1
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Morris MF, Carlson C, Bhagat A. Role of advanced imaging with cardiac computed tomography and MRI in atrial and ventricular ablation. Curr Opin Cardiol 2022; 37:431-438. [PMID: 35880445 DOI: 10.1097/hco.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Increasing evidence supports the use of advanced imaging with cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) in the work-up of patients with arrythmias being considered for ablation. RECENT FINDINGS Advances in imaging technology and postprocessing are facilitating the use of advanced imaging before, during and after ablation in patients with both atrial and ventricular arrhythmias.In atrial arrythmias, quantitative assessment of left atrial wall thickness on CCT and quantification of late gadolinium enhancement (LGE) on CMR identify patients more likely to develop recurrent atrial arrythmias following ablation. In addition, in patients with recurrent arrythmia post ablation, LGE CMR can potentially identify targets for repeat ablation.In ventricular arrythmias, qualitative assessment of LGE can aide in determining the optimal ablation approach and predicts likelihood of ventricular arrythmias inducibility. Quantitative assessment of LGE can identify conduction channels that can be targeted for ablation. On CCT, quantitative assessment of left ventricular wall thickness can demonstrate myocardial ridges associated with re-entrant circuits for ablation. SUMMARY This review focuses on the utility of CCT and CMR in identifying key anatomical components and arrhythmogenic substrate contributing to both atrial and ventricular arrhythmias in patients being considered for ablation. Advanced imaging has the potential to improve procedural outcomes, decrease complications and shorten procedural time.
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Affiliation(s)
| | - Chelsea Carlson
- Department of Medicine, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
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2
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Beltrami M, Dei LL, Milli M. The Role of the Left Atrium: From Multimodality Imaging to Clinical Practice: A Review. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081191. [PMID: 36013370 PMCID: PMC9410416 DOI: 10.3390/life12081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022]
Abstract
In recent years, new interest is growing in the left atrium (LA). LA functional analysis and measurement have an essential role in cardiac function evaluation. Left atrial size and function are key elements during the noninvasive analysis of diastolic function in several heart diseases. The LA represents a “neuroendocrine organ” with high sensitivity to the nervous, endocrine, and immune systems. New insights highlight the importance of left atrial structural, contractile, and/or electrophysiological changes, introducing the concept of “atrial cardiomyopathy”, which is closely linked to underlying heart disease, arrhythmias, and conditions such as aging. The diagnostic algorithm for atrial cardiomyopathy should follow a stepwise approach, combining risk factors, clinical characteristics, and imaging. Constant advances in imaging techniques offer superb opportunities for a comprehensive evaluation of LA function, underlying specific mechanisms, and patterns of progression. In this literature review, we aim to suggest a practical, stepwise algorithm with integrative multimodality imaging and a clinical approach for LA geometry and functional analysis. This integrates diastolic flow analysis with LA remodelling by the application of traditional and new diagnostic imaging techniques in several clinical settings such as heart failure (HF), atrial fibrillation (AF), coronary artery disease (CAD), and mitral regurgitation (MR).
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Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
- Correspondence: ; Tel.: +39-339-541-8158
| | - Lorenzo-Lupo Dei
- Cardiology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Massimo Milli
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
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3
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Li L, Zimmer VA, Schnabel JA, Zhuang X. Medical image analysis on left atrial LGE MRI for atrial fibrillation studies: A review. Med Image Anal 2022; 77:102360. [PMID: 35124370 PMCID: PMC7614005 DOI: 10.1016/j.media.2022.102360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/04/2021] [Accepted: 01/10/2022] [Indexed: 02/08/2023]
Abstract
Late gadolinium enhancement magnetic resonance imaging (LGE MRI) is commonly used to visualize and quantify left atrial (LA) scars. The position and extent of LA scars provide important information on the pathophysiology and progression of atrial fibrillation (AF). Hence, LA LGE MRI computing and analysis are essential for computer-assisted diagnosis and treatment stratification of AF patients. Since manual delineations can be time-consuming and subject to intra- and inter-expert variability, automating this computing is highly desired, which nevertheless is still challenging and under-researched. This paper aims to provide a systematic review on computing methods for LA cavity, wall, scar, and ablation gap segmentation and quantification from LGE MRI, and the related literature for AF studies. Specifically, we first summarize AF-related imaging techniques, particularly LGE MRI. Then, we review the methodologies of the four computing tasks in detail and summarize the validation strategies applied in each task as well as state-of-the-art results on public datasets. Finally, the possible future developments are outlined, with a brief survey on the potential clinical applications of the aforementioned methods. The review indicates that the research into this topic is still in the early stages. Although several methods have been proposed, especially for the LA cavity segmentation, there is still a large scope for further algorithmic developments due to performance issues related to the high variability of enhancement appearance and differences in image acquisition.
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Affiliation(s)
- Lei Li
- School of Data Science, Fudan University, Shanghai, China; School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Veronika A Zimmer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Informatics, Technical University of Munich, Germany
| | - Julia A Schnabel
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Informatics, Technical University of Munich, Germany; Helmholtz Center Munich, Germany
| | - Xiahai Zhuang
- School of Data Science, Fudan University, Shanghai, China.
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4
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Markman TM, Khoshknab M, Nazarian S. Catheter ablation of atrial fibrillation: cardiac imaging guidance as an adjunct to the electrophysiological guided approach. Europace 2021; 23:520-528. [PMID: 33555014 DOI: 10.1093/europace/euaa249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/07/2020] [Accepted: 08/23/2020] [Indexed: 11/12/2022] Open
Abstract
Catheter ablation is increasingly utilized to treat patients with atrial fibrillation (AF). Despite progress in technology and procedural strategy, there remain significant limitations with suboptimal outcomes. The role of imaging has continued to evolve, and multimodality imaging now presents an important opportunity to make substantial progress in the safety and efficacy of ablation. In this review, we discuss the history of imaging in the ablation of AF with a specific focus on the ability of cardiac computed tomography and magnetic resonance imaging to characterize anatomy, arrhythmogenic substrate, and guide ablation strategy. We will review the progress that has been made and highlight many of the limitations as well as future directions for the field.
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Affiliation(s)
- Timothy M Markman
- Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9118, Philadelphia, PA, USA
| | - Mirmilad Khoshknab
- Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9118, Philadelphia, PA, USA
| | - Saman Nazarian
- Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9118, Philadelphia, PA, USA
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5
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Lin Y, Fu S, Yao Y, Li Y, Zhao Y, Luo L. Heart failure with preserved ejection fraction based on aging and comorbidities. J Transl Med 2021; 19:291. [PMID: 34229717 PMCID: PMC8259336 DOI: 10.1186/s12967-021-02935-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a leading cause of hospitalizations and mortality when diagnosed at the age of ≥ 65 years. HFpEF represents multifactorial and multisystemic syndrome and has different pathophysiology and phenotypes. Its diagnosis is difficult to be established based on left ventricular ejection fraction and may benefit from individually tailored approaches, underlying age-related changes and frequent comorbidities. Compared with the rapid development in the treatment of heart failure with reduced ejection fraction, HFpEF presents a great challenge and needs to be addressed considering the failure of HF drugs to improve its outcomes. Further extensive studies on the relationships between HFpEF, aging, and comorbidities in carefully phenotyped HFpEF subgroups may help understand the biology, diagnosis, and treatment of HFpEF. The current review summarized the diagnostic and therapeutic development of HFpEF based on the complex relationships between aging, comorbidities, and HFpEF.
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Affiliation(s)
- Ying Lin
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China
| | - Shihui Fu
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Yao Yao
- Centre for the Study of Ageing and Human Development and Geriatrics Division, Medical School of Duke University, Durham, NC, 27708, USA
- Centre for Healthy Ageing and Development Studies, National School of Development, Peking University, Beijing, 100871, China
| | - Yulong Li
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Yali Zhao
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
| | - Leiming Luo
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
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6
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Sohns C, Marrouche NF. Atrial fibrillation and cardiac fibrosis. Eur Heart J 2021; 41:1123-1131. [PMID: 31713590 DOI: 10.1093/eurheartj/ehz786] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/30/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022] Open
Abstract
The understanding of atrial fibrillation (AF) evolved from a sole rhythm disturbance towards the complex concept of a cardiomyopathy based on arrhythmia substrates. There is evidence that atrial fibrosis can be visualized using late gadolinium enhancement cardiac magnetic resonance imaging and that it is a powerful predictor for the outcome of AF interventions. However, a strategy of an individual and fibrosis guided management of AF looks promising but results from prospective multicentre trials are pending. This review gives an overview about the relationship between cardiac fibrosis and AF focusing on translational aspects, clinical observations, and fibrosis imaging to emphasize the concept of personalized paths in AF management taking into account the individual amount and distribution of fibrosis.
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Affiliation(s)
- Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Nassir F Marrouche
- Cardiac Electrophysiology, Tulane University School of Medicine, 1430 Tulane Avenue, Box 8548, New Orleans, LA 70112, USA
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7
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Habibi M, Lima JAC, Gucuk Ipek E, Spragg D, Ashikaga H, Marine JE, Berger RD, Calkins H, Nazarian S. Short- and long-term associations of atrial fibrillation catheter ablation with left atrial structure and function: A cardiac magnetic resonance study. J Cardiovasc Electrophysiol 2020; 32:316-324. [PMID: 33350536 DOI: 10.1111/jce.14842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effects of atrial fibrillation (AF) catheter ablation on the left atrium (LA) are poorly understood. OBJECTIVES To examine short- and long-term associations of AF catheter ablation with LA function using cardiac magnetic resonance (CMR). METHODS Fifty-one AF patients (mean age 56 ± 8 years) underwent CMR at baseline, 1 day (n = 17) and 11 ± 2 months after ablation (n = 38). LA phasic volumes, emptying fractions (LAEF), and longitudinal strain were measured using feature-tracking CMR. LA fibrosis was quantified using late gadolinium enhancement (LGE). RESULTS There were no acute changes in volume; however, active, total LAEF, and peak LA strain decreased significantly compared to the baseline. During long-term follow-up, there was a decrease in maximum but not minimum LA volume (from 99 ± 5.2 ml to 89 ± 4.7 ml; p = .009) and a decrease in total LAEF (from 43 ± 1.8% to 39 ± 2.0%; p = .001). In patients with AF recurrence, LA volumes were unchanged. However, total LAEF decreased from 38 ± 3% to 33 ± 3%; p = .015. Patients without AF recurrence had no changes in LA functional parameters during follow-up. The amount of LA LGE at long-term follow-up was higher compared to the baseline, however, was significantly less compared to immediately post-procedure (37 ± 1.9% vs. 47 ± 2.8%; p = .015). A higher increase in LA LGE extent compared to the baseline was associated with a greater decrease in total LAEF (r = -.59; p < .001). CONCLUSIONS LA function is impaired acutely following AF catheter ablation. However, long-term changes of LA function are associated positively with the successful restoration of sinus rhythm and inversely with increased LA LGE.
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Affiliation(s)
- Mohammadali Habibi
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Valley Health System and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey, USA
| | - Joao A C Lima
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Esra Gucuk Ipek
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Spragg
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hiroshi Ashikaga
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph E Marine
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald D Berger
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hugh Calkins
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saman Nazarian
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Cardiology, Section for Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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8
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Abstract
Left atrial fibrosis plays an important role in the pathophysiology of atrial fibrillation. Left atrial ablation is an effective and increasingly used strategy to restore and maintain sinus rhythm in patients with atrial fibrillation. Late gadolinium enhancement (LGE) MRI and custom image analysis software have been used to visualize and quantify preablation atrial fibrosis and postablation scar and new fibrosis formation. This article reviews technical aspects of imaging atrial fibrosis/scar by LGE-MRI; use of atrial fibrosis and scar in predicting outcomes; applications of LGE-MRI to assess ablation lesions and optimize ablation parameters while avoiding collateral damage.
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Affiliation(s)
- Eugene G Kholmovski
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA; Utah Center for Advanced Imaging Research (UCAIR), University of Utah, Salt Lake City, UT, USA; Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Alan K Morris
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA
| | - Mihail G Chelu
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA; Division of Cardiovascular Medicine, Section of Electrophysiology, University of Utah, Salt Lake City, UT, USA.
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9
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Kuo L, Zado E, Frankel D, Santangelli P, Arkles J, Han Y, Marchlinski FE, Nazarian S, Desjardins B. Association of Left Atrial High-Resolution Late Gadolinium Enhancement on Cardiac Magnetic Resonance With Electrogram Abnormalities Beyond Voltage in Patients With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2020; 13:e007586. [PMID: 31940244 PMCID: PMC7031051 DOI: 10.1161/circep.119.007586] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Conflicting data have been reported on the association of left atrial (LA) late gadolinium enhancement (LGE) with atrial voltage in patients with atrial fibrillation. The association of LGE with electrogram fractionation and delay remains to be examined. We sought to examine the association between LA LGE on cardiac magnetic resonance and electrogram abnormalities in patients with atrial fibrillation. METHODS High-resolution LGE cardiac magnetic resonance was performed before electrogram mapping and ablation in atrial fibrillation patients. Cardiac magnetic resonance features were quantified using LA myocardial signal intensity Z score (SI-Z), a continuous normalized variable, as well as a dichotomous LGE variable based on previously validated methodology. Electrogram mapping was performed pre-ablation during sinus rhythm or LA pacing, and electrogram locations were coregistered with cardiac magnetic resonance images. Analyses were performed using multilevel patient-clustered mixed-effects regression models. RESULTS In the 40 patients with atrial fibrillation (age, 63.2±9.2 years; 1312.3±767.3 electrogram points per patient), lower bipolar voltage was associated with higher SI-Z in patients who had undergone previous ablation (coefficient, -0.049; P<0.001) but not in ablation-naive patients (coefficient, -0.004; P=0.7). LA electrogram activation delay was associated with SI-Z in patients with previous ablation (SI-Z: coefficient, 0.004; P<0.001 and LGE: coefficient, 0.04; P<0.001) but not in ablation-naive patients. In contrast, increased LA electrogram fractionation was associated with SI-Z (coefficient, 0.012; P=0.03) and LGE (coefficient, 0.035; P<0.001) only in ablation-naive patients. CONCLUSIONS The association of LA LGE with voltage is modified by ablation. Importantly, in ablation-naive patients, atrial LGE is associated with electrogram fractionation even in the absence of voltage abnormalities.
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Affiliation(s)
- Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan;,Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Erica Zado
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - David Frankel
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Pasquale Santangelli
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Jeffrey Arkles
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Yuchi Han
- Cardiovascular Division, Department of Medicine, University of Pennsylvania School of Medicine
| | - Francis E. Marchlinski
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Saman Nazarian
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Benoit Desjardins
- Department of Radiology, Hospital of Pennsylvania Medical Center, Philadelphia, PA
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10
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Trotta O, Alarcón F, Guasch E, Benito EM, San Antonio R, Perea RJ, Prat-Gonzalez S, Apolo J, Sitges M, Tolosana JM, Mont L. Impact of cryoballoon applications on lesion gaps detected by magnetic resonance after pulmonary vein isolation. J Cardiovasc Electrophysiol 2020; 31:638-646. [PMID: 31957087 DOI: 10.1111/jce.14358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/31/2019] [Accepted: 01/13/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Ablation with second-generation cryoballoon technology evolves as an effective and safe alternative to radiofrequency for atrial fibrillation ablation procedures. Nevertheless, the optimal freezing strategy remains unknown. Our objective was to identify the procedural cryoablation parameters predicting successful peri-pulmonary vein (PV) lesions by directly analyzing Postablation gaps in late-gadolinium-enhanced cardiac magnetic resonance (LGE-CMR). METHODS AND RESULTS Forty-nine consecutive patients (196 PVs) undergoing ablation with second-generation cryoballoon at our center were included. The number and duration of cryoballoon application to achieve PV isolation were left to operator discretion. Gap number and length were quantified in all patients with a LGE-CMR performed 3 months postablation. Application time (420 ± 217 seconds), number of applications (2.1 ± 1.2), application time after electrical isolation (311 ± 194 seconds) and minimum temperature (-45.8 ± 6.5°C) were similar in the 4 PVs. Gaps were observed in 148 PVs (76%), averaging 1.3 ± 1 gaps per vein. Gaps were longer and more frequent in the right PVs (91% vs 59% in left PVs, P < .001). Neither the number, total duration of applications, nor postisolation application time predicted relative length or number of gaps. CONCLUSIONS After successful PV isolation was achieved in patients undergoing cryoablation, increasing the number of applications, the total application time or application time postisolation did not result in a reduction in the number or the relative length of gaps.
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Affiliation(s)
- Omar Trotta
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Francisco Alarcón
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eduard Guasch
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eva Maria Benito
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Rodolfo San Antonio
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosario J Perea
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Susanna Prat-Gonzalez
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jose Apolo
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Marta Sitges
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - José María Tolosana
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Lluís Mont
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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11
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Packer M. Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment. Eur J Heart Fail 2019; 22:214-227. [PMID: 31849132 DOI: 10.1002/ejhf.1646] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/14/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023] Open
Abstract
Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk-to-benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post-ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College London, London, UK
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12
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Sivalokanathan S, Zghaib T, Greenland GV, Vasquez N, Kudchadkar SM, Kontari E, Lu DY, Dolores-Cerna K, van der Geest RJ, Kamel IR, Olgin JE, Abraham TP, Nazarian S, Zimmerman SL, Abraham MR. Hypertrophic Cardiomyopathy Patients With Paroxysmal Atrial Fibrillation Have a High Burden of Left Atrial Fibrosis by Cardiac Magnetic Resonance Imaging. JACC Clin Electrophysiol 2019; 5:364-375. [DOI: 10.1016/j.jacep.2018.10.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 12/30/2022]
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13
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New Insights Into the Use of Cardiac Magnetic Resonance Imaging to Guide Decision Making in Atrial Fibrillation Management. Can J Cardiol 2018; 34:1461-1470. [DOI: 10.1016/j.cjca.2018.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/06/2018] [Accepted: 07/08/2018] [Indexed: 12/13/2022] Open
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14
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Chubb H, Lal K, Kiedrowicz R, Karim R, Williams SE, Harrison J, Whitaker J, Wright M, Razavi R, O’Neill M. The value of ablation parameter indices for predicting mature atrial scar formation in humans: An in vivo assessment using cardiac magnetic resonance imaging. J Cardiovasc Electrophysiol 2018; 30:67-77. [DOI: 10.1111/jce.13754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/05/2018] [Accepted: 09/13/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Henry Chubb
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
| | - Kulvinder Lal
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
| | | | - Rashed Karim
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
- Department of Cardiology; St Thomas’ Hospital; London UK
| | - James Harrison
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
| | - Matthew Wright
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
- Department of Cardiology; St Thomas’ Hospital; London UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
| | - Mark O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College London; London UK
- Department of Cardiology; St Thomas’ Hospital; London UK
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15
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Pontecorboli G, Figueras I Ventura RM, Carlosena A, Benito E, Prat-Gonzales S, Padeletti L, Mont L. Use of delayed-enhancement magnetic resonance imaging for fibrosis detection in the atria: a review. Europace 2018; 19:180-189. [PMID: 28172967 DOI: 10.1093/europace/euw053] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/02/2016] [Indexed: 11/13/2022] Open
Abstract
This paper presents a review of the different approaches existing in the literature to detect and quantify fibrosis in contrast-enhanced magnetic resonance images of the left atrial wall. The paper provides a critical analysis of the different methods, stating their advantages and limitations, and providing detailed analysis on the possible sources of variability in the final amount of detected fibrosis coming from the use of different techniques.
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Affiliation(s)
| | | | | | - Eva Benito
- Hospital Clinic, Universitat de Barcelona, Catalonia, Spain
| | | | - Luigi Padeletti
- Department of Heart and Vessels, University of Florence, Florence, Italy.,IRCCS Multimedica, Milan, Italy
| | - Lluís Mont
- Hospital Clinic, Universitat de Barcelona, Catalonia, Spain
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16
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Chubb H, Aziz S, Karim R, Sohns C, Razeghi O, Williams SE, Whitaker J, Harrison J, Chiribiri A, Schaeffter T, Wright M, O’Neill M, Razavi R. Optimization of late gadolinium enhancement cardiovascular magnetic resonance imaging of post-ablation atrial scar: a cross-over study. J Cardiovasc Magn Reson 2018; 20:30. [PMID: 29720202 PMCID: PMC5932811 DOI: 10.1186/s12968-018-0449-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 04/04/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) imaging may be used to visualize post-ablation atrial scar (PAAS), and three-dimensional late gadolinium enhancement (3D LGE) is the most widely employed technique for imaging of chronic scar. Detection of PAAS provides a unique non-invasive insight into the effects of the ablation and may help guide further ablation procedures. However, there is evidence that PAAS is often not detected by CMR, implying a significant sensitivity problem, and imaging parameters vary between leading centres. Therefore, there is a need to establish the optimal imaging parameters to detect PAAS. METHODS Forty subjects undergoing their first pulmonary vein isolation procedure for AF had detailed CMR assessment of atrial scar: one scan pre-ablation, and two scans post-ablation at 3 months (separated by 48 h). Each scan session included ECG- and respiratory-navigated 3D LGE acquisition at 10, 20 and 30 min post injection of a gadolinium-based contrast agent (GBCA). The first post-procedural scan was performed on a 1.5 T scanner with standard acquisition parameters, including double dose (0.2 mmol/kg) Gadovist and 4 mm slice thickness. Ten patients subsequently underwent identical scan as controls, and the other 30 underwent imaging with a reduced, single, dose GBCA (n = 10), half slice thickness (n = 10) or on a 3 T scanner (n = 10). Apparent signal-to-noise (aSNR), contrast-to-noise (aCNR) and imaging quality (Likert Scale, 3 independent observers) were assessed. PAAS location and area (%PAAS scar) were assessed following manual segmentation. Atrial shells with standardised %PAAS at each timepoint were then compared to ablation lesion locations to assess quality of scar delineation. RESULTS A total of 271 3D acquisitions (out of maximum 280, 96.7%) were acquired. Likert scale of imaging quality had high interobserver and intraobserver intraclass correlation coefficients (0.89 and 0.96 respectively), and showed lower overall imaging quality on 3 T and at half-slice thickness. aCNR, and quality of scar delineation increased significantly with time. aCNR was higher with reduced, single, dose of GBCA (p = 0.005). CONCLUSION 3D LGE CMR atrial scar imaging, as assessed qualitatively and quantitatively, improves with time from GBCA administration, with some indices continuing to improve from 20 to 30 min. Imaging should be performed at least 20 min post-GBCA injection, and a single dose of contrast should be considered. TRIAL REGISTRATION Trial registry- United Kingdom National Research Ethics Service 08/H0802/68 - 30th September 2008.
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Affiliation(s)
- Henry Chubb
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Shadman Aziz
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Rashed Karim
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Christian Sohns
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Orod Razeghi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - James Harrison
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Tobias Schaeffter
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Matthew Wright
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Mark O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
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17
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Chubb H, Karim R, Roujol S, Nuñez-Garcia M, Williams SE, Whitaker J, Harrison J, Butakoff C, Camara O, Chiribiri A, Schaeffter T, Wright M, O’Neill M, Razavi R. The reproducibility of late gadolinium enhancement cardiovascular magnetic resonance imaging of post-ablation atrial scar: a cross-over study. J Cardiovasc Magn Reson 2018; 20:21. [PMID: 29554919 PMCID: PMC5858144 DOI: 10.1186/s12968-018-0438-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 02/19/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) imaging has been used to visualise post-ablation atrial scar (PAAS), generally employing a three-dimensional (3D) late gadolinium enhancement (LGE) technique. However the reproducibility of PAAS imaging has not been determined. This cross-over study is the first to investigate the reproducibility of the technique, crucial for both future research design and clinical implementation. METHODS Forty subjects undergoing first time ablation for atrial fibrillation (AF) had detailed CMR assessment of PAAS. Following baseline pre-ablation scan, two scans (separated by 48 h) were performed at three months post-ablation. Each scan session included 3D LGE acquisition at 10, 20 and 30 min post administration of gadolinium-based contrast agent (GBCA). Subjects were allocated at second scan post-ablation to identical imaging parameters ('Repro', n = 10), 3 T scanner ('3 T', n = 10), half-slice thickness ('Half-slice', n = 10) or half GBCA dose ('Half-gad', n = 10). PAAS was compared to baseline scar and then reproducibility was assessed for two measures of thresholded scar (% left atrial (LA) occupied by PAAS (%LA PAAS) and Pulmonary Vein Encirclement (PVE)), and then four measures of non-thresholded scar (point-by-point assessment of PAAS, four normalisation methods). Thresholded measures of PAAS were evaluated against procedural outcome (AF recurrence). RESULTS A total of 271 3D acquisitions (out of maximum 280, 96.7%) were acquired. At 20 and 30 min, inter-scan reproducibility was good to excellent (coefficient of variation at 20 min and 30 min: %LA PAAS 0.41 and 0.20; PVE 0.13 and 0.04 respectively for 'Repro' group). Changes in imaging parameters, especially reduced GBCA dose, reduced inter-scan reproducibility, but for most measures remained good to excellent (ICC for %LA PAAS 0.454-0.825, PVE 0.618-0.809 at 30 min). For non-thresholded scar, highest reproducibility was observed using blood pool z-score normalisation technique: inter-scan ICC 0.759 (absolute agreement, 'Repro' group). There was no significant relationship between indices of PAAS and AF recurrence. CONCLUSION PAAS imaging is a reproducible finding. Imaging should be performed at least 20 min post-GBCA injection, and a blood pool z-score should be considered for normalisation of signal intensities. The clinical implications of these findings remain to be established in the absence of a simple correlation with arrhythmia outcome. TRIAL REGISTRATION United Kingdom National Research Ethics Service 08/H0802/68 - 30th September 2008.
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Affiliation(s)
- Henry Chubb
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Rashed Karim
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Marta Nuñez-Garcia
- PhySense, Department of Information and Communication Technologies Department, Universitat Pompeu Fabra, Barcelona, Spain
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - James Harrison
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Constantine Butakoff
- PhySense, Department of Information and Communication Technologies Department, Universitat Pompeu Fabra, Barcelona, Spain
| | - Oscar Camara
- PhySense, Department of Information and Communication Technologies Department, Universitat Pompeu Fabra, Barcelona, Spain
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Tobias Schaeffter
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Matthew Wright
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Mark O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
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18
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Zghaib T, Keramati A, Chrispin J, Huang D, Balouch MA, Ciuffo L, Berger RD, Marine JE, Ashikaga H, Calkins H, Nazarian S, Spragg DD. Multimodal Examination of Atrial Fibrillation Substrate: Correlation of Left Atrial Bipolar Voltage Using Multi-Electrode Fast Automated Mapping, Point-by-Point Mapping, and Magnetic Resonance Image Intensity Ratio. JACC Clin Electrophysiol 2018; 4:59-68. [PMID: 29520376 PMCID: PMC5836739 DOI: 10.1016/j.jacep.2017.10.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Bipolar voltage mapping, as part of atrial fibrillation (AF) ablation, is traditionally performed in a point-by-point (PBP) approach using single-tip ablation catheters. Alternative techniques for fibrosis-delineation include fast-anatomical mapping (FAM) with multi-electrode circular catheters, and late gadolinium-enhanced magnetic-resonance imaging (LGE-MRI). The correlation between PBP, FAM, and LGE-MRI fibrosis assessment is unknown. Objective In this study, we examined AF substrate using different modalities (PBP, FAM, and LGE-MRI mapping) in patients presenting for an AF ablation. Methods LGE-MRI was performed pre-ablation in 26 patients (73% males, age 63±8years). Local image-intensity ratio (IIR) was used to normalize myocardial intensities. PBP- and FAM-voltage maps were acquired, in sinus rhythm, prior to ablation and co-registered to LGE-MRI. Results Mean bipolar voltage for all 19,087 FAM voltage points was 0.88±1.27mV and average IIR was 1.08±0.18. In an adjusted mixed-effects model, each unit increase in local IIR was associated with 57% decrease in bipolar voltage (p<0.0001). IIR of >0.74 corresponded to bipolar voltage <0.5 mV. A total of 1554 PBP-mapping points were matched to the nearest FAM-point. In an adjusted mixed-effects model, log-FAM bipolar voltage was significantly associated with log-PBP bipolar voltage (ß=0.36, p<0.0001). At low-voltages, FAM-mapping distribution was shifted to the left compared to PBP-mapping; at intermediate voltages, FAM and PBP voltages were overlapping; and at high voltages, FAM exceeded PBP-voltages. Conclusion LGE-MRI, FAM and PBP-mapping show good correlation in delineating electro-anatomical AF substrate. Each approach has fundamental technical characteristics, the awareness of which allows proper assessment of atrial fibrosis.
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Affiliation(s)
- Tarek Zghaib
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ali Keramati
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan Chrispin
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dong Huang
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Muhammad A. Balouch
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Luisa Ciuffo
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald D. Berger
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
- Biomedical Engineering, The Johns Hopkins University, Philadelphia, PA
| | - Joseph E. Marine
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiroshi Ashikaga
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
- Biomedical Engineering, The Johns Hopkins University, Philadelphia, PA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Saman Nazarian
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David D. Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
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19
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Siebermair J, Kholmovski EG, Marrouche N. Assessment of Left Atrial Fibrosis by Late Gadolinium Enhancement Magnetic Resonance Imaging: Methodology and Clinical Implications. JACC Clin Electrophysiol 2017; 3:791-802. [PMID: 29759774 DOI: 10.1016/j.jacep.2017.07.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/07/2017] [Accepted: 07/13/2017] [Indexed: 12/12/2022]
Abstract
Recently, studies using late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) to identify structural changes of atrial tissue have contributed significantly to understanding the pathophysiology and progression of atrial fibrillation (AF). Moreover, imaging of atrial fibrosis using MRI has evolved to be a tool to improve clinical outcome of AF ablation procedures by allowing a patient-specific individualized management approach. LGE-MRI has been shown to predict AF ablation outcome based on pre-procedural imaging to define the extent of atrial fibrosis. The results of the ongoing DECAAF II (Delayed-Enhancement MRI Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation) trial might extend ablation strategies from pulmonary vein isolation alone to a substrate-based approach. Furthermore, an improved understanding of the underlying mechanisms of atrial structural remodeling is crucial in order to reduce the occurrence of AF-associated complications (e.g., ischemic stroke and heart failure). This review article provides current methodology of atrial fibrosis imaging using LGE-MRI and delineates actual clinical implications and future directions for this imaging approach.
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Affiliation(s)
- Johannes Siebermair
- Comprehensive Arrhythmia and Research Management (CARMA) Center, University of Utah School of Medicine, Salt Lake City, Utah; Department of Medicine I, Klinikum Grosshadern, University of Munich, Munich, Germany; German Cardiovascular Research Center (DZHK), partner site Munich Heart Alliance, Munich, Germany
| | - Eugene G Kholmovski
- Comprehensive Arrhythmia and Research Management (CARMA) Center, University of Utah School of Medicine, Salt Lake City, Utah; UCAIR, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah
| | - Nassir Marrouche
- Comprehensive Arrhythmia and Research Management (CARMA) Center, University of Utah School of Medicine, Salt Lake City, Utah.
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20
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Nazarian S. Cardiac Electrophysiology Procedures, Known Unknowns, and Unknown Unknowns. JACC Clin Electrophysiol 2017; 3:104-106. [DOI: 10.1016/j.jacep.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/15/2016] [Indexed: 11/28/2022]
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21
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Kirchhof P, Calkins H. Catheter ablation in patients with persistent atrial fibrillation. Eur Heart J 2017; 38:20-26. [PMID: 27389907 PMCID: PMC5353871 DOI: 10.1093/eurheartj/ehw260] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/29/2016] [Accepted: 06/01/2016] [Indexed: 12/29/2022] Open
Abstract
Catheter ablation is increasingly offered to patients who suffer from symptoms due to atrial fibrillation (AF), based on a growing body of evidence illustrating its efficacy compared with antiarrhythmic drug therapy. Approximately one-third of AF ablation procedures are currently performed in patients with persistent or long-standing persistent AF. Here, we review the available information to guide catheter ablation in these more chronic forms of AF. We identify the following principles: Our clinical ability to discriminate paroxysmal and persistent AF is limited. Pulmonary vein isolation is a reasonable and effective first approach for catheter ablation of persistent AF. Other ablation strategies are being developed and need to be properly evaluated in controlled, multicentre trials. Treatment of concomitant conditions promoting recurrent AF by life style interventions and medical therapy should be a routine adjunct to catheter ablation of persistent AF. Early rhythm control therapy has a biological rationale and trials evaluating its value are underway. There is a clear need to generate more evidence for the best approach to ablation of persistent AF beyond pulmonary vein isolation in the form of adequately powered controlled multi-centre trials.
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Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, IBR, Room # 136, Birmingham B15 2TT, UK
- SWBH and UHB NHS Trusts, Birmingham, UK
- Atrial Fibrillation NETwork (AFNET), Münster, Germany
- Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
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22
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Khurram IM, Habibi M, Gucuk Ipek E, Chrispin J, Yang E, Fukumoto K, Dewire J, Spragg DD, Marine JE, Berger RD, Ashikaga H, Rickard J, Zhang Y, Zipunnikov V, Zimmerman SL, Calkins H, Nazarian S. Left Atrial LGE and Arrhythmia Recurrence Following Pulmonary Vein Isolation for Paroxysmal and Persistent AF. JACC Cardiovasc Imaging 2016; 9:142-8. [PMID: 26777218 PMCID: PMC4744105 DOI: 10.1016/j.jcmg.2015.10.015] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 09/16/2015] [Accepted: 10/08/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The aims of this study were to: 1) use a novel method of late gadolinium enhancement (LGE) quantification that uses normalized intensity measures to confirm the association between LGE extent and atrial fibrillation (AF) recurrence following ablation; and 2) examine the presence of interaction and effect modification between LGE and AF persistence. BACKGROUND Recurrent AF after catheter ablation has been reported to associate with the baseline extent of left atrial LGE on cardiac magnetic resonance. Traditional methods for measurement of intensity lack an objective threshold for quantification and interpatient comparisons of LGE. METHODS The cohort included 165 participants (mean age 60.0 ± 10.2 years, 77% men, 57% with persistent AF) who underwent initial AF ablation. The association of baseline LGE extent with AF recurrence was examined using multivariable Cox proportional hazards models. Multiplicative and additive interactions between AF type and LGE extent were examined. RESULTS During 10.2 ± 5.7 months of follow-up, 63 patients (38.2%) experienced AF recurrence. Baseline LGE extent was independently associated with AF recurrence after adjusting for confounders (hazard ratio: 1.5 per 10% increased LGE; p < 0.001). The hazard ratio for AF recurrence progressively increased as a function of LGE. The magnitude of association between LGE >35% and AF recurrence was greater among patients with persistent AF (hazard ratio: 6.5 [p = 0.001] vs. 3.6 [p = 0.001]); however, there was no evidence for statistical interaction. CONCLUSIONS Regardless of AF persistence at baseline, participants with LGE ≤35% have favorable outcomes, whereas those with LGE >35% have a higher rate of AF recurrence in the first year after ablation. These findings suggest a role for: 1) patient selection for AF ablation using LGE extent; and 2) substrate modification in addition to pulmonary vein isolation in patients with LGE extent exceeding 35% of left atrial myocardium.
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Affiliation(s)
- Irfan M Khurram
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | | | - Esra Gucuk Ipek
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Jonathan Chrispin
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Eunice Yang
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Kotaro Fukumoto
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Jane Dewire
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - David D Spragg
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Joseph E Marine
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Ronald D Berger
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Hiroshi Ashikaga
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Jack Rickard
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Yiyi Zhang
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Vadim Zipunnikov
- Department of Biostatistics, Johns Hopkins University, Baltimore, Maryland
| | | | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Saman Nazarian
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland.
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23
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Giannakidis A, Nyktari E, Keegan J, Pierce I, Suman Horduna I, Haldar S, Pennell DJ, Mohiaddin R, Wong T, Firmin DN. Rapid automatic segmentation of abnormal tissue in late gadolinium enhancement cardiovascular magnetic resonance images for improved management of long-standing persistent atrial fibrillation. Biomed Eng Online 2015; 14:88. [PMID: 26445883 PMCID: PMC4596471 DOI: 10.1186/s12938-015-0083-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/21/2015] [Indexed: 01/11/2023] Open
Abstract
Background Atrial fibrillation (AF) is the most common heart rhythm disorder. In order for late Gd enhancement cardiovascular magnetic resonance (LGE CMR) to ameliorate the AF management, the ready availability of the accurate enhancement segmentation is required. However, the computer-aided segmentation of enhancement in LGE CMR of AF is still an open question. Additionally, the number of centres that have reported successful application of LGE CMR to guide clinical AF strategies remains low, while the debate on LGE CMR’s diagnostic ability for AF still holds. The aim of this study is to propose a method that reliably distinguishes enhanced (abnormal) from non-enhanced (healthy) tissue within the left atrial wall of (pre-ablation and 3 months post-ablation) LGE CMR data-sets from long-standing persistent AF patients studied at our centre. Methods Enhancement segmentation was achieved by employing thresholds benchmarked against the statistics of the whole left atrial blood-pool (LABP). The test-set cross-validation mechanism was applied to determine the input feature representation and algorithm that best predict enhancement threshold levels. Results Global normalized intensity threshold levels TPRE = 1 1/4 and TPOST = 1 5/8 were found to segment enhancement in data-sets acquired pre-ablation and at 3 months post-ablation, respectively. The segmentation results were corroborated by using visual inspection of LGE CMR brightness levels and one endocardial bipolar voltage map. The measured extent of pre-ablation fibrosis fell within the normal range for the specific arrhythmia phenotype. 3D volume renderings of segmented post-ablation enhancement emulated the expected ablation lesion patterns. By comparing our technique with other related approaches that proposed different threshold levels (although they also relied on reference regions from within the LABP) for segmenting enhancement in LGE CMR data-sets of AF patients, we illustrated that the cut-off levels employed by other centres may not be usable for clinical studies performed in our centre. Conclusions The proposed technique has great potential for successful employment in the AF management within our centre. It provides a highly desirable validation of the LGE CMR technique for AF studies. Inter-centre differences in the CMR acquisition protocol and image analysis strategy inevitably impede the selection of a universally optimal algorithm for segmentation of enhancement in AF studies.
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Affiliation(s)
- Archontis Giannakidis
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK. .,National Heart and Lung Institute, Imperial College London, London, UK.
| | - Eva Nyktari
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.
| | - Jennifer Keegan
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK. .,National Heart and Lung Institute, Imperial College London, London, UK.
| | - Iain Pierce
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK. .,National Heart and Lung Institute, Imperial College London, London, UK.
| | - Irina Suman Horduna
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.
| | - Shouvik Haldar
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.
| | - Dudley J Pennell
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK. .,National Heart and Lung Institute, Imperial College London, London, UK.
| | - Raad Mohiaddin
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.
| | - Tom Wong
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.
| | - David N Firmin
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK. .,National Heart and Lung Institute, Imperial College London, London, UK.
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