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Bonczar M, Piątek-Koziej K, Wolska J, Tomala O, Stitou EA, Pękala J, Pękala P, Walocha J, Hołda M, Koziej M. Variations in human pulmonary vein ostia morphology: A systematic review with meta-analysis. Clin Anat 2022; 35:906-926. [PMID: 35460116 DOI: 10.1002/ca.23896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/09/2022]
Abstract
This study aimed to establish the most accurate and up-to-date anatomical knowledge of pulmonary veins (PV), ostia variations, diameters and ostial area, to provide physicians, especially heart and thoracic surgeons with exact knowledge concerning this area. The main online medical databases, such as PubMed, Embase, Scopus, Web of Science, and Google Scholar, were searched to gather all studies in which the variations, maximal diameter, and ostial area of the PVs were investigated. During the study, the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. Additionally, the critical appraisal tool for anatomical meta-analysis (CATAM) was used to provide the highest quality findings. The most common ostia variation is the classical one, which contains the left superior pulmonary vein (LSPV), left inferior pulmonary vein (LIPV), right superior pulmonary vein (RSPV) and right inferior pulmonary vein (RIPV). The mean diameter and ostial area of each pulmonary vein were established in the general population and in multiple variations considering the method of collecting the data and geographical location. Significant variability in PV ostia is observed. Left-sided PVs have smaller ostia than the corresponding right-sided PVs, and the inferior PVs ostia are smaller than the superior. The LCPV ostium size is the largest among all veins analyzed, while the RMPV ostium is the smallest. The results of this meta-analysis are hoped to help clinicians in planning and performing procedures that involve the pulmonary and cardiac areas, especially catheter ablation for atrial fibrillation.
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Affiliation(s)
- Michał Bonczar
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | | | - Joanna Wolska
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Olaf Tomala
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - El-Ayachi Stitou
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Jakub Pękala
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Przemysław Pękala
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Hołda
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, UK
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland.,HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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Siebermair J, Kholmovski EG, Sheffer D, Schroeder J, Jensen L, Kheirkhahan M, Baher AA, Ibrahim MM, Reiter T, Rassaf T, Wakili R, Marrouche NF, McGann CJ, Wilson BD. Saturation recovery-prepared magnetic resonance angiography for assessment of left atrial and esophageal anatomy. Br J Radiol 2021; 94:20210048. [PMID: 34111982 DOI: 10.1259/bjr.20210048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Magnetic resonance angiography (MRA) has been established as an important imaging method in cardiac ablation procedures. In pulmonary vein (PV) isolation procedures, MRA has the potential to minimize the risk of severe complications, such as atrio-esophageal fistula, by providing detailed information on esophageal position relatively to cardiac structures. However, traditional non-gated, first-pass (FP) MRA approaches have several limitations, such as long breath-holds, non-uniform signal intensity throughout the left atrium (LA), and poor esophageal visualization. The aim of this observational study was to validate a respiratory-navigated, ECG-gated (EC), saturation recovery-prepared MRA technique for simultaneous imaging of LA, LA appendage, PVs, esophagus, and adjacent anatomical structures. METHODS Before PVI, 106 consecutive patients with a history of AF underwent either conventional FP-MRA (n = 53 patients) or our new EC-MRA (n = 53 patients). Five quality scores (QS) of LA and esophagus visibility were assessed by two experienced readers. The non-parametric Mann-Whitney U-test was used to compare QS between FP-MRA and EC-MRA groups, and linear regression was applied to assess clinical contributors to image quality. RESULTS EC-MRA demonstrated significantly better image quality than FP-MRA in every quality category. Esophageal visibility using the new MRA technique was markedly better than with the conventional FP-MRA technique (median 3.5 [IQR 1] vs median 1.0, p < 0.001). In contrast to FP-MRA, overall image quality of EC-MRA was not influenced by heart rate. CONCLUSION Our ECG-gated, respiratory-navigated, saturation recovery-prepared MRA technique provides significantly better image quality and esophageal visibility than the established non-gated, breath-holding FP-MRA. Image quality of EC-MRA technique has the additional advantage of being unaffected by heart rate. ADVANCES IN KNOWLEDGE Detailed information of cardiac anatomy has the potential to minimize the risk of severe complications and improve success rates in invasive electrophysiological studies. Our novel ECG-gated, respiratory-navigated, saturation recovery-prepared MRA technique provides significantly better image quality of LA and esophageal structures than the traditional first-pass algorithm. This new MRA technique is robust to arrhythmia (tachycardic, irregular heart rates) frequently observed in AF patients.
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Affiliation(s)
- Johannes Siebermair
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany.,Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA.,Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Eugene G Kholmovski
- Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA.,UCAIR, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Douglas Sheffer
- Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA
| | - Joyce Schroeder
- UCAIR, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Leif Jensen
- UCAIR, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Mobin Kheirkhahan
- Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA.,Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Alex A Baher
- Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA
| | - Majd M Ibrahim
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Theresa Reiter
- Department of Internal Medicine, Cardiology, University Hospital Wuerzburg, Würzburg, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany
| | - Reza Wakili
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany.,Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Nassir F Marrouche
- Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA.,Section of Cardiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christopher J McGann
- Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA.,Swedish Heart and Vascular Institute, Seattle, WA, USA
| | - Brent D Wilson
- Comprehensive Arrhythmia Research & Management Center, University of Utah, Salt Lake City, UT, USA.,Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
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Groarke JD, Waller AH, Vita TS, Michaud GF, Di Carli MF, Blankstein R, Kwong RY, Steigner M. Feasibility study of electrocardiographic and respiratory gated, gadolinium enhanced magnetic resonance angiography of pulmonary veins and the impact of heart rate and rhythm on study quality. J Cardiovasc Magn Reson 2014; 16:43. [PMID: 24947763 PMCID: PMC4078012 DOI: 10.1186/1532-429x-16-43] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 05/23/2014] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND We aimed to assess the feasibility of 3 dimensional (3D) respiratory and ECG gated, gadolinium enhanced magnetic resonance angiography (MRA) on a 3 Tesla (3 T) scanner for imaging pulmonary veins (PV) and left atrium (LA). The impact of heart rate (HR) and rhythm irregularity associated with atrial fibrillation (AF) on image and segmentation qualities were also assessed. METHODS 101 consecutive patients underwent respiratory and ECG gated (ventricular end systolic window) MRA for pre AF ablation imaging. Image quality (assessed by PV delineation) was scored as 1 = not visualized, 2 = poor, 3 = good and 4 = excellent. Segmentation quality was scored on a similar 4 point scale. Signal to noise ratios (SNRs) were calculated for the LA, LA appendage (LAA), and PV. Contrast to noise ratios (CNRs) were calculated between myocardium and LA, LAA and PV, respectively. Associations between HR/rhythm and quality metrics were assessed. RESULTS 35 of 101 (34.7%) patients were in AF at time of MRA. 100 (99%) patients had diagnostic studies, and 91 (90.1%) were of good or excellent quality. Overall, mean ± standard deviation (SD) image quality score was 3.40 ± 0.69. Inter observer agreement for image quality scores was substantial, (kappa = 0.68; 95% confidence interval (CI): 0.46, 0.90). Neither HR adjusting for rhythm [odds ratio (OR) = 1.03, 95% CI = 0.98,1.09; p = 0.22] nor rhythm adjusting for HR [OR = 1.25, 95% CI = 0.20, 7.69; p = 0.81] demonstrated association with image quality. Similarly, SNRs and CNRs were largely independent of HR after adjusting for rhythm. Segmentation quality scores were good or excellent for 77.3% of patients: mean ± SD score = 2.91 ± 0.63, and scores did not significantly differ by baseline rhythm (p = 0.78). CONCLUSIONS 3D respiratory and ECG gated, gadolinium enhanced MRA of the PVs and LA on a 3 T system is feasible during ventricular end systole, achieving high image quality and high quality image segmentation when imported into electroanatomic mapping systems. Quality is independent of HR and heart rhythm for this free breathing, radiation free, alternative strategy to current MRA or CT based approaches, for pre AF ablation imaging of PVs and LA.
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Affiliation(s)
- John D Groarke
- Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alfonso H Waller
- Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tomas S Vita
- Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory F Michaud
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Raymond Y Kwong
- Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Steigner
- Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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