1
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Iwamiya S, Ihara K, Nitta G, Sasano T. Atrial Fibrillation and Underlying Structural and Electrophysiological Heterogeneity. Int J Mol Sci 2024; 25:10193. [PMID: 39337682 PMCID: PMC11432636 DOI: 10.3390/ijms251810193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/16/2024] [Accepted: 09/19/2024] [Indexed: 09/30/2024] Open
Abstract
As atrial fibrillation (AF) progresses from initial paroxysmal episodes to the persistent phase, maintaining sinus rhythm for an extended period through pharmacotherapy and catheter ablation becomes difficult. A major cause of the deteriorated treatment outcome is the atrial structural and electrophysiological heterogeneity, which AF itself can exacerbate. This heterogeneity exists or manifests in various dimensions, including anatomically segmental structural features, the distribution of histological fibrosis and the autonomic nervous system, sarcolemmal ion channels, and electrophysiological properties. All these types of heterogeneity are closely related to the development of AF. Recognizing the heterogeneity provides a valuable approach to comprehending the underlying mechanisms in the complex excitatory patterns of AF and the determining factors that govern the seemingly chaotic propagation. Furthermore, substrate modification based on heterogeneity is a potential therapeutic strategy. This review aims to consolidate the current knowledge on structural and electrophysiological atrial heterogeneity and its relation to the pathogenesis of AF, drawing insights from clinical studies, animal and cell experiments, molecular basis, and computer-based approaches, to advance our understanding of the pathophysiology and management of AF.
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Affiliation(s)
- Satoshi Iwamiya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Kensuke Ihara
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Giichi Nitta
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
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2
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024; 21:e31-e149. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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3
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Gao S, Liu H, Post A, Jaworski L, Bernard D, John M, Cosgriff-Hernandez E, Razavi M, Zhang HK. Enhancing boundary detection of radiofrequency ablation lesions through photoacoustic mapping. Sci Rep 2024; 14:19370. [PMID: 39169048 PMCID: PMC11339419 DOI: 10.1038/s41598-024-68046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 07/18/2024] [Indexed: 08/23/2024] Open
Abstract
Atrial fibrillation (A-fib) is the most common type of heart arrhythmia, typically treated with radiofrequency catheter ablation to isolate the heart from abnormal electrical signals. Monitoring the formation of ablation-induced lesions is crucial for preventing recurrences and complications arising from excessive or insufficient ablation. Existing imaging modalities lack real-time feedback, and their intraoperative usage is in its early stages. A critical need exists for an imaging-based lesion indexing (LSI) method that directly reflects tissue necrosis formation. Previous studies have indicated that spectroscopic photoacoustic (sPA) imaging can differentiate ablated tissues from their non-ablated counterparts based on PA spectrum variation. In this paper, we introduce a method for detecting ablation lesion boundaries using sPA imaging. This approach utilizes ablation LSI, which quantifies the ratio between the signal from ablated tissue and the total tissue signal. We enhance boundary detection accuracy by adapting a regression model-based compensation. Additionally, the method was cross-validated with clinically used intraoperative monitoring parameters. The proposed method was validated with ex vivo porcine cardiac tissues with necrotic lesions created by different ablation durations. The PA-measured lesion size was compared with gross pathology. Statistical analysis demonstrates a strong correlation (R > 0.90) between the PA-detected lesion size and gross pathology. The PA-detected lesion size also exhibits a moderate to strong correlation (R > 0.75) with local impedance changes recorded during procedures. These results suggest that the introduced PA imaging-based LSI has great potential to be incorporated into the clinical workflow, guiding ablation procedures intraoperatively.
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Affiliation(s)
- Shang Gao
- Department of Robotics Engineering, Worcester Polytechnic Institute, 100 Institute Rd, Worcester, MA, 01609, USA.
| | - Haotian Liu
- Department of Robotics Engineering, Worcester Polytechnic Institute, 100 Institute Rd, Worcester, MA, 01609, USA
| | - Allison Post
- Electrophysiology Clinical Research and Innovations, The Texas Heart Institute, 6770 Bertner Ave, Houston, TX, 77030, USA
| | - Lukas Jaworski
- Electrophysiology Clinical Research and Innovations, The Texas Heart Institute, 6770 Bertner Ave, Houston, TX, 77030, USA
| | - Drew Bernard
- Electrophysiology Clinical Research and Innovations, The Texas Heart Institute, 6770 Bertner Ave, Houston, TX, 77030, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, The Texas Heart Institute, 6770 Bertner Ave, Houston, TX, 77030, USA
| | | | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, The Texas Heart Institute, 6770 Bertner Ave, Houston, TX, 77030, USA
| | - Haichong K Zhang
- Department of Robotics Engineering, Worcester Polytechnic Institute, 100 Institute Rd, Worcester, MA, 01609, USA.
- Department of Biomedical Engineering, Worcester Polytechnic Institute, 100 Institute Rd, Worcester, MA, 01609, USA.
- Department of Computer Science, Worcester Polytechnic Institute, 100 Institute Rd, Worcester, MA, 01609, USA.
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4
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:921-1072. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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5
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Gao S, Ashikaga H, Suzuki M, Mansi T, Kim YH, Ghesu FC, Kang J, Boctor EM, Halperin HR, Zhang HK. Cardiac-gated spectroscopic photoacoustic imaging for ablation-induced necrotic lesion visualization. JOURNAL OF BIOPHOTONICS 2024:e202400126. [PMID: 39075610 DOI: 10.1002/jbio.202400126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 07/31/2024]
Abstract
Radiofrequency (RF) ablation is a minimally invasive therapy for atrial fibrillation. Conventional RF procedures lack intraoperative monitoring of ablation-induced necrosis, complicating assessment of completeness. While spectroscopic photoacoustic (sPA) imaging shows promise in distinguishing ablated tissue, multi-spectral imaging is challenging in vivo due to low imaging quality caused by motion. Here, we introduce a cardiac-gated sPA imaging (CG-sPA) framework to enhance image quality using a motion-gated averaging filter, relying on image similarity. Necrotic extent was calculated based on the ratio between spectral unmixed ablated tissue contrast and total tissue contrast, visualizing as a continuous color map to highlight necrotic area. The validation of the concept was conducted in both ex vivo and in vivo swine models. The ablation-induced necrotic lesion was successfully detected throughout the cardiac cycle through CG-sPA imaging. The results suggest the CG-sPA imaging framework has great potential to be incorporated into clinical workflow to guide ablation procedures intraoperatively.
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Affiliation(s)
- Shang Gao
- Department of Robotics Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
| | - Hiroshi Ashikaga
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Masahito Suzuki
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tommaso Mansi
- Siemens Healthineers, Digital Technology and Innovation, Princeton, New Jersey, USA
| | - Young-Ho Kim
- Siemens Healthineers, Digital Technology and Innovation, Princeton, New Jersey, USA
| | | | - Jeeun Kang
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Whiting School of Engineering, Baltimore, Maryland, USA
| | - Emad M Boctor
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Whiting School of Engineering, Baltimore, Maryland, USA
| | - Henry R Halperin
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Haichong K Zhang
- Department of Robotics Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
- Department of Computer Science, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
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6
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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7
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Plank K, Bordignon S, Urbanek L, Chen S, Tohoku S, Schaack D, Hirokami J, Efe T, Chun KRJ, Schmidt B. Early recurrences predict late therapy failure after pulsed field ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:2425-2433. [PMID: 37767744 DOI: 10.1111/jce.16083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Pulsed field ablation (PFA) is a new ablation technology for atrial fibrillation (AF). Data regarding early recurrences of atrial tachyarrhythmia (ERAT) after PFA-pulmonary vein isolation (PVI) are sparse. METHODS Consecutive patients with symptomatic AF were enrolled to undergo PFA-PVI. A dedicated catheter delivering bipolar energy (1.9-2.0 kV) was used. Late recurrence (LR) was defined as documented AF/atrial tachycardia (AT) lasting more than 30 s after a 90-day blanking period. RESULTS Two hundred and thirty-one patients (42% female, age 69 ± 12, 55% paroxysmal AF [PAF]) were included in this analysis. Median follow-up time was 367 days (interquartile range: 253-400). Forty-six patients (21%) experienced ERAT after a median of 23 days (46% in PAF and 54% in persistent AF [persAF]). Kaplan-Meier estimated freedom of AF/AT was 74.2% at 1 year, 81.8% for PAF, and 64.8% for persAF (p = .0079). Of patients experiencing ERAT, an LR was observed in 54%. There was no significant difference of LR between those who presented with very early ERAT (0-45 days) and those with ERAT (46-90 days) (p = .57). In multivariate analysis, ERAT (hazard ratio [HR]: 3.370; 95% confidence interval [95% CI]: 1.851-6.136; p < .001) and female sex (HR: 2.048; 95% CI: 1.114-3.768; p = .021) were the only independent predictors for LR. CONCLUSIONS ERAT could be recorded in 21% of patients after PFA-PVI and was an independent predictor for LR. We found no difference in the rate of LRs among patients experiencing ERAT before or after 45 days.
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Affiliation(s)
- Karin Plank
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - Stefano Bordignon
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - Lukas Urbanek
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - Shota Tohoku
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - David Schaack
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - Jun Hirokami
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - Tolga Efe
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - K R Julian Chun
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien CCB at Agaplesion Markus Krankenhaus, Medizinische Klinik III, Frankfurt am Main, Germany
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8
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Hopman LHGA, van Pouderoijen N, Mulder MJ, van der Laan AM, Bhagirath P, Nazarian S, Niessen HWM, Ferrari VA, Allaart CP, Götte MJW. Atrial Ablation Lesion Evaluation by Cardiac Magnetic Resonance: Review of Imaging Strategies and Histological Correlations. JACC Clin Electrophysiol 2023; 9:2665-2679. [PMID: 37737780 DOI: 10.1016/j.jacep.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/09/2023] [Indexed: 09/23/2023]
Abstract
Cardiac magnetic resonance (CMR) imaging is a valuable noninvasive tool for evaluating tissue response following catheter ablation of atrial tissue. This review provides an overview of the contemporary CMR strategies to visualize atrial ablation lesions in both the acute and chronic postablation stages, focusing on their strengths and limitations. Moreover, the accuracy of CMR imaging in comparison to atrial lesion histology is discussed. T2-weighted CMR imaging is sensitive to edema and tends to overestimate lesion size in the acute stage after ablation. Noncontrast agent-enhanced T1-weighted CMR imaging has the potential to provide more accurate assessment of lesions in the acute stage but may not be as effective in the chronic stage. Late gadolinium enhancement imaging can be used to detect chronic atrial scarring, which may inform repeat ablation strategies. Moreover, novel imaging strategies are being developed, but their efficacy in characterizing atrial lesions is yet to be determined. Overall, CMR imaging has the potential to provide virtual histology that aids in evaluating the efficacy and safety of catheter ablation and monitoring of postprocedural myocardial changes. However, technical factors, scanning during arrhythmia, and transmurality assessment pose challenges. Therefore, further research is needed to develop CMR strategies to visualize the ablation lesion maturation process more effectively.
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Affiliation(s)
| | | | - Mark J Mulder
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Pranav Bhagirath
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Saman Nazarian
- Penn Cardiovascular Institute, Penn Heart and Vascular Center, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania, USA
| | - Hans W M Niessen
- Department of Pathology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Victor A Ferrari
- Penn Cardiovascular Institute, Penn Heart and Vascular Center, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania, USA
| | | | - Marco J W Götte
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands.
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9
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Allen JJ, Keegan J, Mathew G, Conway M, Jenkins S, Pennell DJ, Nielles-Vallespin S, Gatehouse P, Babu-Narayan SV. Fully-modelled blood-focused variable inversion times for 3D late gadolinium-enhanced imaging. Magn Reson Imaging 2023; 98:44-54. [PMID: 36581215 DOI: 10.1016/j.mri.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE Variable heart rate during single-cycle inversion-recovery Late Gadolinium-Enhanced (LGE) scanning degrades image quality, which can be mitigated using Variable Inversion Times (VTIs) in real-time response to R-R interval changes. We investigate in vivo and in simulations an extension of a single-cycle VTI method previously applied in 3D LGE imaging, that now fully models the longitudinal magnetisation (fmVTI). METHODS The VTI and fmVTI methods were used to perform 3D LGE scans for 28 3D LGE patients, with qualitative image quality scores assigned for left atrial wall clarity and total ghosting. Accompanying simulations of numerical phantom images were assessed in terms of ghosting of normal myocardium, blood, and myocardial scar. RESULTS The numerical simulations for fmVTI showed a significant decrease in blood ghosting (VTI: 410 ± 710, fmVTI: 68 ± 40, p < 0.0005) and scar ghosting (VTI: 830 ± 1300, fmVTI: 510 ± 730, p < 0.02). Despite this, there was no significant change in qualitative image quality scores, either for left atrial wall clarity (VTI: 2.0 ± 1.0, fmVTI: 1.8 ± 1.0, p > 0.1) or for total ghosting (VTI: 1.9 ± 1.0, fmVTI: 2.0 ± 1.0, p > 0.7). CONCLUSIONS Simulations indicated reduced ghosting with the fmVTI method, due to reduced Mz variability in the blood signal. However, other sources of phase-encode ghosting and blurring appeared to dominate and obscure this finding in the patient studies available.
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Affiliation(s)
- Jack J Allen
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jennifer Keegan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - George Mathew
- Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Miriam Conway
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Sophie Jenkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dudley J Pennell
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Sonia Nielles-Vallespin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Peter Gatehouse
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Sonya V Babu-Narayan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital. Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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10
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Rav Acha M, Tovia-Brodie O, Michowitz Y, Bayya F, Shaheen FF, Abuhatzera S, Medina A, Glikson M, Wolak A. Cryoballoon-Induced Circumferential Pulmonary Vein Fibrosis, Assessed by Late Gadolinium-Enhancement Cardiac Magnetic Resonance Imaging, and Its Correlation with Clinical Atrial Fibrillation Recurrence. J Clin Med 2023; 12:jcm12062442. [PMID: 36983442 PMCID: PMC10056270 DOI: 10.3390/jcm12062442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/01/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Prior studies evaluating post-atrial fibrillation (AF) ablation pulmonary vein (PV) ostial gaps via magnetic resonance imaging (MRI) have shown circumferential PV fibrosis in a minority of patients, and their correlation with AF recurrence was weak. These studies were mostly based on radio-frequency AF ablations. AIM We aimed to assess cryoballoon ablation-induced PV fibrosis via MRI and its correlation with AF recurrence. METHODS AND RESULTS This was a prospective study of consecutive patients with symptomatic AF who underwent pre- and post-ablation MRI to assess baseline and ablation-induced fibrosis, respectively. Post-ablation PV gaps were assessed by new semi-quantitative visual analysis assisted by computerized ADAS analysis. AF recurrence monitored via multiple ECGs and event monitoring at 6 and 12 months post ablation. Nineteen patients with 80 PVs were included, age 56 ± 11, with paroxysmal and persistent AF in 17/19 and 2/19 patients, respectively. Baseline MRI showed minimal LA fibrosis. All patients underwent successful cryoballoon PV electrical isolation. Post-ablation MRI revealed circumferential PV fibrosis among 63/80 (78.8%) PVs and partial fibrosis with major gaps among 17/80 (21.2%) PVs. AF recurred within one year in 5/9 (55.5%) patients with partial PV fibrosis, while no AF recurred among the 10 patients in whom all PVs had circumferential fibrosis (p < 0.01). Similarly, there were significantly more PVs without circumferential fibrosis (due to major gaps) among patients with AF recurrence as compared with patients without AF recurrence (42.9% vs. 13.5%; p < 0.01). CONCLUSION Cryoballoon AF ablation results in circumferential PV fibrosis in the majority of PVs, as assessed by a new clinically relevant MRI-LGE analysis. Significant correlation was found between major PV gaps on post-ablation MRI and AF recurrence, suggesting that MRI might have the ability to predict AF recurrence.
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Affiliation(s)
- Moshe Rav Acha
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Oholi Tovia-Brodie
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Yoav Michowitz
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Feras Bayya
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Fauzi F Shaheen
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Shalom Abuhatzera
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Aharon Medina
- Shamir Medical Center, Cardiology Department, Be'er-Yaakov 7033001, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 900050, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Arik Wolak
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, Jerusalem 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
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11
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Nelson DW, Dhorepatil A, Kreidieh O, Mekhael M, Noujaim C, Assaf A, Feng H, Marrouche N. Differences in postablation cardiac MRI scar between radiofrequency and cryoballoon ablation: A DECAAF II subanalysis. J Cardiovasc Electrophysiol 2023; 34:810-822. [PMID: 36871178 DOI: 10.1111/jce.15879] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/11/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) using radiofrequency (RF) and cryoballoon (Cryo) ablation are standard approaches for rhythm control in patients with symptomatic atrial fibrillation. Both strategies create scars in the left atrium (LA). There have been few studies investigating the difference in scar formation between patients undergoing RF and Cryo using cardiac magnetic resonance (CMR) imaging. METHODS The current study is a subanalysis of the control arm of the Delayed-Enhancement MRI Determinant of Successful Catheter Ablation of Atrial Fibrillation study (DECAAF II). The study was a multicenter, randomized, controlled, single-blinded trial that evaluated atrial arrhythmia recurrence (AAR) between PVI alone and PVI plus CMR atrial fibrosis-guided ablation. Preablation CMR and 3- to 6-month postablation CMR were obtained to assess baseline LA fibrosis and scar formation, respectively. RESULTS Of the 843 patients randomized in the DECAAF II trial, we analyzed the 408 patients in the primary analysis control arm that received standard PVI. Five patients received combined RF and Cryo ablations, so they were excluded from this subanalysis. Of the 403 patients analyzed, 345 underwent RF and 58 Cryo. The average procedure duration was 146 min for RF and 103 min for Cryo (p = .001). The rate of AAR at ~15 months occurred in 151 (43.8%) patients in the RF group and 28 (48.3%) patients in the Cryo group (p = .62). On 3-month post-CMR, the RF arm had significantly more scar (8.8% vs. 6.4%, p = .001) compared to Cryo. Patients with ≥6.5% LA scar (p < .001) and ≥2.3% LA scar around the PV antra (p = .01) on 3-month post-CMR had less AAR independent of the ablation technique. Cryo caused a greater percentage of right and left pulmonary vein (PV) antral scar (p = .04, p = .02) and less non-PV antral scar (p = .009) compared to RF. On Cox regression, Cryo patients free of AAR had a greater percentage of left PV antral scar (p = .01) and less non-PV antral scar (p = .004) compared to RF free of AAR. CONCLUSION In this subanalysis of the control arm of the DECAAF II trial, we observed that Cryo formed a more significant percentage of PV antral scar and less non-PV antral scar compared to RF. Post ablation LA scar ≥6.5% predicted freedom from AAR, independent of ablation technique. These findings may have prognostic implications in ablation technique selection and freedom from AAR.
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Affiliation(s)
- Daniel Wetherbee Nelson
- Division of Cardiovascular, Tulane University, New Orleans, Louisiana, USA.,TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
| | - Aneesh Dhorepatil
- Division of Cardiovascular, Tulane University, New Orleans, Louisiana, USA.,TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
| | - Omar Kreidieh
- Division of Cardiovascular, Tulane University, New Orleans, Louisiana, USA.,TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
| | - Mario Mekhael
- TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
| | - Charbel Noujaim
- TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
| | - Ala Assaf
- TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
| | - Han Feng
- TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
| | - Nassir Marrouche
- Division of Cardiovascular, Tulane University, New Orleans, Louisiana, USA.,TRIAD Research Group, Tulane University, New Orleans, Louisiana, USA
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12
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Quintana RA, Dong T, Vajapey R, Reyaldeen R, Kwon DH, Harb S, Wang TKM, Klein AL. Intra- and Postprocedural Multimodality Imaging in Atrial Fibrillation. Circ Cardiovasc Imaging 2022; 15:e014804. [PMID: 36378776 DOI: 10.1161/circimaging.122.014804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Multi-modality imaging plays critical roles during and after procedures associated with atrial fibrillation. Transesophageal echocardiography is an invaluable tool for left atrial appendage occlusion during the procedure and at follow-up. Both cardiac computed tomography and cardiac magnetic resonance contribute to postprocedural evaluation of pulmonary vein isolation ablation. The present review is the second of a 2-part series where we discuss the roles of cardiac imaging in the evaluation and management of patients with atrial fibrillation, focusing on intraprocedural and postprocedural assessment, including the clinical evidence and outcomes data supporting this future applications.
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Affiliation(s)
- Raymundo A Quintana
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus (R.A.Q.)
| | - Tiffany Dong
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Ramya Vajapey
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Reza Reyaldeen
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Deborah H Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Serge Harb
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
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13
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Chen J, Zhang H, Mohiaddin R, Wong T, Firmin D, Keegan J, Yang G. Adaptive Hierarchical Dual Consistency for Semi-Supervised Left Atrium Segmentation on Cross-Domain Data. IEEE TRANSACTIONS ON MEDICAL IMAGING 2022; 41:420-433. [PMID: 34534077 DOI: 10.1109/tmi.2021.3113678] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Semi-supervised learning provides great significance in left atrium (LA) segmentation model learning with insufficient labelled data. Generalising semi-supervised learning to cross-domain data is of high importance to further improve model robustness. However, the widely existing distribution difference and sample mismatch between different data domains hinder the generalisation of semi-supervised learning. In this study, we alleviate these problems by proposing an Adaptive Hierarchical Dual Consistency (AHDC) for the semi-supervised LA segmentation on cross-domain data. The AHDC mainly consists of a Bidirectional Adversarial Inference module (BAI) and a Hierarchical Dual Consistency learning module (HDC). The BAI overcomes the difference of distributions and the sample mismatch between two different domains. It mainly learns two mapping networks adversarially to obtain two matched domains through mutual adaptation. The HDC investigates a hierarchical dual learning paradigm for cross-domain semi-supervised segmentation based on the obtained matched domains. It mainly builds two dual-modelling networks for mining the complementary information in both intra-domain and inter-domain. For the intra-domain learning, a consistency constraint is applied to the dual-modelling targets to exploit the complementary modelling information. For the inter-domain learning, a consistency constraint is applied to the LAs modelled by two dual-modelling networks to exploit the complementary knowledge among different data domains. We demonstrated the performance of our proposed AHDC on four 3D late gadolinium enhancement cardiac MR (LGE-CMR) datasets from different centres and a 3D CT dataset. Compared to other state-of-the-art methods, our proposed AHDC achieved higher segmentation accuracy, which indicated its capability in the cross-domain semi-supervised LA segmentation.
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14
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Chen J, Yang G, Khan H, Zhang H, Zhang Y, Zhao S, Mohiaddin R, Wong T, Firmin D, Keegan J. JAS-GAN: Generative Adversarial Network Based Joint Atrium and Scar Segmentations on Unbalanced Atrial Targets. IEEE J Biomed Health Inform 2022; 26:103-114. [PMID: 33945491 DOI: 10.1109/jbhi.2021.3077469] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Automated and accurate segmentations of left atrium (LA) and atrial scars from late gadolinium-enhanced cardiac magnetic resonance (LGE CMR) images are in high demand for quantifying atrial scars. The previous quantification of atrial scars relies on a two-phase segmentation for LA and atrial scars due to their large volume difference (unbalanced atrial targets). In this paper, we propose an inter-cascade generative adversarial network, namely JAS-GAN, to segment the unbalanced atrial targets from LGE CMR images automatically and accurately in an end-to-end way. Firstly, JAS-GAN investigates an adaptive attention cascade to automatically correlate the segmentation tasks of the unbalanced atrial targets. The adaptive attention cascade mainly models the inclusion relationship of the two unbalanced atrial targets, where the estimated LA acts as the attention map to adaptively focus on the small atrial scars roughly. Then, an adversarial regularization is applied to the segmentation tasks of the unbalanced atrial targets for making a consistent optimization. It mainly forces the estimated joint distribution of LA and atrial scars to match the real ones. We evaluated the performance of our JAS-GAN on a 3D LGE CMR dataset with 192 scans. Compared with the state-of-the-art methods, our proposed approach yielded better segmentation performance (Average Dice Similarity Coefficient (DSC) values of 0.946 and 0.821 for LA and atrial scars, respectively), which indicated the effectiveness of our proposed approach for segmenting unbalanced atrial targets.
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15
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Peters DC, Lamy J, Sinusas AJ, Baldassarre LA. Left atrial evaluation by cardiovascular magnetic resonance: sensitive and unique biomarkers. Eur Heart J Cardiovasc Imaging 2021; 23:14-30. [PMID: 34718484 DOI: 10.1093/ehjci/jeab221] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Left atrial (LA) imaging is still not routinely used for diagnosis and risk stratification, although recent studies have emphasized its importance as an imaging biomarker. Cardiovascular magnetic resonance is able to evaluate LA structure and function, metrics that serve as early indicators of disease, and provide prognostic information, e.g. regarding diastolic dysfunction, and atrial fibrillation (AF). MR angiography defines atrial anatomy, useful for planning ablation procedures, and also for characterizing atrial shapes and sizes that might predict cardiovascular events, e.g. stroke. Long-axis cine images can be evaluated to define minimum, maximum, and pre-atrial contraction LA volumes, and ejection fractions (EFs). More modern feature tracking of these cine images provides longitudinal LA strain through the cardiac cycle, and strain rates. Strain may be a more sensitive marker than EF and can predict post-operative AF, AF recurrence after ablation, outcomes in hypertrophic cardiomyopathy, stratification of diastolic dysfunction, and strain correlates with atrial fibrosis. Using high-resolution late gadolinium enhancement (LGE), the extent of fibrosis in the LA can be estimated and post-ablation scar can be evaluated. The LA LGE method is widely available, its reproducibility is good, and validations with voltage-mapping exist, although further scan-rescan studies are needed, and consensus regarding atrial segmentation is lacking. Using LGE, scar patterns after ablation in AF subjects can be reproducibly defined. Evaluation of 'pre-existent' atrial fibrosis may have roles in predicting AF recurrence after ablation, predicting new-onset AF and diastolic dysfunction in patients without AF. LA imaging biomarkers are ready to enter into diagnostic clinical practice.
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Affiliation(s)
- Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Jérôme Lamy
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Albert J Sinusas
- Department of Cardiology, Yale School of Medicine, New Haven, CT, USA
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16
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Gottlieb LA, Dekker LRC, Coronel R. The Blinding Period Following Ablation Therapy for Atrial Fibrillation: Proarrhythmic and Antiarrhythmic Pathophysiological Mechanisms. JACC Clin Electrophysiol 2021; 7:416-430. [PMID: 33736761 DOI: 10.1016/j.jacep.2021.01.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/14/2021] [Accepted: 01/17/2021] [Indexed: 02/01/2023]
Abstract
Atrial fibrillation (AF) causes heart failure, ischemic strokes, and poor quality of life. The number of patients with AF is estimated to increase to 18 million in Europe in 2050. Pharmacological therapy does not cure AF in all patients. Ablative pulmonary vein isolation is recommended for patients with drug-resistant symptomatic paroxysmal AF but is successful in only about 60%. In patients in whom ablative therapy is successful on the long term, recurrence of AF may occur in the first weeks to months after pulmonary vein ablation. The early recurrence (or delayed cure) of AF is not understood but forms the basis for the generally accepted 3-month blinding (or blanking) period after ablation therapy, which is not included in the evaluation of the eventual success rate of the procedures. The underlying pathophysiological processes responsible for early recurrence and the delayed cure are unknown. The implicit assumption of the blinding period is that the AF mechanism in this period is different from the ablation-targeted AF mechanism (ectopy from the pulmonary veins). In this review, we evaluate the temporary and long-lasting pro- and antiarrhythmic effects of each of the pathophysiological processes and interventions (necrosis, ischemia, oxidative stress, edema, inflammation, autonomic nervous activity, tissue repair, mechanical remodeling, and use of antiarrhythmic drugs) occurring in the blinding period that can modulate AF mechanisms. We propose that stretch-reducing ablation scar is a permanent antiarrhythmic mechanism that develops during the blinding period and is the reason for delayed cure.
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Affiliation(s)
- Lisa A Gottlieb
- Electrophysiology and Heart Modelling Institute, University of Bordeaux, Pessac, France; Department of Experimental Cardiology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, the Netherlands
| | - Lukas R C Dekker
- Department of Electrical Engineering, University of Technology, Eindhoven, the Netherlands; Cardiology Department, Catharina Hospital, Eindhoven, the Netherlands.
| | - Ruben Coronel
- Electrophysiology and Heart Modelling Institute, University of Bordeaux, Pessac, France; Department of Experimental Cardiology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, the Netherlands
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17
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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: 135] [Impact Index Per Article: 45.0] [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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18
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Zhou Y, Yu M, Cui J, Hu F, Yang Z, Yuan J, Qiao S. The predictive value of epicardial adipose tissue volume assessed by cardiac magnetic resonance for atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy. Int J Cardiovasc Imaging 2021; 37:1383-1393. [PMID: 33392874 DOI: 10.1007/s10554-020-02092-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and potentially increase the risk of embolic stroke and aggravate progressive heart failure in patients with hypertrophic cardiomyopathy (HCM). Recent studies demonstrated that epicardial adipose tissue (EAT) was closely associated with AF in general population. However, the relationship between EAT and AF in HCM patients remains unclear. A total of 93 consecutive patients with hypertrophic obstructive cardiomyopathy (HOCM) at Fuwai Hospital were enrolled in our study. There were 18 patients with AF and 75 patients without it. Cardiac magnetic resonance (CMR) imaging was performed in all participants. EAT volume (EATV) and left atrial volume (LAV) were determined by E-3D medical model software. HOCM patients with AF had significantly greater EATV index (EATVI, P < 0.001), LAV index (LAVI, P < 0.001) and left ventricular end-systole volume index (LVESVI, P = 0.039), and lower left ventricular ejection fraction (LVEF, P = 0.002). In multivariable logistic regression analysis, EATVI, LAVI, and LVEF remained independent determinants of AF occurrence (OR = 1.023, 95% CI, 1.003-1.043, P = 0.023, OR = 1.043, 95% CI, 1.012-1.075, P = 0.006, and OR = 0.887, 95% CI, 0.818-0.962, P = 0.004, respectively). Furthermore, receiver operating characteristic (ROC) curve analysis demonstrated that integration of EATVI, LAVI and LVEF provided better discriminatory performance for incident AF in HOCM patients with a high sensitivity of 94.4% and a specificity of 69.3% (AUC = 0.864, 95% CI, 0.771-0.958, P < 0.001). EATVI is an independent predictor of the presence of AF, and integration of EATVI, LVEF and LAVI determined by CMR provide greater discriminatory performance for identifying AF in HOCM patients.
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Affiliation(s)
- Yue Zhou
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.,Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Miao Yu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jingang Cui
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Fenghuan Hu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Zhuoxuan Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jiansong Yuan
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Shubin Qiao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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19
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Mannion J, Galvin J, Boles U. Left atrial scar identification and quantification in sinus rhythm and atrial fibrillation. J Arrhythm 2020; 36:967-973. [PMID: 33335611 PMCID: PMC7733578 DOI: 10.1002/joa3.12421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 11/30/2022] Open
Abstract
Identification and quantification of low voltage areas (LVA) in atrial fibrillation (AF), identified by their bipolar voltages (BiV) via electro-anatomical voltage mapping is an area of interest to prognosis of AF free burden. LVAs have been linked to diseased left atrial (LA) tissue which results in pro-fibrillatory potentials. These LVAs are dominantly found within the pulmonary veins, however, as the disease progresses other areas of the LA show low voltage. The scar burden of the LA is linked to recurrence of the arrhythmia and can be a target of further modification. This burden is classically assessed once sinus rhythm (SR) is attained, but this is susceptible to operator variability with overestimated dense LA scar (<0.2 mV) and underestimated diseased LA tissue (<0.5 mV). The novel automated voltage histogram analysis (VHA) tool may increase accuracy, however, is yet to be fully validated. A recent study indicates that LVAs can be assessed just as reliably in AF as SR, but BiV is lower with linear correlation to SR values (0.24-0.5 mV respectively). In this paper, we review current data as well as review current methods of identifying, quantifying, and grading LA scar. We also compared AF vs SR voltages of a patient undergoing catheter ablation in our site using our VHA tool to compare the results. In keeping with the cited papers, we found lower voltages in our patient measured in AF. This area warrants further study to assess correlation in more patients, with view to developing prognostic and therapeutic grading systems.
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Affiliation(s)
- James Mannion
- Cardiology Department, Heart and Vascular CentreMater Private HospitalDublinIreland
| | - Joseph Galvin
- Cardiology Department, Heart and Vascular CentreMater Private HospitalDublinIreland
| | - Usama Boles
- Cardiology Department, Heart and Vascular CentreMater Private HospitalDublinIreland
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20
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O'Neill L, Karim R, Mukherjee RK, Whitaker J, Sim I, Harrison J, Razeghi O, Niederer S, Ismail T, Wright M, O'Neill MD, Williams SE. Pulmonary vein encirclement using an Ablation Index-guided point-by-point workflow: cardiovascular magnetic resonance assessment of left atrial scar formation. Europace 2020; 21:1817-1823. [PMID: 31793653 PMCID: PMC6887923 DOI: 10.1093/europace/euz226] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/24/2019] [Indexed: 11/12/2022] Open
Abstract
AIMS A point-by-point workflow for pulmonary vein isolation (PVI) targeting pre-defined Ablation Index values (a composite of contact force, time, and power) and minimizing interlesion distance may optimize the creation of contiguous ablation lesions whilst minimizing scar formation. We aimed to compare ablation scar formation in patients undergoing PVI using this workflow to patients undergoing a continuous catheter drag workflow. METHODS AND RESULTS Post-ablation cardiovascular magnetic resonance imaging was performed in patients undergoing 1st-time PVI using a parameter-guided point-by-point workflow (n = 26). Total left atrial scar burden and the width and continuity of the pulmonary vein encirclement were determined on analysis of atrial late gadolinium enhancement sequences. Comparison was made with a cohort of patients (n = 20) undergoing PVI using continuous drag lesions. Mean post-ablation scar burden and scar width were significantly lower in the point-by-point group than in the control group (6.6 ± 6.8% vs. 9.6 ± 5.0%, P = 0.03 and 7.9 ± 3.6 mm vs. 10.7 ± 2.3 mm, P = 0.003). More complete bilateral pulmonary vein encirclements were seen in the point-by-point group (P = 0.038). All patients achieved acute PVI. CONCLUSION Pulmonary vein isolation using a point-by-point workflow is feasible and results in a lower scar burden and scar width with more complete pulmonary vein encirclements than a conventional drag lesion approach.
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Affiliation(s)
- Louisa O'Neill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - Rashed Karim
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - Rahul K Mukherjee
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - John Whitaker
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Iain Sim
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - James Harrison
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - Orod Razeghi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - Steven Niederer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - Tevfik Ismail
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Matthew Wright
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Mark D O'Neill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Steven E Williams
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
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21
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Gunasekaran S, Kim D. Is Otsu thresholding the answer to reproducible quantification of left atrial scar from late gadolinium-enhancement MRI? J Cardiovasc Electrophysiol 2020; 31:2833-2835. [PMID: 32931626 DOI: 10.1111/jce.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Suvai Gunasekaran
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
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22
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Antoniou CK, Manolakou P, Arsenos P, Dilaveris P, Gatzoulis K, Tousoulis D. Antithrombotic Treatment after Atrial Fibrillation Ablation. Curr Pharm Des 2020; 26:2703-2714. [DOI: 10.2174/1381612826666200407154329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/17/2020] [Indexed: 01/06/2023]
Abstract
:Atrial fibrillation is a major cause of debilitating strokes and anticoagulation is an established and indispensable therapy for reducing their rate. Ablation of the arrhythmia has emerged as a putative means of disrupting its natural course by isolating its triggers and modifying its substrate, dependent on the chosen method. An important dilemma lies in the need for continuation of anticoagulation therapy in those previously receiving it following an, apparently, successful intervention, purportedly preventing arrhythmia recurrence with considerably high rates. Current guidance, given scarcity of high-quality data from randomized trials, focuses on established knowledge and recommends anticoagulation continuation based solely on estimated thromboembolic risk. In the present review, it will be attempted to summarize the pathophysiological rationale for maintaining anticoagulation post-successful ablation, along with the latter’s definition, including the two-fold effects of the procedure per se on thrombogenicity. Available evidence pointing to an overall clinical benefit of anticoagulation withdrawal following careful patient assessment will be discussed, including ongoing randomized trials aiming to offer definitive answers. Finally, the proposed mode of post-ablation anticoagulation will be presented, including the emerging, guideline-endorsed, role of direct oral anticoagulants in the field, altering cost/benefit ratio of anticoagulation and potentially affecting the very decision regarding its discontinuation.
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Affiliation(s)
| | - Panagiota Manolakou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Petros Arsenos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Konstantinos Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
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23
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Mehra N, Kowlgi GN, Deshmukh AJ. Predictors of Outcomes in Patients with Atrial Fibrillation: What Can Be Used Now and What Hope Is in the Future. CURRENT CARDIOVASCULAR RISK REPORTS 2020. [DOI: 10.1007/s12170-020-00645-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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24
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Yang G, Chen J, Gao Z, Li S, Ni H, Angelini E, Wong T, Mohiaddin R, Nyktari E, Wage R, Xu L, Zhang Y, Du X, Zhang H, Firmin D, Keegan J. Simultaneous left atrium anatomy and scar segmentations via deep learning in multiview information with attention. FUTURE GENERATIONS COMPUTER SYSTEMS : FGCS 2020; 107:215-228. [PMID: 32494091 PMCID: PMC7134530 DOI: 10.1016/j.future.2020.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 01/03/2020] [Accepted: 02/02/2020] [Indexed: 05/20/2023]
Abstract
Three-dimensional late gadolinium enhanced (LGE) cardiac MR (CMR) of left atrial scar in patients with atrial fibrillation (AF) has recently emerged as a promising technique to stratify patients, to guide ablation therapy and to predict treatment success. This requires a segmentation of the high intensity scar tissue and also a segmentation of the left atrium (LA) anatomy, the latter usually being derived from a separate bright-blood acquisition. Performing both segmentations automatically from a single 3D LGE CMR acquisition would eliminate the need for an additional acquisition and avoid subsequent registration issues. In this paper, we propose a joint segmentation method based on multiview two-task (MVTT) recursive attention model working directly on 3D LGE CMR images to segment the LA (and proximal pulmonary veins) and to delineate the scar on the same dataset. Using our MVTT recursive attention model, both the LA anatomy and scar can be segmented accurately (mean Dice score of 93% for the LA anatomy and 87% for the scar segmentations) and efficiently ( ∼ 0.27 s to simultaneously segment the LA anatomy and scars directly from the 3D LGE CMR dataset with 60-68 2D slices). Compared to conventional unsupervised learning and other state-of-the-art deep learning based methods, the proposed MVTT model achieved excellent results, leading to an automatic generation of a patient-specific anatomical model combined with scar segmentation for patients in AF.
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Affiliation(s)
- Guang Yang
- Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College London, London, SW7 2AZ, UK
- Corresponding author at: Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK.
| | - Jun Chen
- School of Biomedical Engineering, Sun Yat-Sen University, Shenzhen, 510006, China
| | - Zhifan Gao
- Department of Medical Imaging, Western University, London, ON, N6A 3K7, Canada
| | - Shuo Li
- Department of Medical Imaging, Western University, London, ON, N6A 3K7, Canada
| | - Hao Ni
- Department of Mathematics, University College London, London, WC1E 6BT, UK
- Alan Turing Institute, London, NW1 2DB, UK
| | - Elsa Angelini
- NIHR Imperial Biomedical Research Centre, ITMAT Data Science Group, Imperial College London, London, SW7 2AZ, UK
| | - Tom Wong
- Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College London, London, SW7 2AZ, UK
| | - Raad Mohiaddin
- Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College London, London, SW7 2AZ, UK
| | - Eva Nyktari
- Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK
| | - Ricardo Wage
- Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | | | - Heye Zhang
- School of Biomedical Engineering, Sun Yat-Sen University, Shenzhen, 510006, China
- Corresponding author.
| | - David Firmin
- Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College London, London, SW7 2AZ, UK
| | - Jennifer Keegan
- Cardiovascular Research Centre, Royal Brompton Hospital, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College London, London, SW7 2AZ, UK
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25
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Aparina OP, Mironov NY, Fedorova EA, Dzaurova KM, Maikov EB, Stukalova OV, Golitsyn SP. [Cardiac magnetic resonance imaging with contrast enhancement in treatment of atrial fibrillation]. ACTA ACUST UNITED AC 2020; 60:119-125. [PMID: 32375624 DOI: 10.18087/cardio.2020.3.n582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/18/2022]
Abstract
Catheter ablation is presently the main method for interventional treatment of atrial fibrillation (AF). Despite improvements of the method and accumulation of personnel's experience, incidence of recurrent AF following catheter interventions remains high. This review addresses a possibility of using contrast-enhanced cardiac magnetic resonance imaging to increase the effectiveness of interventional treatment of arrhythmia.
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Affiliation(s)
- O P Aparina
- National Medical Research Center of Cardiology
| | | | | | | | - E B Maikov
- National Medical Research Center of Cardiology
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26
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Yang G, Chen J, Gao Z, Zhang H, Ni H, Angelini E, Mohiaddin R, Wong T, Keegan J, Firmin D. Multiview Sequential Learning and Dilated Residual Learning for a Fully Automatic Delineation of the Left Atrium and Pulmonary Veins from Late Gadolinium-Enhanced Cardiac MRI Images. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2018:1123-1127. [PMID: 30440587 DOI: 10.1109/embc.2018.8512550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Accurate delineation of heart substructures is a prerequisite for abnormality detection, for making quantitative and functional measurements, and for computer-aided diagnosis and treatment planning. Late Gadolinium-Enhanced Cardiac MRI (LGE-CMRI) is an emerging imaging technology for myocardial infarction or scar detection based on the differences in the volume of residual gadolinium distribution between scar and healthy tissues. While LGE-CMRI is a well-established non-invasive tool for detecting myocardial scar tissues in the ventricles, its application to left atrium (LA) imaging is more challenging due to its very thin wall of the LA and poor quality images, which may be produced because of motion artefacts and low signal-to-noise ratio. As the LGE-CMRI scan is designed to highlight scar tissues by altering the gadolinium kinetics, the anatomy among different heart substructures has less distinguishable boundaries. An accurate, robust and reproducible method for LA segmentation is highly in demand because it can not only provide valuable information of the heart function but also be helpful for the further delineation of scar tissue and measuring the scar percentage. In this study, we proposed a novel deep learning framework working on LGE-CMRI images directly by combining sequential learning and dilated residual learning to delineate LA and pulmonary veins fully automatically. The achieved results showed accurate segmentation results compared to the state-of-the-art methods. The proposed framework leads to an automatic generation of a patient-specific model that can potentially enable an objective atrial scarring assessment for the atrial fibrillation patients.
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27
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Linhart M, Alarcon F, Borràs R, Benito EM, Chipa F, Cozzari J, Caixal G, Enomoto N, Carlosena A, Guasch E, Arbelo E, Tolosana JM, Prat-Gonzalez S, Perea RJ, Doltra A, Sitges M, Brugada J, Berruezo A, Mont L. Delayed Gadolinium Enhancement Magnetic Resonance Imaging Detected Anatomic Gap Length in Wide Circumferential Pulmonary Vein Ablation Lesions Is Associated With Recurrence of Atrial Fibrillation. Circ Arrhythm Electrophysiol 2019; 11:e006659. [PMID: 30562102 DOI: 10.1161/circep.118.006659] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is limited knowledge about the impact of anatomic gaps as assessed by delayed gadolinium enhancement cardiac magnetic resonance on atrial fibrillation (AF) recurrence after first pulmonary vein (PV) isolation. METHODS Consecutive patients underwent delayed gadolinium enhancement cardiac magnetic resonance 3 months after radiofrequency circumferential PV isolation. Delayed gadolinium enhancement cardiac magnetic resonance images were assessed from 360 PV resulting in 2880 segments in the 2×8-segment model from 94 patients (52±11 years, 62% paroxysmal AF). Left atria were segmented using dedicated software. Anatomic gap was defined as discontinuation of the ablation line by ≥3 mm. Relative gap length was calculated as absolute gap length divided by the total length of the ablation line. AF recurrence was assessed after a mean follow-up duration of 15±10 months Results: Mean number of anatomic gaps was 5.4 per patient. Recurrence within the first year of ablation was observed in 21 patients with paroxysmal AF (36%) and 19 patients with persistent AF (53%). In the univariate analysis, CHA2DS2-VASc score, AF type, and relative gap length were predictive of recurrence. In the multivariate analysis, only relative gap length was significantly associated with recurrence (hazard ratio, 1.16 [1.02-1.31] per each 10% of gap). CONCLUSIONS The total relative gap length but not the number of anatomic gaps in the PV ablation line as assessed by delayed gadolinium enhancement cardiac magnetic resonance was associated with AF recurrence 1 year after first PV isolation. An increase of 10% relative gap length increased the likelihood of AF recurrence by 16%.
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Affiliation(s)
- Markus Linhart
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Francisco Alarcon
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Roger Borràs
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Eva M Benito
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Unitat de Fibril.lació Auricular (UFA), Hospital Clínic de Barcelona, Catalonia, Spain (E.M.B., G.C., E.G., E.A., S.P.-G., M.S., L.M.)
| | - Fredy Chipa
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Jennifer Cozzari
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Gala Caixal
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Norihiro Enomoto
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Alicia Carlosena
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Eduard Guasch
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Unitat de Fibril.lació Auricular (UFA), Hospital Clínic de Barcelona, Catalonia, Spain (E.M.B., G.C., E.G., E.A., S.P.-G., M.S., L.M.).,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain (E.G., E.A., J.M.T., M.S., J.B., A.B., L.M.)
| | - Elena Arbelo
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Unitat de Fibril.lació Auricular (UFA), Hospital Clínic de Barcelona, Catalonia, Spain (E.M.B., G.C., E.G., E.A., S.P.-G., M.S., L.M.).,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain (E.G., E.A., J.M.T., M.S., J.B., A.B., L.M.)
| | - Jose Maria Tolosana
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain (E.G., E.A., J.M.T., M.S., J.B., A.B., L.M.)
| | - Susana Prat-Gonzalez
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Unitat de Fibril.lació Auricular (UFA), Hospital Clínic de Barcelona, Catalonia, Spain (E.M.B., G.C., E.G., E.A., S.P.-G., M.S., L.M.)
| | - Rosario J Perea
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Adelina Doltra
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.)
| | - Marta Sitges
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Unitat de Fibril.lació Auricular (UFA), Hospital Clínic de Barcelona, Catalonia, Spain (E.M.B., G.C., E.G., E.A., S.P.-G., M.S., L.M.).,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain (E.G., E.A., J.M.T., M.S., J.B., A.B., L.M.)
| | - Josep Brugada
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Unitat de Fibril.lació Auricular (UFA), Hospital Clínic de Barcelona, Catalonia, Spain (E.M.B., G.C., E.G., E.A., S.P.-G., M.S., L.M.).,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain (E.G., E.A., J.M.T., M.S., J.B., A.B., L.M.)
| | - Antonio Berruezo
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain (E.G., E.A., J.M.T., M.S., J.B., A.B., L.M.)
| | - Lluís Mont
- Institut Clínic de Malalties Cardiovasculars, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.Z., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.L., F.A., R.B., E.M.B., F.C., J.C., G.C., N.E., A.C., E.G., E.A., J.M.T., S.P.-G., R.J.P., A.D., M.S., J.B., A.B., L.M.).,Unitat de Fibril.lació Auricular (UFA), Hospital Clínic de Barcelona, Catalonia, Spain (E.M.B., G.C., E.G., E.A., S.P.-G., M.S., L.M.).,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain (E.G., E.A., J.M.T., M.S., J.B., A.B., L.M.)
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Li B, Ma H, Guo H, Liu P, Wu Y, Fan L, Cao Y, Jian Z, Sun C, Li H. Pulmonary vein parameters are similar or better predictors than left atrial diameter for paroxysmal atrial fibrillation after cryoablation. ACTA ACUST UNITED AC 2019; 52:e8446. [PMID: 31482999 PMCID: PMC6720024 DOI: 10.1590/1414-431x20198446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/10/2019] [Indexed: 11/21/2022]
Abstract
Left atrial diameter (LAD) has been considered an independent risk factor for atrial fibrillation (AF) relapse after pulmonary vein isolation (PVI). However, whether LAD or other factors are more predictive of late recurrence in patients with paroxysmal AF remains unclear. We aimed to evaluate the value of pulmonary vein (PV) parameters for predicting AF relapse 1 year after patients underwent cryoablation for paroxysmal AF. Ninety-seven patients with paroxysmal AF who underwent PVI successfully were included. PV parameters were measured through computed tomography scans prior to PVI. A total of 28 patients had recurrence of AF at one-year follow-up. The impact of several variables on recurrence was evaluated in multivariate analyses. LAD and the time from first diagnosis of AF to ablation maintained its significance in predicting the relapse of AF after relevant adjustments in multivariate analysis. When major diameter of right inferior pulmonary vein (RIPV) (net reclassification improvement (NRI) 0.179, CI=0.031–0.326, P<0.05) and cross-sectional area (CSA) of RIPV (NRI: 0.122, CI=0.004–0.240, P<0.05) entered the AF risk model separately, the added predictive capacity was large. The accuracy of the two parameters in predicting recurrence of AF were not inferior (AUC: 0.665 and 0.659, respectively) to echocardiographic LAD (AUC: 0.663). The inclusion of either RIPV major diameter or CSA of RIPV in the model increased the C-index (0.766 and 0.758, respectively). We concluded that major diameter of RIPV had predictive capacity similar to or even better than that of LAD for predicting AF relapse after cryoablation PVI.
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Affiliation(s)
- Bolin Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Honglan Ma
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Medical College, Xi'an, Shaanxi, China
| | - Huihui Guo
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Peng Liu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yue Wu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Lihong Fan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yumeng Cao
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zhijie Jian
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chaofeng Sun
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hongbing Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Ghannam M, Oral H. Mapping and Imaging in Non-paroxysmal AF. Arrhythm Electrophysiol Rev 2019; 8:202-209. [PMID: 31463058 PMCID: PMC6702463 DOI: 10.15420/aer.2019.18.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/25/2019] [Indexed: 01/22/2023] Open
Abstract
Despite intense research efforts, maintenance of sinus rhythm in patients with non-paroxysmal AF remains challenging with suboptimal outcomes. A major limitation to the success of current ablation-based treatments is that our understanding of AF pathophysiology is incomplete. Advances in imaging and mapping tools have been reported to improve ablation outcomes. However, the role of these new approaches on the clinical care of patients with AF remains to be validated and better understood before wide adoption can occur. This article reviews the current techniques of imaging and mapping that can be applied in the management of patients with non-paroxysmal AF with a focus on their relevance to catheter ablation. Future applications and opportunities for new knowledge are also discussed.
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Affiliation(s)
- Michael Ghannam
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan Ann Arbor, MI, US
| | - Hakan Oral
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan Ann Arbor, MI, US
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30
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Herczeg S, Walsh K, Keaney JJ, Keelan E, Travers J, Szeplaki G, Galvin J. Quantitative assessment of left atrial scar using high-density voltage mapping and a novel automated voltage analysis tool. J Interv Card Electrophysiol 2019; 59:5-12. [PMID: 31165967 DOI: 10.1007/s10840-019-00570-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 05/19/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE Left atrial (LA) fibrosis plays an important role in the pathogenesis and perpetuation of atrial fibrillation (AF). It may be identified by bipolar voltage (BiV) mapping, but quantification of fibrosis which previously relied on visual estimation of scar has been shown to be inaccurate. Our aim was to use a novel automated voltage histogram analysis (VHA) tool to quantify LA scar burden accurately in patients with AF. METHODS LA voltage was assessed in 100 consecutive patients undergoing first pulmonary vein isolation (PVI) for paroxysmal or persistent AF using a circular multielectrode catheter to create high-density LA BiV maps which were analysed using the VHA tool after the procedure. RESULTS High-density electro-anatomic maps took 10 min to create and contained a median of 1049 points. The VHA algorithm accurately quantified the burden of Diseased LA Tissue (≤ 0.5 mV) and Dense LA Scar (≤ 0.2 mV) with a median of 17.8% and 3.5% respectively. A quartile classification was applied based on diseased LA tissue burden. Patients in class IV with the highest diseased LA burden were older (p < 0.0001), more likely female (p = 0.0095), had higher CHA2DS2-VASc scores (p = 0.0024) and were more likely to have persistent rather than paroxysmal AF (p = 0.0179) than those in classes I-III. CONCLUSIONS The VHA algorithm is able to quantify percentage surface area voltage rapidly and according to preset ranges for the first time. The algorithm offers the potential for classification of patients undergoing AF ablation into different classes of diseased LA burden, which may have diagnostic, therapeutic and prognostic implications.
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Affiliation(s)
- Szilvia Herczeg
- Heart and Vascular Center, Semmelweis University, 68 Varosmajor Street, Budapest, 1122, Hungary
| | - Katie Walsh
- Heart and Vascular Centre, Mater Private Hospital, Eccles Street, Dublin 7, Ireland
| | - John J Keaney
- Heart and Vascular Centre, Mater Private Hospital, Eccles Street, Dublin 7, Ireland
| | - Edward Keelan
- Heart and Vascular Centre, Mater Private Hospital, Eccles Street, Dublin 7, Ireland
| | - John Travers
- Heart and Vascular Centre, Mater Private Hospital, Eccles Street, Dublin 7, Ireland
| | - Gabor Szeplaki
- Heart and Vascular Centre, Mater Private Hospital, Eccles Street, Dublin 7, Ireland
| | - Joseph Galvin
- Heart and Vascular Centre, Mater Private Hospital, Eccles Street, Dublin 7, Ireland.
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El-Harasis MA, DeSimone CV, Yao X, Noseworthy PA. Prediction and Management of Recurrences after Catheter Ablation in Atrial Fibrillation and Heart Failure. Cardiol Clin 2019; 37:221-230. [PMID: 30926023 DOI: 10.1016/j.ccl.2019.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Catheter ablation is recommended in patients with symptomatic atrial fibrillation (AF) refractory to pharmacologic therapy. AF recurrence is common postablation, particularly in patients with heart failure, because of multiple structural and functional changes that can occur. Determining predictors of AF recurrence has become increasingly important. These include increased left atrial volume, termination of AF during the index ablation, electrocardiogram parameters, and serum biomarkers. Cardiac MRI can also determine the degree of scarring and left atrial sphericity, which is used in risk prediction scores. In patients with recurrence, further treatment options include pharmacologic therapy and atrioventricular nodal ablation with pacing.
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Affiliation(s)
- Majd A El-Harasis
- Division of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Xiaoxi Yao
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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32
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Benito EM, Alarcon F, Mont L. LGE-MRI Characterization of Left Atrial Fibrosis: a Tool to Establish Prognosis and Guide Atrial Fibrillation Ablation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0604-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Jefairi NA, Camaioni C, Sridi S, Cheniti G, Takigawa M, Nivet H, Denis A, Derval N, Mathilde Merle, Laurent F, Montaudon M, Sacher F, Hocini M, Haissaguerre M, Jais P, Cochet H. Relationship between atrial scar on cardiac magnetic resonance and pulmonary vein reconnection after catheter ablation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:727-740. [DOI: 10.1111/jce.13908] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/22/2019] [Accepted: 02/10/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Nora Al Jefairi
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
| | - Claudia Camaioni
- Department of Cardiovascular ImagingHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
| | - Soumaya Sridi
- Department of Cardiovascular ImagingHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
| | - Ghassen Cheniti
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
| | - Masateru Takigawa
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
| | - Hubert Nivet
- Department of Cardiovascular ImagingHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
| | - Arnaud Denis
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
| | - Nicolas Derval
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Mathilde Merle
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Francois Laurent
- Department of Cardiovascular ImagingHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Michel Montaudon
- Department of Cardiovascular ImagingHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Frederic Sacher
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Mélèze Hocini
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Michel Haissaguerre
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Pierre Jais
- Department of Cardiac Pacing and ElectrophysiologyHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
| | - Hubert Cochet
- Department of Cardiovascular ImagingHôpital Cardiologique du Haut‐Lévêque, CHU de BordeauxPessac France
- Department of Healthcare TechnologiesIHU LIRYC, Université de Bordeaux–InsermPessac France
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Correia ETDO, Barbetta LMDS, Silva OMPD, Mesquita ET. Left Atrial Stiffness: A Predictor of Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation - A Systematic Review and Meta-Analysis. Arq Bras Cardiol 2019; 112:501-508. [PMID: 30843918 PMCID: PMC6555566 DOI: 10.5935/abc.20190040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/05/2018] [Indexed: 01/18/2023] Open
Abstract
Background Radiofrequency catheter ablation (RFCA) is a standard procedure for patients
with atrial fibrillation (AF) not responsive to previous treatments, that
has been increasingly considered as a first-line therapy. In this context,
perioperative screening for risk factors has become important. A previous
study showed that a high left atrial (LA) pressure is associated with AF
recurrence after ablation, which may be secondary to a stiff left
atrium. Objective To investigate, through a systematic review and meta-analysis, if LA
stiffness could be a predictor of AF recurrence after RFCA, and to discuss
its clinical use. Methods The meta-analysis followed the MOOSE recommendations. The search was
performed in MEDLINE and Cochrane Central Register of Controlled Trials
databases, until March 2018. Two authors performed screening, data
extraction and quality assessment of the studies. Results All studies were graded with good quality. A funnel plot was constructed,
which did not show any publication bias. Four prospective observational
studies were included in the systematic review and 3 of them in the
meta-analysis. Statistical significance was defined at p value < 0.05. LA
stiffness was a strong independent predictor of AF recurrence after RFCA (HR
= 3.55, 95% CI 1.75-4.73, p = 0.0002). Conclusion A non-invasive assessment of LA stiffness prior to ablation can be used as a
potential screening factor to select or to closely follow patients with
higher risks of AF recurrence and development of the stiff LA syndrome.
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Korodi S, Toganel R, Benedek T, Hodas R, Chitu M, Ratiu M, Kovacs I, Mester A, Benedek I. Impact of inflammation-mediated myocardial fibrosis on the risk of recurrence after successful ablation of atrial fibrillation - the FIBRO-RISK study: Protocol for a non-randomized clinical trial. Medicine (Baltimore) 2019; 98:e14504. [PMID: 30817568 PMCID: PMC6831404 DOI: 10.1097/md.0000000000014504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Interventional ablation has been demonstrated to represent an effective therapy in patients with atrial fibrillation (AF), leading to restoration and maintenance of sinus rhythm in the majority of cases. However, recurrence of AF is encountered in 35% to 40% of cases, and the causes for this frequent complication have not been elucidated so far. MATERIAL AND METHODS Here we present the study protocol of the FIBRO-RISK trial, a prospective, single-center, cohort study which aims to investigate the impact of inflammatory-mediated myocardial fibrosis on the risk of recurrence after successful catheter ablation of atrial fibrillation. The level of systemic inflammation in the pre-ablation and immediate post-ablation period will be assessed on the basis of serum levels of inflammatory biomarkers (hsCRP, matrix metalloproteases, interleukin-6), while the level of cardiac fibrosis will be determined based on cardiac magnetic resonance imaging associated with complex post-processing techniques for mapping myocardial fibrosis at the level of left atrium and left ventricle. At the same time, the amount of epicardial fat will serve as an indirect marker of localized inflammation and will be determined at different levels in the heart (surrounding left atrium, right atrium or the entire heart), while ventricular function will be assessed on the basis of serum levels of NT-proBNP prior to the procedure. All these parameters will be investigated in patients with successful ablation of AF, who will be divided into 2 groups: group 1 - patients who develop AF recurrence at 1-year, and group 2 - patients with no recurrence of AF at 1-year. In all patients, the following biomarkers will be determined: serum levels of inflammatory biomarkers and NT-proBNP at 24 hours and 1-year post procedure, the amount of myocardial fibrosis at the level of left atrium and left ventricle at baseline +/- 7 days, and the amount of epicardial fat surrounding left atrium, right atrium and the entire heart at baseline +/- 7 days.The primary endpoint of the study will be represented by the rate of AF recurrence at 1-year post ablation, documented by either ECG or Holter monitoring. The secondary endpoints of the study will consist in:In conclusion, FIBRO-RISK will be the first CMR-based study that will investigate the impact of inflammation-mediated myocardial fibrosis and ventricular remodeling on the risk of recurrence after successful ablation of AF, aiming to validate inflammatory biomarkers and myocardial fibrosis as predictors for AF recurrence.
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Affiliation(s)
| | - Rodica Toganel
- University of Medicine, Pharmacy, Sciences and Technology
- Department of Advanced Research in Multimodality Cardiovascular Imaging, Cardio Med Medical Center
| | - Theodora Benedek
- University of Medicine, Pharmacy, Sciences and Technology
- Emergency Clinical County Hospital, Tirgu Mures, Romania
| | - Roxana Hodas
- University of Medicine, Pharmacy, Sciences and Technology
- Department of Advanced Research in Multimodality Cardiovascular Imaging, Cardio Med Medical Center
| | - Monica Chitu
- University of Medicine, Pharmacy, Sciences and Technology
- Department of Advanced Research in Multimodality Cardiovascular Imaging, Cardio Med Medical Center
| | - Mihaela Ratiu
- University of Medicine, Pharmacy, Sciences and Technology
- Department of Advanced Research in Multimodality Cardiovascular Imaging, Cardio Med Medical Center
| | - Istvan Kovacs
- University of Medicine, Pharmacy, Sciences and Technology
- Department of Advanced Research in Multimodality Cardiovascular Imaging, Cardio Med Medical Center
| | - Andras Mester
- University of Medicine, Pharmacy, Sciences and Technology
- Department of Advanced Research in Multimodality Cardiovascular Imaging, Cardio Med Medical Center
| | - Imre Benedek
- University of Medicine, Pharmacy, Sciences and Technology
- Emergency Clinical County Hospital, Tirgu Mures, Romania
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36
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Quail M, Grunseich K, Baldassarre LA, Mojibian H, Marieb MA, Cornfeld D, Soufer A, Sinusas AJ, Peters DC. Prognostic and functional implications of left atrial late gadolinium enhancement cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2019; 21:2. [PMID: 30602395 PMCID: PMC6317232 DOI: 10.1186/s12968-018-0514-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/04/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Left atrial (LA) late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is indicative of fibrosis, and has been correlated with reduced LA function, increased LA volume, and poor procedural outcomes in cohorts with atrial fibrillation (AF). However, the role of LGE as a prognostic biomarker for arrhythmia in cardiac disease has not been examined. METHODS In this study, we assessed LA LGE using a 3D LGE CMR sequence to examine its relationships with new onset atrial arrhythmia, and LA and left ventricular (LV) mechanical function. RESULTS LA LGE images were acquired in 111 patients undergoing CMR imaging, including 66 patients with no prior history of an atrial arrhythmia. During the median follow-up of 2.7 years (interquartile range (IQR) 1.8-3.7 years), 15/66 (23%) of patients developed a new atrial arrhythmia. LA LGE ≥10% of LA myocardial volume was significantly associated with an increased rate of new-onset atrial arrhythmia, with a hazard ratio of 3.16 (95% CI 1.14-8.72), p = 0.026. There were significant relationships between LA LGE and both LA ejection fraction (r = - 0.39, p < 0.0005) and echocardiographic LV septal e' (r = - 0.24, p = 0.04) and septal E/e' (r = 0.31, p = 0.007). CONCLUSIONS Elevated LA LGE is associated with reduced LA function and reduced LV diastolic function. LA LGE is associated with new onset atrial arrhythmia during follow-up.
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Affiliation(s)
- Michael Quail
- Department of Internal Medicine (Cardiology), Yale School of Medicine, 300 Cedar St, New Haven, CT 06520 USA
- Centre for Cardiovascular Imaging, Institute of Cardiovascular Science, University College London, London, UK
| | - Karl Grunseich
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Lauren A. Baldassarre
- Department of Internal Medicine (Cardiology), Yale School of Medicine, 300 Cedar St, New Haven, CT 06520 USA
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Hamid Mojibian
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Mark A. Marieb
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Daniel Cornfeld
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Aaron Soufer
- Department of Internal Medicine (Cardiology), Yale School of Medicine, 300 Cedar St, New Haven, CT 06520 USA
| | - Albert J. Sinusas
- Department of Internal Medicine (Cardiology), Yale School of Medicine, 300 Cedar St, New Haven, CT 06520 USA
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Dana C. Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
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37
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Advanced Imaging of the Left Atrium with Cardiac Magnetic Resonance: A Review of Current and Emerging Methods and Clinical Applications. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0303-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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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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39
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Guler TE, Yalin K, Aksu T, Golcuk E, Sanli S, Kaya Bilge A, Adalet K. Prognostic value role of radiofrequency lesion size by cardiac magnetic resonance imaging on outcomes of ablation in patients with ischemic scar-related ventricular tachycardia: A single center pilot study. Medicine (Baltimore) 2018; 97:e12955. [PMID: 30431569 PMCID: PMC6257390 DOI: 10.1097/md.0000000000012955] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Inadequate ablation lesion formation may be responsible for post-ablation ventricular tachycardia (VT) recurrences.We aimed to evaluate whether visualisation of radiofrequency (RF) lesion size by cardiac magnetic resonance imaging (CMR) has any role in predicting adequacy of lesion and in estimating outcome.Retrospective pilot studyNine consecutive patients (8 male, age 60 ± 13 years) underwent ablation for sustained VT because of ischemic scar were evaluated for pre- and post-procedure scar tissue by CMR to characterize ablation lesions. Microvascular obstruction (MVO) surrounded by late gadolinium enhancement was defined as irreversible RF lesion. All patients were followed for at least 6 months for recurrences.Five of the patients had previous inferior myocardial infarction (MI), whereas remaining 4 had anterior MI. Acute procedural success, as defined by termination of the arrhythmia without recurrence in 30 minutes, was attained in all patients. Contrast enhancement and wall motion abnormality in presumed infarction area were confirmed by pre-ablation CMR images. MVO was detected at the reported ablation site in 6/9 patients, all arrhythmia- and symptom-free at median 24 months (range 8-38 months) follow-up. In remaining 3 patients who had VT recurrence (clinical VT in 2, sustain VT with a new morphology in 1), MVO was not detected despite achievement of acute procedural success. There was no correlation with pre-ablation scar size and clinical arrhythmia recurrence.CMR is a useful imaging modality to guide ablation procedures by detecting scar tissue. Additionally MVO seen by post-procedural imaging may be related to adequacy of RF ablation lesions and may correlate with clinical outcome.
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Affiliation(s)
- Tümer Erdem Guler
- University of Health Sciences, Kocaeli Derince Education and Research Hospital, Department of Cardiology, Kocaeli
| | - Kivanç Yalin
- Usak University, Faculty of Medicine, Department of Cardiology, Usak
| | - Tolga Aksu
- University of Health Sciences, Kocaeli Derince Education and Research Hospital, Department of Cardiology, Kocaeli
| | - Ebru Golcuk
- Balikesir University, Faculty of Medicine, Department of Cardiology, Balikesir
| | | | - Ahmet Kaya Bilge
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Kamil Adalet
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
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40
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Cheniti G, Vlachos K, Pambrun T, Hooks D, Frontera A, Takigawa M, Bourier F, Kitamura T, Lam A, Martin C, Dumas-Pommier C, Puyo S, Pillois X, Duchateau J, Klotz N, Denis A, Derval N, Jais P, Cochet H, Hocini M, Haissaguerre M, Sacher F. Atrial Fibrillation Mechanisms and Implications for Catheter Ablation. Front Physiol 2018; 9:1458. [PMID: 30459630 PMCID: PMC6232922 DOI: 10.3389/fphys.2018.01458] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023] Open
Abstract
AF is a heterogeneous rhythm disorder that is related to a wide spectrum of etiologies and has broad clinical presentations. Mechanisms underlying AF are complex and remain incompletely understood despite extensive research. They associate interactions between triggers, substrate and modulators including ionic and anatomic remodeling, genetic predisposition and neuro-humoral contributors. The pulmonary veins play a key role in the pathogenesis of AF and their isolation is associated to high rates of AF freedom in patients with paroxysmal AF. However, ablation of persistent AF remains less effective, mainly limited by the difficulty to identify the sources sustaining AF. Many theories were advanced to explain the perpetuation of this form of AF, ranging from a single localized focal and reentrant source to diffuse bi-atrial multiple wavelets. Translating these mechanisms to the clinical practice remains challenging and limited by the spatio-temporal resolution of the mapping techniques. AF is driven by focal or reentrant activities that are initially clustered in a relatively limited atrial surface then disseminate everywhere in both atria. Evidence for structural remodeling, mainly represented by atrial fibrosis suggests that reentrant activities using anatomical substrate are the key mechanism sustaining AF. These reentries can be endocardial, epicardial, and intramural which makes them less accessible for mapping and for ablation. Subsequently, early interventions before irreversible remodeling are of major importance. Circumferential pulmonary vein isolation remains the cornerstone of the treatment of AF, regardless of the AF form and of the AF duration. No ablation strategy consistently demonstrated superiority to pulmonary vein isolation in preventing long term recurrences of atrial arrhythmias. Further research that allows accurate identification of the mechanisms underlying AF and efficient ablation should improve the results of PsAF ablation.
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Affiliation(s)
- Ghassen Cheniti
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Cardiology Department, Hopital Sahloul, Universite de Sousse, Sousse, Tunisia
| | - Konstantinos Vlachos
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Thomas Pambrun
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Darren Hooks
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Antonio Frontera
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Masateru Takigawa
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Felix Bourier
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Takeshi Kitamura
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Anna Lam
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Claire Martin
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | | | - Stephane Puyo
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Xavier Pillois
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France
| | - Josselin Duchateau
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Klotz
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Arnaud Denis
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Derval
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Pierre Jais
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Hubert Cochet
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Department of Cardiovascular Imaging, Hopital Haut Leveque, Bordeaux, France
| | - Meleze Hocini
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Michel Haissaguerre
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Frederic Sacher
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
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41
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Nakamori S, Ngo LH, Tugal D, Manning WJ, Nezafat R. Incremental Value of Left Atrial Geometric Remodeling in Predicting Late Atrial Fibrillation Recurrence After Pulmonary Vein Isolation: A Cardiovascular Magnetic Resonance Study. J Am Heart Assoc 2018; 7:e009793. [PMID: 30371333 PMCID: PMC6404907 DOI: 10.1161/jaha.118.009793] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/10/2018] [Indexed: 11/18/2022]
Abstract
Background Left atrial ( LA ) enlargement is a marker for increased risk of atrial fibrillation ( AF ). However, LA remodeling is a complex process that is poorly understood, and LA geometric remodeling may also be associated with the development of AF . We sought to determine whether LA spherical remodeling or its temporal change predict late AF recurrence after pulmonary vein isolation ( PVI ). Methods and Results Two hundred twenty-seven consecutive patients scheduled for their first PVI for paroxysmal or persistent AF who underwent cardiovascular magnetic resonance before and within 6 months after PVI were retrospectively identified. The LA sphericity index was computed as the ratio of the measured LA maximum volume to the volume of a sphere with maximum LA length diameter. During mean follow-up of 25 months, 88 patients (39%) experienced late recurrence of AF . Multivariable Cox regression analyses identified an increased pre- PVI LA sphericity index as an independent predictor of late AF recurrence (hazard ratio, 1.32; 95% confidence interval, 1.07-1.62, P=0.009). Patients in the highest LA sphericity index tertile were at highest risk of late recurrence (highest versus lowest: 59% versus 28%; P<0.001). The integration of the LA sphericity index to the LA minimum volume index and passive emptying fraction provided important incremental prognostic information for predicting late AF recurrence post PVI (categorical net reclassification improvement, 0.43; 95% confidence interval, 0.16-0.69, P=0.001). Conclusions The assessment of pre- PVI LA geometric remodeling provides incremental prognostic information regarding late AF recurrence and may be useful to identify those for whom PVI has reduced success or for whom more aggressive ablation or medications may be useful.
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Affiliation(s)
- Shiro Nakamori
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMA
| | - Long H. Ngo
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMA
| | - Derin Tugal
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMA
| | - Warren J. Manning
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMA
- Department of RadiologyBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMA
| | - Reza Nezafat
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMA
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42
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Hu C, Huber S, Latif SR, Santacana-Laffitte G, Mojibian HR, Baldassarre LA, Peters DC. REPAIRit: Improving Myocardial Nulling and Ghosting Artifacts of 3D Navigator-Gated Late Gadolinium Enhancement Imaging During Arrhythmia. J Magn Reson Imaging 2018; 49:688-699. [DOI: 10.1002/jmri.26284] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 11/05/2022] Open
Affiliation(s)
- Chenxi Hu
- Department of Radiology and Biomedical Imaging; Yale School of Medicine; New Haven Connecticut USA
| | - Steffen Huber
- Department of Radiology and Biomedical Imaging; Yale School of Medicine; New Haven Connecticut USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine; New Haven Connecticut USA
| | - Syed R. Latif
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine; New Haven Connecticut USA
| | - Guido Santacana-Laffitte
- Department of Radiology and Biomedical Imaging; Yale School of Medicine; New Haven Connecticut USA
| | - Hamid R. Mojibian
- Department of Radiology and Biomedical Imaging; Yale School of Medicine; New Haven Connecticut USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine; New Haven Connecticut USA
| | - Lauren A. Baldassarre
- Department of Radiology and Biomedical Imaging; Yale School of Medicine; New Haven Connecticut USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine; New Haven Connecticut USA
| | - Dana C. Peters
- Department of Radiology and Biomedical Imaging; Yale School of Medicine; New Haven Connecticut USA
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Left atrial compliance: an overlooked predictor of clinical outcome in patients with mitral stenosis or atrial fibrillation undergoing invasive management. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2018; 14:120-127. [PMID: 30008763 PMCID: PMC6041835 DOI: 10.5114/aic.2018.76402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/29/2018] [Indexed: 01/06/2023] Open
Abstract
In the assessment of cardiovascular disease, the clinical significance of left atrial (LA) pressure-volume relations has largely been overlooked in contrast to left ventricular (LV) compliance. However, LA compliance has recently gained more attention. Net atrioventricular compliance (Cn), a joint measure of LA and LV compliance, can be calculated non-invasively by a previously validated method using parameters from standard echocardiography. Compliance measurement may be of relevance in selected clinical settings. First, subjects with low Cn are more likely to have their mitral valve area overestimated by the traditional mitral pressure half-time method. Consequently, low Cn in mitral stenosis, usually resulting from reduced LA compliance, can be mistaken for mild mitral stenosis. Second, low Cn independently predicted pulmonary hypertension and disease progression in medically treated mitral stenosis, and late cardiovascular complications after successful percutaneous mitral valvuloplasty. Decreased LA compliance also accounts for stiff LA syndrome, a rare complication of radiofrequency catheter ablation for atrial fibrillation, manifesting as otherwise unexplained heart failure with elevated LA pressure and pulmonary hypertension. Finally, depressed pre-ablation LA stiffness index, i.e. the ratio of the change in LA pressure to the corresponding change in LA volume during passive LA filling, was an independent predictor of arrhythmia recurrence. Thus, LA stiffening translates into adverse clinical outcomes in patients with mitral stenosis or atrial fibrillation undergoing interventional procedures. Whether reduced LA compliance after LA appendage occlusion can result in the LA stiff syndrome, has not been reported so far.
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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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Yang G, Zhuang X, Khan H, Haldar S, Nyktari E, Li L, Wage R, Ye X, Slabaugh G, Mohiaddin R, Wong T, Keegan J, Firmin D. Fully automatic segmentation and objective assessment of atrial scars for long-standing persistent atrial fibrillation patients using late gadolinium-enhanced MRI. Med Phys 2018; 45:1562-1576. [PMID: 29480931 PMCID: PMC5969251 DOI: 10.1002/mp.12832] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/01/2018] [Accepted: 02/17/2018] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Atrial fibrillation (AF) is the most common heart rhythm disorder and causes considerable morbidity and mortality, resulting in a large public health burden that is increasing as the population ages. It is associated with atrial fibrosis, the amount and distribution of which can be used to stratify patients and to guide subsequent electrophysiology ablation treatment. Atrial fibrosis may be assessed noninvasively using late gadolinium-enhanced (LGE) magnetic resonance imaging (MRI) where scar tissue is visualized as a region of signal enhancement. However, manual segmentation of the heart chambers and of the atrial scar tissue is time consuming and subject to interoperator variability, particularly as image quality in AF is often poor. In this study, we propose a novel fully automatic pipeline to achieve accurate and objective segmentation of the heart (from MRI Roadmap data) and of scar tissue within the heart (from LGE MRI data) acquired in patients with AF. METHODS Our fully automatic pipeline uniquely combines: (a) a multiatlas-based whole heart segmentation (MA-WHS) to determine the cardiac anatomy from an MRI Roadmap acquisition which is then mapped to LGE MRI, and (b) a super-pixel and supervised learning based approach to delineate the distribution and extent of atrial scarring in LGE MRI. We compared the accuracy of the automatic analysis to manual ground truth segmentations in 37 patients with persistent long-standing AF. RESULTS Both our MA-WHS and atrial scarring segmentations showed accurate delineations of cardiac anatomy (mean Dice = 89%) and atrial scarring (mean Dice = 79%), respectively, compared to the established ground truth from manual segmentation. In addition, compared to the ground truth, we obtained 88% segmentation accuracy, with 90% sensitivity and 79% specificity. Receiver operating characteristic analysis achieved an average area under the curve of 0.91. CONCLUSION Compared with previously studied methods with manual interventions, our innovative pipeline demonstrated comparable results, but was computed fully automatically. The proposed segmentation methods allow LGE MRI to be used as an objective assessment tool for localization, visualization, and quantitation of atrial scarring and to guide ablation treatment.
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Affiliation(s)
- Guang Yang
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
- National Heart and Lung InstituteImperial College LondonLondonSW7 2AZUK
| | - Xiahai Zhuang
- School of Data ScienceFudan UniversityShanghai201203China
| | - Habib Khan
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
| | - Shouvik Haldar
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
| | - Eva Nyktari
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
| | - Lei Li
- Department of Biomedical EngineeringShanghai Jiao Tong UniversityShanghai200240China
| | - Ricardo Wage
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
| | - Xujiong Ye
- School of Computer ScienceUniversity of LincolnLincolnLN6 7TSUK
| | - Greg Slabaugh
- Department of Computer ScienceCity University LondonLondonEC1V 0HBUK
| | - Raad Mohiaddin
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
- National Heart and Lung InstituteImperial College LondonLondonSW7 2AZUK
| | - Tom Wong
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
| | - Jennifer Keegan
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
- National Heart and Lung InstituteImperial College LondonLondonSW7 2AZUK
| | - David Firmin
- Cardiovascular Research CentreRoyal Brompton HospitalLondonSW3 6NPUK
- National Heart and Lung InstituteImperial College LondonLondonSW7 2AZUK
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Nakamori S, Nezafat M, Ngo LH, Manning WJ, Nezafat R. Left Atrial Epicardial Fat Volume Is Associated With Atrial Fibrillation: A Prospective Cardiovascular Magnetic Resonance 3D Dixon Study. J Am Heart Assoc 2018; 7:JAHA.117.008232. [PMID: 29572324 PMCID: PMC5907571 DOI: 10.1161/jaha.117.008232] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies demonstrated a strong association between atrial fibrillation (AF) and epicardial fat around the left atrium (LA). We sought to assess whether epicardial fat volume around the LA is associated with AF, and to determine the additive value of LA-epicardial fat measurements to LA structural remodeling for identifying patients with AF using 3-dimensional multi-echo Dixon fat-water separated cardiovascular magnetic resonance. METHODS AND RESULTS A total of 105 subjects were studied: 53 patients with a history of AF and 52 age-matched patients with other cardiovascular diseases but no history of AF. The 3-dimensional multi-echo Dixon fat-water separated sequence was performed for LA-epicardial fat measurements. AF patients had significantly greater LA-epicardial fat (28.9±12.3 and 14.2±7.3 mL for AF and non-AF, respectively; P<0.001) and LA volume (110.8±38.2 and 89.7±30.3 mL for AF and non-AF, respectively; P=0.002). LA-epicardial fat adjusted for LA volume was still higher in patients with AF compared with those without AF (P<0.001). LA-epicardial fat and hypertension were independently associated with the risk of AF (odds ratio, 1.17; 95% confidence interval, 1.10%-1.25%, P<0.001, and odds ratio, 3.29; 95% confidence interval, 1.17%-9.27%, P=0.03, respectively). In multivariable logistic regression analysis adjusted for body surface area, LA-epicardial fat remained significant and an increase per mL was associated with a 42% increase in the odds of AF presence (odds ratio, 1.42; 95% confidence interval, 1.23%-1.62%, P<0.001). Combined assessment of LA-epicardial fat and LA volume provided greater discriminatory performance for detecting AF than LA volume alone (c-statistic=0.88 and 0.74, respectively, DeLong test; P<0.001). CONCLUSIONS Cardiovascular magnetic resonance 3-dimensional Dixon-based LA-epicardial fat volume is significantly increased in AF patients. LA-epicardial fat measured by 3-dimensional Dixon provides greater performance for detecting AF beyond LA structural remodeling.
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Affiliation(s)
- Shiro Nakamori
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Maryam Nezafat
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Long H Ngo
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Warren J Manning
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.,Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Reza Nezafat
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Fahmy AS, Neisius U, Tsao CW, Berg S, Goddu E, Pierce P, Basha TA, Ngo L, Manning WJ, Nezafat R. Gray blood late gadolinium enhancement cardiovascular magnetic resonance for improved detection of myocardial scar. J Cardiovasc Magn Reson 2018; 20:22. [PMID: 29562921 PMCID: PMC5863465 DOI: 10.1186/s12968-018-0442-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/02/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Low scar-to-blood contrast in late gadolinium enhanced (LGE) MRI limits the visualization of scars adjacent to the blood pool. Nulling the blood signal improves scar detection but results in lack of contrast between myocardium and blood, which makes clinical evaluation of LGE images more difficult. METHODS GB-LGE contrast is achieved through partial suppression of the blood signal using T2 magnetization preparation between the inversion pulse and acquisition. The timing parameters of GB-LGE sequence are determined by optimizing a cost-function representing the desired tissue contrast. The proposed 3D GB-LGE sequence was evaluated using phantoms, human subjects (n = 45) and a swine model of myocardial infarction (n = 5). Two independent readers subjectively evaluated the image quality and ability to identify and localize scarring in GB-LGE compared to black-blood LGE (BB-LGE) (i.e., with complete blood nulling) and conventional (bright-blood) LGE. RESULTS GB-LGE contrast was successfully generated in phantoms and all in-vivo scans. The scar-to-blood contrast was improved in GB-LGE compared to conventional LGE in humans (1.1 ± 0.5 vs. 0.6 ± 0.4, P < 0.001) and in animals (1.5 ± 0.2 vs. -0.03 ± 0.2). In patients, GB-LGE detected more tissue scarring compared to BB-LGE and conventional LGE. The subjective scores of the GB-LGE ability for localizing LV scar and detecting papillary scar were improved as compared with both BB-LGE (P < 0.024) and conventional LGE (P < 0.001). In the swine infarction model, GB-LGE scores for the ability to localize LV scar scores were consistently higher than those of both BB-LGE and conventional-LGE. CONCLUSION GB-LGE imaging improves the ability to identify and localize myocardial scarring compared to both BB-LGE and conventional LGE. Further studies are warranted to histologically validate GB-LGE.
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Affiliation(s)
- Ahmed S. Fahmy
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
- Biomedical Engineering Department, School of Engineering, Cairo University, Giza, Egypt
| | - Ulf Neisius
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
| | - Connie W. Tsao
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
| | - Sophie Berg
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
| | - Elizabeth Goddu
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
| | - Patrick Pierce
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
| | - Tamer A. Basha
- Biomedical Engineering Department, School of Engineering, Cairo University, Giza, Egypt
| | - Long Ngo
- Department of Medicine (Division of General Medicine and Primary Care), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA USA
| | - Warren J. Manning
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA USA
| | - Reza Nezafat
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 USA
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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: 38] [Impact Index Per Article: 6.3] [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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Zghaib T, Malayeri AA, Ipek EG, Habibi M, Huang D, Balouch MA, Bluemke DA, Calkins H, Nazarian S, Zimmerman SL. Visualization of acute edema in the left atrial myocardium after radiofrequency ablation: Application of a novel high-resolution 3-dimensional magnetic resonance imaging sequence. Heart Rhythm 2018. [PMID: 29530833 DOI: 10.1016/j.hrthm.2018.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ablation-induced left atrial (LA) edema may result in procedural failure due to reversible pulmonary vein isolation. Conventional T2-weighted magnetic resonance edema imaging is limited by low spatial resolution. OBJECTIVE The purpose of this pilot study was to optimize and validate a 3-dimensional (3D) sampling perfection with application-optimized contrasts using different flip-angle evolution (SPACE) sequence for quantification of T2 signal in the LA, and to apply it in recently ablated patients, comparing myocardial edema on T2-SPACE to tissue damage on late gadolinium enhancement (LGE) imaging. METHODS Phantom studies were performed to identify 3D-SPACE parameters for optimal contrast between normal and edematous myocardium. Fourteen AF patients were imaged with both 3D-SPACE and dark-blood turbo-spin echo (DB-TSE) to compare image quality and signal intensity between the 2 techniques. Eight patients underwent pre- and postablation 3D-SPACE and 3D-LGE imaging. Ablation points were co-registered with corresponding myocardial sectors, and ablation-induced changes in T2 and LGE signal intensities were measured. RESULTS Signal-to-noise ratio and contrast-to-noise ratio were higher on SPACE vs DB-TSE (65.5 ± 33.9 vs 35.7 ± 17.9; P = .01; and 59.4 ± 33.0 vs 32.9 ± 17.7; P = .04, respectively). T2-signal correlated well on 3D-SPACE and DB-TSE, such that each unit increase in TSE intensity correlated with a 0.69-unit increase in SPACE intensity (95% confidence interval 0.56-0.82; P <.001). T2 and LGE signal intensities were acutely increased at ablation sites. The extent of postablation edema was higher compared to LGE, although the spatial distribution of hyperenhancement around pulmonary veins seemed similar in both modalities. CONCLUSION T2-SPACE can be used to map the extent of acute postablation edema in the thin LA myocardium, with improved resolution and lower artifact compared to traditional DB-TSE.
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Affiliation(s)
- Tarek Zghaib
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Ashkan A Malayeri
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Esra G Ipek
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammadali Habibi
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dong Huang
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Muhammad A Balouch
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David A Bluemke
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saman Nazarian
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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50
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Cheng WH, Lo LW, Lin YJ, Chang SL, Hu YF, Hung Y, Chung FP, Chang TY, Huang TC, Yamada S, Salim S, Te ALD, Liao JN, Tuan TC, Chao TF, Tsai TY, Liu SH, Chen SA. Cigarette smoking causes a worse long-term outcome in persistent atrial fibrillation following catheter ablation. J Cardiovasc Electrophysiol 2018; 29:699-706. [DOI: 10.1111/jce.13451] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/19/2018] [Accepted: 01/23/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Wen-Han Cheng
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Yuan Hung
- Division of Cardiology, Department of Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Ting-Yung Chang
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Ting-Chung Huang
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Shinya Yamada
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Simon Salim
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Abigail Louise D. Te
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
| | - Tseng-Ying Tsai
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Shin-Huei Liu
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Institute; National Yang-Ming University; Taipei Taiwan
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