the procedure with controlled impulses. That is how the type of the arrhythmia, where it starts and the route it spreads along are recorded.

The triggering is done in a controlled setting, with your rhythm monitored continuously, and it is ended the same way when necessary.

How Does Three-Dimensional Mapping Work?

The system works out where the tip of the catheter is inside the heart by measuring a magnetic or an electrical field.

As the catheter is moved along the wall of a heart chamber, the position of every point of contact is recorded, together with the timing of the electrical signal there. As the points join up, a digital model of the chamber emerges.

That model is then coloured in. The area the impulse reaches earliest is shown in one colour, the area it reaches last in another. The source of the arrhythmia becomes visible on this colour map.

What Does Three-Dimensional Ablation Change?

The Conduction Pathways Are Marked on the Map

The heart’s own natural conduction pathways are marked on the map and identified as an area not to be touched. When working near it, the boundary stays visible on screen throughout.

This detail matters: damage to a conduction pathway can mean a permanent pacemaker. A boundary marked on the map is a concrete way of managing that risk.

The Force of Contact Is Measured

While energy is being delivered, how firmly the catheter is pressing on the tissue is seen moment by moment. If the contact is too light, the energy does not reach far enough into the tissue and conduction can return in time. If it is too firm, more harm is done to the tissue than intended.

That figure on the screen lets the cardiologist work to the same degree at every point.

X-Ray Exposure Falls, or Disappears Altogether

In the conventional method the catheters are followed on an X-ray picture, which means radiation throughout the procedure. With three-dimensional mapping the system works out the position of the catheters itself, so the need for X-rays falls markedly.

In suitable patients the procedure can be completed without any X-rays at all. That matters particularly in young patients, in children and in pregnancy.

Which Rhythm Disorders Is It Used For?

Supraventricular tachycardia (SVT): episodes of palpitations that start and stop suddenly, reaching 150 to 200 beats a minute.
Wolff-Parkinson-White (WPW) syndrome: palpitations caused by an extra conduction pathway present from birth.
Atrial flutter: the atria beating regularly but very fast.
Atrial tachycardia: a fast rhythm arising from a single focus in an atrium.
Ablation for ectopic beats: early beats that give a sense of the heart stumbling or missing a beat. It is considered where they are frequent and troublesome, or where they have begun to affect the pumping strength of the heart.
Ventricular tachycardia: a fast rhythm arising from the ventricles. This is one of the areas where three-dimensional mapping makes the most difference.
Atrial fibrillation: covered in detail on its own page.

How Three-Dimensional and Conventional Ablation Differ

Both have the same goal: to find the source of the arrhythmia and put it out of action. The difference is in how the cardiologist finds their way inside the heart.

The conventional (two-dimensional) method: the catheters are followed on an X-ray picture. That picture is a flat shadow with no information about depth. The cardiologist interprets the position from experience and from views taken at different angles. X-rays are used throughout.
Three-dimensional ablation: a digital model of the heart is built. The position of the catheter is calculated along three axes and every point it touches is recorded on the map. The points where energy has been delivered stay marked on screen.

That last point matters in practice. With the conventional method the cardiologist has to remember where energy has already been delivered. On a three-dimensional map those points stay visible, so gaps along a line are less likely to be left.

Against that, a three-dimensional system calls for extra preparation and equipment. In a straightforward arrhythmia those extra steps may bring no benefit.

Is a Three-Dimensional Map Needed for Every Ablation?

No. This should be said plainly on this page.

In a simple SVT with a clear source, the conventional method can be enough; the procedure is short and no additional system is needed.

Three-dimensional mapping comes to the fore in these situations:

Where the source of the arrhythmia is complicated, or there is more than one focus
Where an ablation has been done before and the rhythm disorder has returned
Where there is scar tissue in the heart from an earlier heart attack or operation
Where a wide area of an atrium or ventricle has to be surveyed
In patients for whom X-rays should be avoided

The arrhythmia decides the method. A more advanced system does not mean a better result in every patient.

How Is the Procedure Carried Out?

Beforehand

Bring a full list of the medicines you take. Some rhythm medicines suppress the arrhythmia, so you may be asked to stop them for a period before the procedure; that decision is your doctor’s, so do not act on it yourself. You will be told how long to fast.

Always bring any ECG and Holter recordings made during your palpitations. They have a direct bearing on the plan for the procedure.

During the Procedure

It is done under local anaesthetic with sedation, through the vein in the groin. The catheters are placed, the type of arrhythmia is established with an EPS, the three-dimensional map is built and the target point is marked.

Once the energy has been applied, an attempt is made to bring the arrhythmia on again. If it cannot be brought on, the procedure is ended; this confirming step is not skipped.

Afterwards

Pressure is applied at the access site in the groin and bed rest is advised for a period. Your rhythm is monitored. For most patients discharge is planned for the same day or the day after.

Who Is It For?

Patients whose episodes of palpitations continue despite medication
Those who cannot take rhythm medicines because of side effects
Younger patients who do not want to take medicines for many years
People who faint, or nearly faint, with their palpitations
People in whom frequent ectopic beats have begun to affect the pumping strength of the heart
Conditions such as WPW syndrome, where medication does not remove the risk

When It May Not Be Suitable

Where the source of the arrhythmia lies very close to the heart’s natural conduction pathway
Where there is a clot in the heart; the procedure is postponed
Where there is a correctable cause; a thyroid disorder, for instance, is treated first
Infrequent ectopic beats that cause no symptoms and do not affect the heart
An active infection

Whether it suits you is decided by weighing your rhythm recordings and your symptoms together.

What Are the Possible Risks?

Bruising, bleeding or injury to the vessel at the access site
Effects on the heart’s natural conduction pathway, with the need for a permanent pacemaker; this is why the conduction pathways are marked on the map
Fluid collecting in the sac around the heart; rare, and drained if needed
The arrhythmia returning in time, with a second procedure needed
Risks relating to neighbouring structures, which vary with the area being treated

The risks are weighed against the benefit expected from the procedure and discussed in detail for your own situation at the consultation beforehand.

After the Procedure

There may be tenderness and bruising in the groin for the first few days, settling within a few days.
You may feel palpitations now and then. While the treated tissue is healing, this is to be expected.
Whether your medicines are stopped is your doctor’s decision. Do not stop them on your own.
A return to heavy activity is planned in stages.
Cardiology review is carried out at set intervals, with rhythm recordings repeated if needed.

If you notice palpitations that go on for a long time, fainting, or marked swelling at the access site, see your doctor without waiting.

Three-Dimensional Ablation in Antalya

Prof. Dr. Umuttan Doğan is a cardiologist who trained in electrophysiology at the Gülhane Military Medical Academy in 2012; ablation of rhythm disorders under three-dimensional mapping is one of the areas he works in. The procedures are carried out in the catheter laboratory at Antalya American Hospital.

If you have palpitations, or ablation has been suggested to you, you can be seen at the clinic in Konyaaltı with your ECG and Holter recordings. For the other forms of energy see cryoablation and PFA, and for the other procedures the rhythm disorders and ablation page. You will find his background and contact details on their own pages.

Frequently Asked Questions

Are an EPS and an ablation the same thing?

No. An EPS examines the electrical system of the heart with catheters and is a diagnostic method. Ablation applies energy to the source that has been found, and is the treatment. The two are usually done in the same session; in some patients an EPS alone is enough.

Will my palpitations be brought on during the procedure?

Most probably yes. To find the source of the arrhythmia, that rhythm has to be seen. The triggering is done in a controlled setting, with your rhythm monitored continuously, and ended the same way when necessary. Knowing this beforehand reduces the worry during the procedure.

Will I be exposed to X-rays during an ablation?

Where three-dimensional mapping is used, the need for X-rays falls markedly. In suitable patients the procedure can be completed without any at all. That matters particularly in children, in younger patients and in pregnancy.

Will my medicines be stopped after an ablation?

That depends on the type of procedure and on your own situation. In some patients rhythm medicines are reduced in stages, in others they are continued. If you take a blood thinner, the decision about it follows separate criteria. Do not stop your medicines on your own.

Is ablation done for every kind of palpitation?

No. The cause of the palpitations is established first. Anxiety, anaemia, a thyroid disorder or a medicine you are taking can all cause palpitations, and ablation does not come into it in those cases. Ablation is considered for rhythm disorders that arise in the heart and cause symptoms.

The information on this page is for general guidance and does not replace a consultation. Decisions about diagnosis and treatment are made by your doctor after assessing your own situation.