WO2017125794A1

WO2017125794A1 - Device and method for dynamic mapping by intracardiac electrogram overlay namely for diagnosis or treatment of atrial fibrillation

Info

Publication number: WO2017125794A1
Application number: PCT/IB2016/052137
Authority: WO
Inventors: Pedro Manuel PULIDO GARCIA ADRAGÃO
Original assignee: Pulido Garcia Adragão Pedro Manuel
Priority date: 2016-01-19
Filing date: 2016-04-14
Publication date: 2017-07-27

Abstract

Device and method for dynamic mapping of intracardiac electrograms for use in diagnosis or treatment of abnormal cardiac electrical activity, in particular atrial fibrillation, the device comprising: a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over the atrium, and a digital data processor configured for, carry out the method of, sequentially over a period of time: capturing substantially simultaneous intracardiac electrical signals read by the intracardiac catheter and distributed over the atrium; scanning and storing the intracardiac electrical signals captured; and three-dimensionally mapping the intracardiac electrical signals in relation to the corresponding anatomical location in the heart cavity; subsequently overlaying said three-dimensional maps obtained over the period of time. The overlay of the maps can be obtained by time acceleration of the sequence of maps obtained over the period of time, or by the sum, arithmetic mean, or by a measure of central tendency of said maps.

Description

D E S C R I P T I O N

DEVICE AND METHOD FOR DYNAMIC MAPPING BY INTRACARDIAC ELECTROGRAM OVERLAY NAMELY FOR DIAGNOSIS OR TREATMENT OF

ATRIAL FIBRILLATION

Technical field

[0001] The present disclosure refers to dynamic mapping of intracardiac electrograms of fractionated potentials. The disclosure includes a device and method for dynamic mapping by intracardiac electrograms overlay, in particular of fractionated potentials, e.g. Complex Fractionated Atrial Electrograms (CFAE or CFEs). In particular, the device and method are useful for diagnosis or treatment of abnormal cardiac electrical activity, in particular fibrillation, very particularly atrial fibrillation.

Background

[0002] The electrophysiological study is the method for arrhythmia diagnosis involving the positioning of intracardiac catheters in the regions of interest, allowing the recording of intracardiac electrical signals. The conventional method involves only the use of fluoroscopy and intracavitary electrogram recording, which affects the assessment of cardiac anatomy as well as the accuracy of the location of the catheters, at the same time being associated with a long exposure to radiation and causing thereby consequences both for the patient and the operator.

[0003] Electroanatomical mapping systems have emerged aiming at reducing the fluoroscopy time, while potentiating the efficacy and safety of the procedure. In mapping arrhythmias, these allow mapping the heart cavity in three dimensions by recording the intracardiac electrical activation in relation to the corresponding anatomical location. In this way, the precise identification of the location of the arrhythmia origin and the guidance of the catheter positioning without the need for fluoroscopic guidance are intended.

[0004] These systems substantially improve the success of procedures, namely ablation procedures, since they facilitate the electroanatomical mapping, especially in case of complex arrhythmias and abnormal cardiac anatomy.

[0005] Ablation consists of surgical application, with the use of catheters, of radio frequency waves in areas near the junction of the pulmonary vein with the atrium, thus blocking the foci which give rise to extrasystoles triggering fibrillation.

[0006] Ablation is a useful procedure for treating atrial fibrillation, but it is very important to accurately identify the areas to be intervened.

[0007] Among data provided by mapping systems are the reconstruction of the heart cavity of interest, marking of important anatomical points and ablation lesions, guidance of diagnostic catheters and mapping without need for fluoroscopy, integration of CT images in the system, and activation and voltage mapping.

[0008] By way of example, reference is made to the following electroanatomical mapping systems: CARTO™ (Biosense Webster), NavX™ (St. Jude Medical) and Rhythmia™ (Boston Scientific).

[0009] The navigation system CARTO™ (fig. 1) is based on a hybrid technology combining magnetic navigation with impedance, making it very accurate.

[0010] The system can calculate the position and orientation of the catheter through the sensor present on the tip thereof in relation to the set with sensors placed underneath the patient table, wherein the integration of both allows accurate spatial location and independent from other factors. The CARTO system uses static magnetic fields, which are calibrated and controlled by computer, and due to the nature of these fields, the location of the catheter can also be calculated when the tip thereof is not in motion.

[0011] NavX™ system (fig. 2) uses an impedance technology for the visualisation of catheters and electroanatomical mapping. The impedance measurement is carried out using the six patches that are placed on the patient. Each pair of patches is placed on perpendicular locations, a current flowing between them, one of the patches of the pair being the transmitter of said current, and the other patch on the opposite side being the receiver. The electrodes of the electrocatheter measure the impedance variation between each pair of patches, which results in an electrocatheter image based on such gradient variations. The NavX™ system requires selecting a catheter as spatial reference, which can become less accurate if any change in the previously defined reference position occurs.

[0012] Rhythmia™ System is based on an integration between magnetic technology and impedance measurement for the creation of electroanatomical maps and catheter visualisation. It uses the multipolar mapping catheter IntellaMap Orion™, which allows the creation of high density maps in a short time.

[0013] Basket catheters are multielectrode catheters that usually present a basket shape, where the electrodes are evenly distributed over linear metallic structures called splines, as ribs joining in a convex fashion two tops defining a volume.

[0014] The current basket catheters typically have 8 equidistant splines each having 8 electrodes, providing a total of 64 unipolar electrograms and 32 or 56 bipolar electrograms (depending on the electrode combination scheme) recorded simultaneously (or substantially simultaneous, i.e. a sufficiently short period of time). The electrodes may be 1 to 2 mm long and 1 mm in diameter, and interelectrode distance may vary between 3 to 10 mm depending on the diameter of the catheter. These catheters can be percutaneously inserted with the aid of long sheaths, and the size thereof is selected based on the echocardiographic dimensions of the heart cavity of interest to be mapped.

[0015] For example, Constelation™ basket catheter (Boston Scientific) (fig. 3) is 120 cm long, 8F; the diameter ranges between 31 and 75 mm; the electrode spacing varies between 2 to 7 mm; 64 electrodes, allowing mapping in real time only during a heart cycle; splines in super elastic alloy; allows capturing longitudinal and circumferential signals obtained simultaneously, thus obtaining high resolution electrograms. [0016] For example, basket catheter IntellaMap Orion™ (Boston Scientific) (fig. 4) is a mini-basket, 8F, with 2.5 mm spacing (center to center); variable expansion, the largest diameter being 1.8 cm; having 64 "low noise" electrodes evenly distributed over 8 splines; having magnetic and impedance location sensors.

[0017] For example, basket catheter FIRMap (Focal Impulse and Rotor Modulation) (fig. 5) is a diagnosis catheter that detects continuous electrical activity; it is used for capturing electrical potentials from the endocardium; there are two different possible diameters: 50 mm and 60 mm. The size is chosen according to the measurements of the cavity meant to be mapped. The catheter conforms to the shape of the heart chamber, thereby allowing creating maps of areas of difficult access, such as next to distal and proximal ends. It has a total of 64 evenly-spaced electrodes, distributed between 8 splines (8 electrodes per spline). Catheter data is sent to the RhythmView™ mapping system for creating activation maps of the rotors responsible for atrial fibrillation.

[0018] Atrial Fibrillation (AF) is a type of cardiac arrhythmia, characterized by heartbeat irregularity. This irregularity is due to the fact that the two upper chambers of the heart (the atria) quiver or "fibrillate" rather than performing normal contraction. During a normal heartbeat, the electrical pulses that cause the atria to contract originate from a small area in the right atrium called the sinus node. During this arrhythmia these pulses originate from the entire atrium, triggering 300 to 500 contractions per minute therein.

[0019] The origin of this arrhythmia is still unsolved, and there are currently two theories seeking to explain it: the theory of rotors and the theory of CFAEs.

[0020] The rotors consist of rotational consistent activity around a centre and can be maintained by hundreds to thousands of cycles comprising several minutes. This definition excludes transient rotational activity that results from passive activation.

[0021] According to clinical publications, the existence of rotors may be one of the mechanisms explaining Atrial Fibrillation since it has been shown that arrhythmia is sustained by a small number of rotors, which are stable over extended periods of time. In patients with paroxysmal AF fewer rotors are found, compared with patients with persistent AF, and these may be observed in both atria, with only about 1/3 in the right atrium.

[0022] A mapping system only focused on the detection of rotors is available: Topera RhythmView^®. This system, together with the FIRMap^® catheter allows collecting all information from the cavity of interest via the 64 electrodes available during a single heart cycle, thereby allowing the identification of both existence and location of rotors responsible for AF in the left atrium.

[0023] Complex Fractionated Atrial Electrograms (CFAEs) are usually defined as low amplitude fractionated atrial electrograms and with a cycle length <120 ms. The definition of CFAEs is of average knowledge in the field, being substantially identical. Fast electrical pulses coming from rotors are driven through the atria and the fragmentation thereof occurs from the interaction with functional and anatomical limits. These areas with CFAEs are another mechanism that seem to explain the existence of atrial fibrillation and in which investments are made aiming at their location for elimination thereof.

[0024] The CFAE module (CARTO^® Biosense Webster) is a software that analyses atrial electrograms obtained by ablation catheter for 2.5 seconds, and interprets them according to two variables:

- The shortest complex interval (SCL), the shortest interval found (in ms) of all intervals identified during consecutive CFAE complexes;

- Interval Confidence Level (ICL), the number of intervals identified among complexes, identified as consecutive CFAEs, where it is assumed that the more complex intervals are recorded - i.e., the more repetitions occur during a given period - the more reliable CFAE categorization shall be.

[0025] The information coming from these variables is projected in 3D electroanatomical map, according to a colour scale. This allows selecting the CFAE areas with interest in performing ablation. [0026] These facts are described to illustrate the technical problem solved by the embodiments of the present document.

Summary

[0027] It is an object of the present embodiments to provide a solution for intracardiac electroanatomical mapping of the three-dimensional atrium in particular aiming to accurately identify the location of arrhythmia origin, particularly for accurately guiding the positioning of the surgery. The advantages include the substantial improvement in the success of procedures, namely ablation procedures.

[0028] The use of a basket catheter in the left atrium allows simultaneous recording of multiple points, as for instance 64 points (or substantially simultaneous, i.e. a sufficiently short period of time for obtaining an electrogram map). By applying a commercially available algorithm to signals captured by the electrode allows defining a CFAE map. Alternatively, maps with other available algorithms can also be used, including activation and voltage maps. Also, other types of catheters may be used.

[0029] In a preferred embodiment, maps with multiple points obtained simultaneously (or typically within a very short time interval, for example, in the same millisecond) over a period of time including multiple heartbeats, preferably including a predetermined time interval or a predetermined number of heartbeats, are captured and calculated. Each individual map is captured within a short time interval, but this maybe up to a few seconds, depending for example on the specific catheter. The specific time for each map will be normally whatever is necessary to capture and process an individual electrogram map for a specific catheter and respective electronic circuitry.

[0030] Then, these maps obtained over time are overlaid. For example, by obtaining a film accelerated in time of temporally sequential maps or by aggregating data into a single map by a suitable mathematical method (e.g., the sum or average of individual measurements) along the temporally sequential maps. [0031] Unexpectedly and contrary to what is customary in this technical field, the areas with greater CFAE intensity captured at short time intervals are neither the most important areas which maintain atrial fibrillation, nor those that should be targeted for treatment. In fact, areas registering CFAEs in a more stable (more constant) fashion, over the disclosed prolonged captured period of time, seem both to be the most important areas which maintain atrial fibrillation and those that should be targeted for treatment.

[0032] Clearly, the length of time used in capturing data is highly relevant, because it must be sufficient to obtain the areas registering CFAEs in a more stable manner. Until now, the length of the time used in capturing data has not been a parameter commonly considered as relevant in the art for identifying the areas which crucially contribute to atrial fibrillation and those areas that should be targeted for treatment, and yet, it is an aspect of the present embodiments.

[0033] By visualising the overlay of individual maps, for example by visualising the accelerated film or overlay map, the doctor can specify the areas that must be addressed.

[0034] The maps can be repeated after the ablative lesions have been performed to identify the operated modifications and define new areas of interest.

[0035] Disclosed herein is a device for dynamic mapping of intracardiac electrograms for use in the diagnosis or treatment of abnormal cardiac electrical activity, comprising: a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over the atrium, and

a digital data processor configured for, sequentially over a period of time:

capturing substantially simultaneous intracardiac electrical signals read by the intracardiac catheter and distributed over the atrium;

scanning and storing the intracardiac electrical signals captured; and

three-dimensionally mapping the intracardiac electrical signals in relation to the corresponding anatomical location in the heart cavity;

the digital data processor being further configured for:

overlaying said three-dimensional maps obtained over the period of time. [0036] It is also disclosed a method of dynamic mapping of intracardiac electrograms for use in the diagnosis or treatment ofabnormal cardiac electrical activity, comprising the steps of,

via a digital data processor configured for the purpose,

and sequentially over a period of time:

capturing substantially simultaneous intracardiac electrical signals read by a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over the atrium;

scanning and storing the captured intracardiac electrical signals; and

three-dimensionally mapping the intracardiac electrical signals in relation to the corresponding anatomical location in the heart cavity; and subsequently:

overlaying said three-dimensional maps obtained over the period of time.

[0037] Arrhythmia is an important abnormal cardiac electrical activity according to the present disclosure, in particular fibrillation, very particularly atrial fibrillation.

[0038] In an embodiment, the catheter is a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over the whole atrium.

[0039] In an embodiment, the catheter is a multielectrode catheter, in particular with the electrodes arranged in convex splines.

[0040] In an embodiment, the catheter is a basket-type catheter.

[0041] In an embodiment, the electrical signals, after being captured, are subjected to a signal processing filter for fractionated potentials.

[0042] In an embodiment, said maps are CFAE maps.

[0043] In an embodiment, said maps are activation maps, voltage maps or rotor maps.

[0044] In an embodiment, the overlay of the maps is obtained by time acceleration of the sequence of maps obtained over time, in particular wherein the map reproduction speed is at least 5 times the map capture normal speed, more particularly wherein the map reproduction speed is at least 10 times the map capture normal speed, even more particularly wherein the map reproduction speed is at least 20 times the map capture normal speed, more particularly wherein the map reproduction speed is at least 30 times the map capture normal speed.

[0045] In an embodiment, the overlay of maps is obtained by the sum, by the arithmetic mean, by the median, by the truncated mean, by a weighted mean, or by any other measure of central tendency of said maps.

[0046] In an embodiment, said period of time is a period of time sufficient for the map overlay to obtain stable zones marked in said maps.

[0047] In an embodiment, said period of time is a period of time sufficient for the map overlay to obtain stable zones of potential activation of atrial fibrillation.

[0048] In an embodiment, said period of time is at least 30s, in particular at least 40s, more particularly at least 60s, more particularly at least 300s, more particularly at least 600s, more particularly at least 900s.

[0049] In an embodiment, the substantially simultaneous capture of intracardiac electrical signals read by the intracardiac catheter distributed over the atrium occurs within a time range less than 5 ms, particularly less than 2 ms, particularly less than lms.

[0050] In an embodiment, the analysis of prolonged-time records simultaneously gathered of several electrograms, either globally or regionally distributed over the atrium, during atrial tachycardia can also be performed to provide relevant data enabling accurately defining ablation targets.

[0051] In an embodiment, electrograms can be assessed in their different aspects, namely activation maps, voltage maps and/or complex fractionated electrogram maps (CFEs).

[0052] These maps can be interactive and can be incorporated to obtain a complete understanding of the tachyarrhythmia maintenance mechanism.

[0053] Also described herein is a non-transitory storage medium, as for instance a nonvolatile memory, comprising program instructions for implementing a dynamic mapping method of intracardiac electrograms for use in the diagnosis or treatment of atrial fibrillation, the program instructions including instructions executable to carry out the method of any of the described method embodiments. Brief Description of the drawings

[0054] The following figures provide preferred embodiments for illustrating the description and should not be seen as limiting the scope of the disclosure.

[0055] Figure 1: Schematic presentation of a CARTO™-type catheter.

[0056] Figure 2: Schematic presentation of a NavX™-type system.

[0057] Figure 3: Schematic presentation of a Constelation™-type basket catheter.

[0058] Figure 4: Schematic representation of a IntellaMap Orion™ basket catheter.

[0059] Figure 5: Schematic presentation of a FIRMap basket-type catheter (Focal Impulse and Rotor Modulation).

[0060] Figure 6: Individual CFAE maps obtained at different moments and heartbeats of the same patient.

[0061] Figure 7: Overlay map of temporally sequential CFAE maps wherein areas of greater stability are identified.

[0062] Figure 8: Map and electrogram of a first application of radiofrequency ablation.

[0063] Figure 9: Map and electrogram of a first application of radiofrequency ablation, wherein prolonged of the cycle can be observed.

[0064] Figure 10: Map and electrogram of a second application of radiofrequency ablation, wherein suppression of electrical activity on the posterior wall can be observed.

Detailed Description

[0065] In Figures 6a-6g, areas corresponding to individual CFAEs obtained at different moments and heartbeats in the same patient can be observed in red/orange. One can observe the fluctuation in these areas and how the identification of an area for ablation based on just one of these images could very well be incorrect. [0066] In fact, areas registering CFAEs in a more stable (constant) fashion, over the captured period of time, are the important areas for maintaining atrial fibrillation and those that should be targeted for treatment.

[0067] The overlay of the images allows specifying the stable areas for CFAE recording therefore being of interest to maintain atrial fibrillation and that should be selected for treatment (ablation).

[0068] Figure 7 shows a map overlay of said CFAE maps wherein areas of increased stability and increased interest for treatment are identified.

[0069] Figures 8 to 10 show that after identification of the overlay map, showing CFAEs in the ostium of the left pulmonary veins, applying radiofrequency energy in this area suppresses fibrillation activity over the entire posterior wall of the left atrium.

[0070] The term "comprising" whenever used in this document is intended to indicate the presence of stated features, integers, steps, components, but not to preclude the presence or addition of one or more other features, integers, steps, components or groups thereof.

[0071] It will be appreciated by those of ordinary skill in the art that unless otherwise indicated herein, the particular sequence of steps described is illustrative only and can be varied without departing from the disclosure. Thus, unless otherwise stated the steps described are so unordered meaning that, when possible, the steps can be performed in any convenient or desirable order.

[0072] It is to be appreciated that certain embodiments of the disclosure as described herein may be incorporated as code (e.g., a software algorithm or program) residing in firmware and/or on computer useable medium having control logic for enabling execution on a computer system having a computer processor, such as any of the servers described herein. Such a computer system typically includes memory storage configured to provide output from execution of the code which configures a processor in accordance with the execution. The code can be arranged as firmware or software, and can be organized as a set of modules, including the various modules and algorithms described herein, such as discrete code modules, function calls, procedure calls or objects in an object-oriented programming environment. If implemented using modules, the code can comprise a single module or a plurality of modules that operate in cooperation with one another to configure the machine in which it is executed to perform the associated functions, as described herein.

[0073] The disclosed embodiments are combinable.

[0074] The disclosure is of course not in any way restricted to the embodiments described herein and a person with ordinary skill in the art will foresee many possibilities to modifications thereof without departing from the basic disclosure as defined in the appended claims and substitutions of technical features for equivalents, according to requirements in each situation, as defined in the appended claims.

Claims

C L A I M S

1. Device for dynamic mapping of intracardiac electrograms for use in the diagnosis or treatment of abnormal cardiac electrical activity comprising:

a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over the atrium, and

a digital data processor configured for, sequentially over a period of time:

scanning and storing the intracardiac electrical signals captured; and

the digital data processor being further configured for subsequently:

overlaying said three-dimensional maps obtained over the period of time.

2. Device according to the previous claim, wherein the catheter is a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over the whole atrium.

3. Device according to any of the previous claims, wherein the catheter is a multielectrode catheter, in particular with the electrodes arranged in convex splines.

4. Device according to any of the previous claims, wherein the catheter is a basket- type catheter.

5. Method according to claim 1, wherein the catheter is a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over a region of the atrium.

6. Device according to any of the previous claims, wherein the electrical signals, after being captured, are subjected to a signal processing filter for fractionated potentials.

7. Device according to any of the previous claims, wherein said maps are CFAE maps.

8. Device according to any one of claims 1-6 wherein said maps are activation maps, voltage maps or rotor maps.

9. Device according to any of the previous claims, wherein the overlay of the maps is obtained by time acceleration of the sequence of maps obtained over the period of time, particularly wherein the map reproduction speed is at least 5 times the map capture normal speed, more particularly wherein the map reproduction speed is at least 10 times the map capture normal speed, even more particularly wherein the map reproduction speed is at least 20 times the map capture normal speed, more particularly wherein the map reproduction speed is at least 30 times the map capture normal speed.

10. Device according to any one of claims 1-8, wherein the overlay of maps is obtained by the sum, by the arithmetic mean, by the median, by the truncated mean, by a weighted mean, or by a measure of central tendency of said maps.

11. Device according to any of the previous claims, wherein said period of time is a period of time sufficient for the map overlay to obtain stable zones marked in said maps.

12. Device according to any of the previous claims, wherein said period of time is a period of time sufficient for the map overlay to obtain stable zones of potential activation of atrial fibrillation.

13. Device according to any of the previous claims, wherein said period of time is at least 30s, in particular at least 40s, more particularly at least 60s, more particularly at least 300s, more particularly at least 600s, more particularly at least 900s.

14. Device according to any of the previous claims, wherein the capture of substantially simultaneous intracardiac electrical signals read by the intracardiac catheter distributed over the atrium occurs within a time range of less than 5 ms, particularly less than 2 ms, particularly less than 1ms.

15. Device according to any of the previous claims, wherein the abnormal cardiac electrical activity is atrial fibrillation.

16. Method for dynamic mapping of intracardiac electrograms for use in the diagnosis or treatment of abnormal cardiac electrical activity comprising the steps of, using a digital data processor,

and sequentially over a period of time:

capturing substantially simultaneous intracardiac electrical signals read by a multipolar mapping intracardiac catheter for reading intracardiac electrical signals and distributed over the atrium;

scanning and storing the captured intracardiac electrical signals; and

and subsequently:

overlaying said three-dimensional maps obtained over the period of time.

17. Method according to the previous claim, wherein the abnormal cardiac electrical activity is atrial fibrillation.

18. Method according to the previous claim, wherein the catheter is a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over the whole atrium.

19. Method according to any one of claims 16-18, wherein the catheter is a multielectrode catheter, in particular with the electrodes arranged in convex splines.

20. Method according to any one of the claims 16-19, wherein the catheter is a basket-type catheter.

21. Method according to any one of claims 16-20, wherein the catheter is a multipolar mapping intracardiac catheter for reading intracardiac electrical signals distributed over a region of the atrium.

22. Method according to any one of claims 16-21, wherein the electrical signals, after being captured, are subjected to a signal processing filter for fractionated potentials.

23. Method according to any one of claims 16-22, wherein said maps are CFAE maps.

24. Method according to any one of claims 16-22, wherein said maps are activation maps, voltage maps or rotor maps.

25. Method according to any one of claims 16-24, wherein the overlay of the maps is obtained by time acceleration of the sequence of maps obtained over the period of time, in particular wherein the map reproduction speed is at least 5 times the map capture normal speed, more particularly wherein the map reproduction speed is at least 10 times the map capture normal speed, even more particularly wherein the map reproduction speed is at least 20 times the map capture normal speed, more particularly wherein the map reproduction speed is at least 30 times the map capture normal speed.

26. Method according to any one of claims 16-24, wherein the overlay of maps is obtained by the sum, by the arithmetic mean, by the median, by the truncated mean, by a weighted mean, or by a measure of central tendency of said maps.

27. Method according to any one of claims 16-26, wherein said period of time is a period of time sufficient for the map overlay to obtain stable zones marked in said maps.

28. Method according to any one of claims 16-27, wherein said period of time is a period of time sufficient for the map overlay to obtain stable zones of potential activation of atrial fibrillation.

29. Method according to any one of claims 16-28, wherein said period of time is at least 30s, in particular at least 40s, more particularly at least 60s, more particularly at least 300s, more particularly at least 600s, more particularly at least 900s.

30. Method according to any one of claims 16-29, wherein the capture of substantially simultaneous intracardiac electrical signals read by the intracardiac catheter distributed over the atrium occurs within a time range of less than 5 ms, particularly less than 2 ms, particularly less than 1ms.

31. Method according to any one of the claims 16-30 wherein said maps simultaneously group a plurality of electrograms, globally or regionally distributed over the atrium.

32. Non-transitory storage medium comprising program instructions for implementing a dynamic mapping method of intracardiac electrograms for use in the diagnosis or treatment of atrial fibrillation, the program instructions including instructions executable to carry out the method of any one of claims 16-31.