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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45:3314-3414. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Agarwal PP, Nasr LA, Ghoshhajra BB, Brown RKJ, Collier P, De Cecco CN, Fuss C, Goldstein JN, Kallianos K, Malik SB, Maroules CD, Meyersohn NM, Nazarian S, Scherer MD, Singh S, Tailor TD, Tong MS, Koweek LM. ACR Appropriateness Criteria® Preprocedural Planning for Left Atrial Procedures in Atrial Fibrillation. J Am Coll Radiol 2024; 21:S237-S248. [PMID: 38823947 DOI: 10.1016/j.jacr.2024.02.024] [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: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
This document summarizes the relevant literature for the selection of preprocedural imaging in three clinical scenarios in patients needing endovascular treatment or cardioversion of atrial fibrillation. These clinical scenarios include preprocedural imaging prior to radiofrequency ablation; prior to left atrial appendage occlusion; and prior to cardioversion. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Layla A Nasr
- Research Author, Allegheny Health Network Imaging Institute, Pittsburgh, Pennsylvania
| | | | - Richard K J Brown
- University of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Cristina Fuss
- Oregon Health & Science University, Portland, Oregon
| | - Jennifer N Goldstein
- ChristianaCare Health System, Newark, Delaware; Society of General Internal Medicine
| | | | - Sachin B Malik
- VA Palo Alto Health Care System, Palo Alto, California; Stanford University, Stanford, California
| | | | | | - Saman Nazarian
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Heart Rhythm Society
| | - Markus D Scherer
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Society of Cardiovascular Computed Tomography
| | - Simranjit Singh
- Indiana University School of Medicine, Indianapolis, Indiana; American College of Physicians
| | - Tina D Tailor
- Duke University Medical Center, Durham, North Carolina
| | - Matthew S Tong
- Ohio State University, Columbus, Ohio; Society for Cardiovascular Magnetic Resonance
| | - Lynne M Koweek
- Specialty Chair, Duke University Medical Center, Durham, North Carolina
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Deneke T, Kutyifa V, Hindricks G, Sommer P, Zeppenfeld K, Carbucicchio C, Pürerfellner H, Heinzel FR, Traykov VB, De Riva M, Pontone G, Lehmkuhl L, Haugaa K. Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology. Europace 2024; 26:euae108. [PMID: 38743765 PMCID: PMC11104536 DOI: 10.1093/europace/euae108] [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: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.
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Affiliation(s)
- Thomas Deneke
- Clinic for Rhythmology at Klinikum Nürnberg Campus Süd, University Hospital of the Paracelsus Medical University, Nuremberg, Germany
| | | | | | | | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Helmut Pürerfellner
- Department of Clinical Electrophysiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Frank R Heinzel
- Städtisches Klinikum Dresden, Department of Cardiology, Angiology and Intensive Care Medicine, Dresden, Germany
| | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Marta De Riva
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Lukas Lehmkuhl
- Department of Radiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Germany
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Chen L, Zhang D, Sang C, Wu Y, Ren Y, Lu Y. Left atrial strain associated with interatrial block in patients with ST-segment elevation myocardial infarction. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:477-485. [PMID: 38117379 DOI: 10.1007/s10554-023-03011-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023]
Abstract
Both interatrial block (IAB) and left atrium (LA) strain are associated with atrial arrhythmias in ST-segment elevation myocardial infarction (STEMI) patients, but the relationship between IAB and LA strain has not yet been reported. This study was to investigate the correlation between LA strain and IAB in STEMI patients. This is a single-center retrospective clinical observational study. The STEMI patients with primary percutaneous coronary intervention (pPCI) were enrolled, and all patients completed cardiac magnetic resonance (CMR). A standard 12-lead electrocardiogram (ECG) was recorded on the same day as CMR. IAB was measured by p duration on ECG at follow-up. 302 patients were enrolled, including 91 (30.1%) with IAB. The reservoir strain, conduit strain and booster strain were included in model 1, model 2 and model 3, respectively. In model 1, age (OR 1.025; 95%CI 1.003-1.047; p = 0.026), hypertension (OR 2.188; 95%CI 1.288-3.719; p = 0.004), and reservoir strain (OR 0.947; 95%CI 0.920-0.974; p < 0.001) were independent factors for IAB. In model 2, age (OR 1.031; 95%CI 1.009-1.053; p = 0.006), hypertension (OR 2.058; 95%CI 1.202-3.522; p = 0.008), RCA lesions (OR 1.797; 95%CI 1.036-3.113; p = 0.037), and conduit strain (OR 0.910; 95%CI 0.868-0.953; p < 0.001) were independent factors for IAB. In model 3, age (OR 1.022; 95%CI 1.001-1.045; p = 0.044), hypertension (OR 2.239; 95%CI 1.329-3.773; p = 0.002), and booster strain (OR 0.948; 95%CI 0.908-0.991; p = 0.019) were independent factors for IAB. With the lowest AIC and BIC values, model 2 was the best-fit model. LA strain associated with IAB in STEMI patients. The model including conduit strain was the best-fit one.
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Affiliation(s)
- Lei Chen
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99#, Huaihai West Road, Xuzhou, 221002, China
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dongdong Zhang
- Department of Cardiology, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, China
| | - Chuanyi Sang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99#, Huaihai West Road, Xuzhou, 221002, China
| | - Yixuan Wu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99#, Huaihai West Road, Xuzhou, 221002, China
| | - Yanfei Ren
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99#, Huaihai West Road, Xuzhou, 221002, China
| | - Yuan Lu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99#, Huaihai West Road, Xuzhou, 221002, China.
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Fiedler L, Roca I, Lorgat F, Lacotte J, Haqqani H, Jesser E, Williams C, Roithinger FX, Steven D. Characterization of high-density mapping in catheter ablation for persistent atrial fibrillation: results from the Advisor™ HD Grid Mapping Catheter Observational study. J Interv Card Electrophysiol 2023; 66:1411-1421. [PMID: 36481832 PMCID: PMC9735148 DOI: 10.1007/s10840-022-01442-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND We quantified and characterized the outcomes of ablation in persistent atrial fibrillation (PersAF) subjects, and the utility of electroanatomical mapping with a market-released high-density (HD) mapping catheter. METHODS PersAF subjects received electroanatomical mapping with the Advisor™ HD Grid mapping catheter, Sensor Enabled™ (HD Grid) and radiofrequency (RF) ablation to gather data regarding ablation strategies, mapping efficiency, quality, and outcomes. Subjects were enrolled from January 2019 to April 2020 across 25 international sites and followed for 12 months after the procedure. RESULTS Three hundred thirty-four PersAF subjects (average age 64.2 years; 76% male; 25.4% previous AF ablation) were enrolled. Multiple map types were generated in a variety of rhythms using HD Grid. Significant differences in low voltage areas were identified in maps generated with the HD Wave Solution™ electrode configuration when compared to the standard configuration, which in some cases, influenced physicians' ablation strategies. PV-only ablation strategy was used in 59.0% of subjects and 34.1% of subjects received PV ablation and additional lesions. Of the subjects, 82.0% were free from recurrent atrial arrhythmias at 12 months and new or increased dose of class I/III antiarrhythmic drugs. About 6.0% of subjects experienced a serious adverse event or serious adverse device effect through 12 months including 1 event deemed related to HD Grid and the index procedure by the investigator and 1 death unrelated to study devices. CONCLUSIONS The results of this study (NCT03733392) support the safety and utility of electroanatomical mapping with HD Grid in subjects with complex arrhythmias, such as PersAF in the real-world setting.
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Affiliation(s)
- Lukas Fiedler
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria.
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Poelten, Austria.
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, 5020, Salzburg, Austria.
| | - Ivo Roca
- Hospital Clinic I Provincial de Barcelona, 170, 08036, Barcelona, Catalonia, Spain
| | - Faizel Lorgat
- Christiaan Barnard Memorial Hospital, 181 Longmarket Street, Cape Town, 8001, South Africa
| | - Jérôme Lacotte
- Institute Cardio. Paris-Sud - Institut Jacques Cartier, Massy, France
| | - Haris Haqqani
- The Prince Charles Hospital, Rode Road, Queensland, 4032, Chermside, Australia
| | - Emily Jesser
- Abbott, 5050 Nathan Ln N, Plymouth, MN, 55441, USA
| | | | - Franz Xaver Roithinger
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Poelten, Austria
| | - Daniel Steven
- Heart center at the University of Cologne, Kerpener Strasse 62, 50937, Cologne, North Rhine, Germany
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Regmi MR, Bhattarai M, Parajuli P, Botchway A, Tandan N, Abdelkarim J, Labedi M. Prediction of Recurrence of Atrial Fibrillation Post-ablation Based on Atrial Fibrosis Seen on Late Gadolinium Enhancement MRI: A Metaanalysis. Curr Cardiol Rev 2023; 19:e051222211571. [PMID: 36475341 PMCID: PMC10280994 DOI: 10.2174/1573403x19666221205100148] [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: 06/08/2022] [Revised: 09/15/2022] [Accepted: 10/21/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES This meta-analysis aims to investigate the recurrence of atrial fibrillation (AF) post-ablation based on the various stages of fibrosis seen in the late gadolinium enhancement magnetic resonance imaging (LGE-MRI). METHODS Electronic databases were searched using specific terms and identified nine studies that met the inclusion criteria. A total of 1,787 patients underwent LGE-MRI to assess atrial fibrosis before catheter ablation for AF. We performed three analyses: first, we compared stage IV versus stage I (reference group). The second set examined the combined stages III and IV versus stages I and II (reference group). The third set compared stage IV versus combined stages I, II, and III. The metanalysis relied on a random-effects model to pool the odds ratios (OR) and 95% confidence intervals (CI) using the DerSimonian and Laird method. The data was analyzed using StatsDirect software in England. RESULTS The study showed a higher rate of AF recurrence after ablation in stage IV atrial fibrosis than in stage I (OR, 9.54; 95% CI, 3.81 to 28.89; P<00001). Also, in patients with combined stages III & IV of atrial fibrosis, AF recurrence was significantly higher after ablation than in stages I & II groups (OR, 2.37; 95% CI, 1.61 to 3.50; P<00001). Similarly, compared to combined stages I, II, and III, patients with stage IV have higher odds of recurrence post-ablation (OR, 4.24; 95% CI, 2.39- 7.52, P < 0.001). CONCLUSION This metanalysis demonstrates the strong association between left atrial fibrosis in LGE-MRI and AF post-ablation recurrence. The finding of this study will further assist clinicians in predicting the recurrence rate of AF based on the amount of fibrosis and tailor therapeutic decisions for further management.
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Affiliation(s)
- Manjari Rani Regmi
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Ill, USA
| | - Mukul Bhattarai
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Ill, USA
| | - Priyanka Parajuli
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Albert Botchway
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Ill, USA
| | - Nitin Tandan
- Division of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Jumana Abdelkarim
- Division of Endocrinology, Southern Illinois University School of Medicine, Springfield, Ill, USA
| | - Mohamed Labedi
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Ill, USA
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O’Neill L, Sim I, O’Hare D, Whitaker J, Mukherjee RK, Razeghi O, Niederer S, Wright M, Chiribiri A, Frigiola A, O’Neill MD, Williams SE. CArdiac MagnEtic resonance assessment of bi-Atrial fibrosis in secundum atrial septal defects patients: CAMERA-ASD study. Eur Heart J Cardiovasc Imaging 2022; 23:1231-1239. [PMID: 34568942 PMCID: PMC9365304 DOI: 10.1093/ehjci/jeab188] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Indexed: 12/25/2022] Open
Abstract
AIMS Atrial septal defects (ASD) are associated with atrial arrhythmias, but the arrhythmia substrate in these patients is poorly defined. We hypothesized that bi-atrial fibrosis is present and that right atrial fibrosis is associated with atrial arrhythmias in ASD patients. We aimed to evaluate the extent of bi-atrial fibrosis in ASD patients and to investigate the relationships between bi-atrial fibrosis, atrial arrhythmias, shunt fraction, and age. METHODS AND RESULTS Patients with uncorrected secundum ASDs (n = 36; 50.4 ± 13.6 years) underwent cardiac magnetic resonance imaging with atrial late gadolinium enhancement. Comparison was made to non-congenital heart disease patients (n = 36; 60.3 ± 10.5 years) with paroxysmal atrial fibrillation (AF). Cardiac magnetic resonance parameters associated with atrial arrhythmias were identified and the relationship between bi-atrial structure, age, and shunt fraction studied. Bi-atrial fibrosis burden was greater in ASD patients than paroxysmal AF patients (20.7 ± 14% vs. 10.1 ± 8.6% and 14.8 ± 8.5% vs. 8.6 ± 6.1% for right and left atria respectively, P = 0.001 for both). In ASD patients, right atrial fibrosis burden was greater in those with than without atrial arrhythmias (33.4 ± 18.7% vs. 16.8 ± 10.3%, P = 0.034). On receiver operating characteristic analysis, a right atrial fibrosis burden of 32% had a 92% specificity and 71% sensitivity for predicting the presence of atrial arrhythmias. Neither age nor shunt fraction was associated with bi-atrial fibrosis burden. CONCLUSION Bi-atrial fibrosis burden is greater in ASD patients than non-congenital heart disease patients with paroxysmal AF. Right atrial fibrosis is associated with the presence of atrial arrhythmias in ASD patients. These findings highlight the importance of right atrial fibrosis to atrial arrhythmogenesis in ASD patients.
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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
| | - Iain Sim
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, 4th Floor North, Wing, St. Thomas’, Hospital, London SE1 7EH, UK
| | - Daniel O’Hare
- 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
| | - 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
| | - 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
| | - Matthew Wright
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, 4th Floor North, Wing, St. Thomas’, Hospital, London SE1 7EH, UK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, 4th Floor North, Wing, St. Thomas’, Hospital, 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
| | - 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
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Lee JH, Hwang I, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Lower pulmonary vein-to-left atrium volume ratio predicts poor rhythm outcome after atrial fibrillation catheter ablation. Front Cardiovasc Med 2022; 9:934168. [PMID: 35911561 PMCID: PMC9334901 DOI: 10.3389/fcvm.2022.934168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Although left atrial (LA) dimension (LAD) is one of the predictors of atrial fibrillation (AF) recurrence after catheter ablation, repetitive recurrences occur in patients without enlarged LAD. We explored the predictive value of pulmonary vein (PV) to LA volume percent ratio (PV/LA%vol) for rhythm outcomes after AF catheter ablation (AFCA). We included 2913 patients (73.5% male, 60.0 [52.0–67.0] years old, 60.6% paroxysmal AF) who underwent AFCA. We evaluated the association between PV/LA%vol and AF recurrence after AFCA and compared the predictive value for AF recurrences according to the LA size with LAD. We additionally investigated the association between PV/LA%vol and PITX2 gene using a genome-wide association study. LAD affected 1-year recurrence only in the highest tertile group (T3, p = 0.046), but PV/LA%vol determined 1-year recurrence in all LAD groups (T1, p = 0.044; T2, p = 0.021; and T3, p = 0.045). During 20.0 (8.0–45.0) months of follow-up, AF recurrence rate was significantly higher in patients with lower PV/LA%vol (Log-rank p = 0.004, HR 0.91 [0.84–1.00], p = 0.044). In the T1 and T2 LAD groups, predicting AF recurrences was better with PV/LA%vol than with LAD (AUC 0.63 vs. 0.51, p < 0.001 at T1; AUC 0.61 vs. 0.50, p = 0.007 at T2). We replicated PITX2-related rs12646447, which was independently associated with PV/LA%vol (β = 0.15 [0–0.30], p = 0.047). In conclusion, smaller PV volumes after LA volume adjustments have genetic background of PITX2 gene and predictive value for poorer rhythm outcomes after AFCA, especially in patients without LA enlargement.
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Affiliation(s)
- Jae-Hyuk Lee
- Department of Cardiology, Myongji Hospital, Hanyang University Medical Center, Gyeonggi-do, South Korea
| | - Inseok Hwang
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Hee Tae Yu
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Tae-Hoon Kim
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Jae-Sun Uhm
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Boyoung Joung
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Moon-Hyoung Lee
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Hui-Nam Pak
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
- *Correspondence: Hui-Nam Pak,
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Role of CMR-derived Atrial Deformation Analysis in the Prediction of Atrial Fibrillation Recurrence Rate after Pulmonary Vein Isolation. Eur J Radiol 2022; 155:110452. [DOI: 10.1016/j.ejrad.2022.110452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/04/2022] [Accepted: 07/20/2022] [Indexed: 11/23/2022]
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10
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Stacy MR, Lin BA, Thorn SL, Lobb DC, Maxfield MW, Novack C, Zellars KN, Freeburg L, Akar JG, Sinusas AJ, Spinale FG. Regional heterogeneity in determinants of atrial matrix remodeling and association with atrial fibrillation vulnerability postmyocardial infarction. Heart Rhythm 2022; 19:847-855. [PMID: 35066183 PMCID: PMC9064890 DOI: 10.1016/j.hrthm.2022.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 01/05/2022] [Accepted: 01/18/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Left ventricular (LV) remodeling following a myocardial infarction (MI) is associated with new-onset atrial fibrillation (AF). LV remodeling post-MI is characterized by regional changes in matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs), causing extracellular matrix (ECM) remodeling. OBJECTIVE The purpose of this study was to test the hypothesis that a shift in regional atrial MMP activity, MMP/TIMP expression, and ECM remodeling occurs post-MI, which cause increased vulnerability to AF. METHODS MI was induced in pigs (weight 25 kg; coronary ligation; n = 9). At approximately 14 days post-MI, an atrial electrical stimulation protocol was performed, after which an MMP radiotracer was infused, MMP/TIMP mRNA profiling performed, and ECM collagen assessed by histochemistry. An additional 7 non-MI pigs served as controls. RESULTS AF could be induced in 89% (8/9) of the post-MI pigs but none of the controls. MMP activity (MMP radiotracer uptake) increased by approximately 2-fold in most atrial regions post-MI, whereas fibrillar collagen content was unchanged or actually reduced in right atrial regions and increased in left atrial regions. MMP/TIMP profiles revealed a heterogeneous pattern from the left atrial appendage to right atrial regions. CONCLUSION AF vulnerability early post-MI was associated with a heterogeneous pattern of atrial ECM remodeling, detectable by noninvasive molecular imaging. Detection of early atrial MMP activation post-MI may help define the myocardial substrate underlying AF.
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Affiliation(s)
- Mitchel R. Stacy
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Ben A. Lin
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Stephanie L. Thorn
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - David C. Lobb
- Cell Biology & Anatomy, University of South Carolina School of Medicine, Columbia, SC
| | - Mark W. Maxfield
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Craig Novack
- Cell Biology & Anatomy, University of South Carolina School of Medicine, Columbia, SC
| | - Kia N. Zellars
- Cell Biology & Anatomy, University of South Carolina School of Medicine, Columbia, SC
| | - Lisa Freeburg
- Cell Biology & Anatomy, University of South Carolina School of Medicine, Columbia, SC
| | - Joseph G. Akar
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Albert J. Sinusas
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Francis G. Spinale
- Cell Biology & Anatomy, University of South Carolina School of Medicine, Columbia, SC,Columbia VA Health Care System, Columbia, SC
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11
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Liu Y, Wang W, Luo G, Wang K, Liang D, Li S. Uncertainty-guided symmetric multi-level supervision network for 3D left atrium segmentation in late gadolinium-enhanced MRI. Med Phys 2022; 49:4554-4565. [PMID: 35420165 DOI: 10.1002/mp.15670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/21/2022] [Accepted: 04/06/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Atrial fibrillation is a common arrhythmia and requires volumetric imaging to guide the therapy procedure. Late gadolinium-enhanced magnetic resonance imaging (LGE MRI) is an efficient non-invasive technology for imaging the diseased heart. Three-dimensional segmentation of the left atrium (LA) in LGE MRI is a fundamental step for guiding the therapy of patients with atrial fibrillation. However, the low contrast and fuzzy surface of the LA in LGE MRI make accurate and objective LA segmentation challenge. The purpose of this study is to propose an automatic and efficient LA segmentation model based on a convolutional neural network to obtain a more accurate predicted surface and improve the LA segmentation results. METHODS In this study, we proposed an uncertainty-guided symmetric multi-level supervision network for 3D LA segmentation in LGE MRI. Firstly, we constructed a symmetric multi-level supervision structure to combine the corresponding features from the encoding and decoding stages to learn the multi-scale representation of LA. Secondly, we formulated the discrepancy of predictions of our model as model uncertainty. Then we proposed an uncertainty-guided objective function to further increase the segmentation accuracy on the surface. RESULTS We evaluated our proposed model on the public LA segmentation database using four universal metrics. The proposed model achieved Hausdorff Distance of 11.68 mm, average symmetric surface distance of 0.92 mm, Dice score of 0.92, and Jaccard of 0.85. Compared with state-of-the-art models, our model achieved the best Hausdorff Distance that is sensitive to surface accuracy. For the other three metrics, our model also achieved better or comparable performance. CONCLUSIONS We proposed an efficient automatic LA segmentation model that consisted of a symmetric multi-level supervision structure and an uncertainty-guided objective function. Compared to other models, we designed an additional supervision branch in the encoding stage to learn more detailed representations of LA while learning global context information through the multi-level structure of each supervision branch. To address the fuzzy surface challenge of LA segmentation in LGE MRI, we leveraged the model uncertainty to enhance the distinguishing ability of the model on the surface, thereby the predicted accuracy of the LA surface can be further increased. We conducted extensive ablation and comparative experiments with state-of-the-art models. The experiment results demonstrated that our proposed model could handle the complex structure of LA and had superior advantages in improving the segmentation performance on the surface. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yashu Liu
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin, 150001, China
| | - Wei Wang
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin, 150001, China
| | - Gongning Luo
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin, 150001, China
| | - Kuanquan Wang
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin, 150001, China
| | - Dong Liang
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin, 150001, China
| | - Shuo Li
- Department of Medical Imaging, Western University, London, Ontario, N6A 3K7, Canada
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12
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Nakamura T, Kiuchi K, Fukuzawa K, Takami M, Watanabe Y, Izawa Y, Takemoto M, Sakai J, Yatomi A, Sonoda Y, Takahara H, Nakasone K, Yamamoto K, Suzuki Y, Tani K, Negi N, Kono A, Ashihara T, Hirata K. The impact of the atrial wall thickness in normal/mild late-gadolinium enhancement areas on atrial fibrillation rotors in persistent atrial fibrillation patients. J Arrhythm 2022; 38:221-231. [PMID: 35387140 PMCID: PMC8977582 DOI: 10.1002/joa3.12676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/03/2021] [Accepted: 01/03/2022] [Indexed: 11/20/2022] Open
Abstract
Background Some of atrial fibrillation (AF) drivers are found in normal/mild late-gadolinium enhancement (LGE) areas, as well as moderate ones. The atrial wall thickness (AWT) has been reported to be important as a possible AF substrate. However, the AWT and degree of LGEs as an AF substrate has not been fully validated in humans. Objective The purpose of this study was to evaluate the impact of the AWT in normal/mild LGE areas on AF drivers. Methods A total of 287 segments in 15 persistent AF patients were assessed. AF drivers were defined as non-passively activated areas (NPAs), where rotational activation was frequently observed, and were detected by the novel real-time phase mapping (ExTRa Mapping), mild LGE areas were defined as areas with a volume ratio of the enhancement voxel of 0% to <10%. The AWT was defined as the minimum distance from the manually determined endocardium to the epicardial border on the LGE-MRI. Results NPAs were found in 20 (18.0%) of 131 normal/mild LGE areas where AWT was significantly thicker than that in the passively activated areas (PAs) (2.5 ± 0.3 vs. 2.2 ± 0.3 mm, p < .001). However, NPAs were found in 41 (26.3%) of 156 moderate LGE areas where AWT was thinner than that of PAs (2.1 ± 0.2 mm vs. 2.23 ± 0.3 mm, p = .02). An ROC curve analysis yielded an optimal cutoff value of 2.2 mm for predicting the presence of an NPA in normal/mild LGE areas. Conclusion The location of AF drivers in normal/mild LGE areas might be more accurately identified by evaluating AWT.
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Affiliation(s)
- Toshihiro Nakamura
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kunihiko Kiuchi
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Koji Fukuzawa
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Mitsuru Takami
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yoshiaki Watanabe
- Department of RadiologyKobe University Graduate School of MedicineKobeJapan
| | - Yu Izawa
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Makoto Takemoto
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Jun Sakai
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Atsusuke Yatomi
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yusuke Sonoda
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hiroyuki Takahara
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kazutaka Nakasone
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kyoko Yamamoto
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yuya Suzuki
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Ken‐ichi Tani
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Noriyuki Negi
- Division of RadiologyCenter for Radiology and Radiation OncologyKobe University HospitalKobeJapan
| | - Atsushi Kono
- Department of RadiologyKobe University Graduate School of MedicineKobeJapan
| | - Takashi Ashihara
- Department of Medical Informatics and Biomedical EngineeringShiga University of Medical ScienceOtsuJapan
| | - Ken‐ichi Hirata
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
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13
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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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14
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Roney CH, Sillett C, Whitaker J, Lemus JAS, Sim I, Kotadia I, O'Neill M, Williams SE, Niederer SA. Applications of multimodality imaging for left atrial catheter ablation. Eur Heart J Cardiovasc Imaging 2021; 23:31-41. [PMID: 34747450 PMCID: PMC8685603 DOI: 10.1093/ehjci/jeab205] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Indexed: 11/13/2022] Open
Abstract
Atrial arrhythmias, including atrial fibrillation and atrial flutter, may be treated through catheter ablation. The process of atrial arrhythmia catheter ablation, which includes patient selection, pre-procedural planning, intra-procedural guidance, and post-procedural assessment, is typically characterized by the use of several imaging modalities to sequentially inform key clinical decisions. Increasingly, advanced imaging modalities are processed via specialized image analysis techniques and combined with intra-procedural electrical measurements to inform treatment approaches. Here, we review the use of multimodality imaging for left atrial ablation procedures. The article first outlines how imaging modalities are routinely used in the peri-ablation period. We then describe how advanced imaging techniques may inform patient selection for ablation and ablation targets themselves. Ongoing research directions for improving catheter ablation outcomes by using imaging combined with advanced analyses for personalization of ablation targets are discussed, together with approaches for their integration in the standard clinical environment. Finally, we describe future research areas with the potential to improve catheter ablation outcomes.
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Affiliation(s)
- Caroline H Roney
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Charles Sillett
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | | | - Iain Sim
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Irum Kotadia
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
- Centre for Cardiovascular Science, The University of Edinburgh, Scotland, UK
| | - Steven A Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
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15
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Munoz C, Sim I, Neji R, Kunze KP, Masci PG, Schmidt M, O'Neill M, Williams S, Botnar RM, Prieto C. Evaluation of accelerated motion-compensated 3d water/fat late gadolinium enhanced MR for atrial wall imaging. MAGMA (NEW YORK, N.Y.) 2021; 34:877-887. [PMID: 34165670 PMCID: PMC8578113 DOI: 10.1007/s10334-021-00935-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/28/2021] [Accepted: 06/03/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE 3D late gadolinium enhancement (LGE) imaging is a promising non-invasive technique for the assessment of atrial fibrosis. However, current techniques result in prolonged and unpredictable scan times and high rates of non-diagnostic images. The purpose of this study was to compare the performance of a recently proposed accelerated respiratory motion-compensated 3D water/fat LGE technique with conventional 3D LGE for atrial wall imaging. MATERIALS AND METHODS 18 patients (age: 55.7±17.1 years) with atrial fibrillation underwent conventional diaphragmatic navigator gated inversion recovery (IR)-prepared 3D LGE (dNAV) and proposed image-navigator motion-corrected water/fat IR-prepared 3D LGE (iNAV) imaging. Images were assessed for image quality and presence of fibrosis by three expert observers. The scan time for both techniques was recorded. RESULTS Image quality scores were improved with the proposed compared to the conventional method (iNAV: 3.1 ± 1.0 vs. dNAV: 2.6 ± 1.0, p = 0.0012, with 1: Non-diagnostic to 4: Full diagnostic). Furthermore, scan time for the proposed method was significantly shorter with a 59% reduction is scan time (4.5 ± 1.2 min vs. 10.9 ± 3.9 min, p < 0.0001). The images acquired with the proposed method were deemed as inconclusive less frequently than the conventional images (expert 1/expert 2: 4/7 dNAV and 2/4 iNAV images inconclusive). DISCUSSION The motion-compensated water/fat LGE method enables atrial wall imaging with diagnostic quality comparable to the current conventional approach with a significantly shorter scan of about 5 min.
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Affiliation(s)
- Camila Munoz
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK.
| | - Iain Sim
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK
| | - Radhouene Neji
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK
- MR Research Collaborations, Siemens Healthcare Limited, Frimley, UK
| | - Karl P Kunze
- MR Research Collaborations, Siemens Healthcare Limited, Frimley, UK
| | - Pier-Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK
| | - Michaela Schmidt
- Cardiovascular MR Predevelopment, Siemens Healthcare GmbH, Erlangen, Germany
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK
| | - Steven Williams
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK
| | - René M Botnar
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK
- Escuela de Ingeniería, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Prieto
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, 3rd Floor, Lambeth Wing, London, SE1 7EH, UK
- Escuela de Ingeniería, Pontificia Universidad Católica de Chile, Santiago, Chile
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16
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Hopman LHGA, Mulder MJ, van der Laan AM, Demirkiran A, Bhagirath P, van Rossum AC, Allaart CP, Götte MJW. Impaired left atrial reservoir and conduit strain in patients with atrial fibrillation and extensive left atrial fibrosis. J Cardiovasc Magn Reson 2021; 23:131. [PMID: 34758820 PMCID: PMC8582184 DOI: 10.1186/s12968-021-00820-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with profound structural and functional changes in the atria. In the present study, we investigated the association between left atrial (LA) phasic function and the extent of LA fibrosis using advanced cardiovascular magnetic resonance (CMR) imaging techniques, including 3-dimensional (3D) late gadolinium enhancement (LGE) and feature tracking. METHODS Patients with paroxysmal and persistent AF (n = 105) underwent CMR in sinus rhythm. LA global reservoir strain, conduit strain and contractile strain were derived from cine CMR images using CMR feature tracking. The extent of LA fibrosis was assessed from 3D LGE images. Healthy subjects underwent CMR and served as controls (n = 19). RESULTS Significantly lower LA reservoir strain, conduit strain and contractile strain were found in AF patients, as compared to healthy controls (- 15.9 ± 3.8% vs. - 21.1 ± 3.6% P < 0.001, - 8.7 ± 2.7% vs. - 12.6 ± 2.5% P < 0.001 and - 7.2 ± 2.3% vs. - 8.6 ± 2.2% P = 0.02, respectively). Patients with a high degree of LA fibrosis (dichotomized by the median value) had lower reservoir strain and conduit strain compared to patients with a low degree of LA fibrosis (- 15.0 ± 3.9% vs. - 16.9 ± 3.3%, P = 0.02 and - 7.9 ± 2.7% vs. - 9.5 ± 2.6%, P = 0.01, respectively). In contrast, no difference was found for LA contractile strain (- 7.1 ± 2.4% vs. - 7.4 ± 2.3%, P = 0.55). CONCLUSIONS Impaired LA reservoir and conduit strain are present in AF patients with extensive atrial fibrosis. Future studies are needed to examine the biologic nature of this association and possible therapeutic implications.
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Affiliation(s)
- Luuk H. G. A. Hopman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Mark J. Mulder
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Anja M. van der Laan
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Pranav Bhagirath
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Albert C. van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Cornelis P. Allaart
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Marco J. W. Götte
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
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17
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Marrouche NF, Dagher L, Wazni O, Akoum N, Mansour M, El Hajjar AH, Bhatnagar A, Hua H. Effect of DrOnedarone on atrial fibrosis progression and atrial fibrillation recurrence postablation: Design of the EDORA randomized clinical trial. J Cardiovasc Electrophysiol 2021; 32:3203-3210. [PMID: 34664772 PMCID: PMC9298087 DOI: 10.1111/jce.15274] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/16/2021] [Accepted: 09/29/2021] [Indexed: 01/08/2023]
Abstract
Background Atrial fibrillation (AF) recurrence after catheter ablation is associated with worse outcomes and quality of life. Left atrial (LA) structural remodeling provides the essential substrate for AF perpetuation. Baseline extent and the progression of LA fibrosis after ablation are strong predictors of postprocedural AF recurrence. Dronedarone is an antiarrhythmic drug proven to efficiently maintain sinus rhythm. Objective We sought to investigate the effect of the antiarrhythmic drug Dronedarone in decreasing LA fibrosis progression and AF recurrence after ablation of AF patients. Methods EDORA (NCT04704050) is a multicenter, prospective, randomized controlled clinical trial. Patients with persistent or paroxysmal AF undergoing AF ablation will be randomized into Dronedarone versus placebo/standard of care. The co‐primary outcomes are the recurrence of atrial arrhythmias (AA) within 13 months of follow‐up after ablation and the progression of left atrial fibrosis postablation. All patients will receive a late‐gadolinium enhancement magnetic resonance imaging at baseline, 3‐ and 12‐month follow‐up for the quantification of LA fibrosis and ablation‐related scarring. AA recurrence and burden will be assessed using a 30‐day ECG patch every 3 months with daily ECG recordings in between. Quality of life improvement is assessed using the AFEQT and AFSS questionnaires. Conclusion EDORA will be the first trial to assess the progression of LA structural remodeling after ablation and its association with Dronedarone treatment and ablation success in a randomized controlled fashion. The trial will provide insight into the pathophysiology of AF recurrence after ablation and may provide potential therapeutic targets to optimize procedural outcomes.
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Affiliation(s)
- Nassir F Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - Lilas Dagher
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - Oussama Wazni
- Department of Cardiac Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nazem Akoum
- Department of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Moussa Mansour
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Abdel Hadi El Hajjar
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - Arezu Bhatnagar
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - He Hua
- Department of Epidemiology, Tulane University School of Public Health, New Orleans, Los Angeles, USA
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18
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Hanna B, Akoum N. Assessment of Atrial Fibrosis and Its Implications in Atrial Fibrillation and Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00952-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Gong S, Zhou J, Li B, Kang S, Ma X, Cai Y, Guo Y, Hu R, Zhang X. The Association of Left Atrial Appendage Morphology to Atrial Fibrillation Recurrence After Radiofrequency Ablation. Front Cardiovasc Med 2021; 8:677885. [PMID: 34458330 PMCID: PMC8387723 DOI: 10.3389/fcvm.2021.677885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/09/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: The probability of late recurrent atrial fibrillation (AF) after radiofrequency ablation (RFA) has not yet been fully clarified. This study aims to study the association of left atrial appendage (LAA) morphology with AF recurrence after RFA. Methods: We retrospectively enrolled 84 patients (24 patients had persistent AF, 60 patients had paroxysmal AF) who underwent RFA in Shanghai East Hospital from June 2014 to May 2018. The mean follow-up of these patients was 618.6 days. According to preoperative transesophageal echocardiography (TEE), the morphology feature of LAA was classified and evaluated by two classification methods. The first method was divided into chicken-wing, windsock, cactus, and cauliflower, and the second method was divided into one lobe, two lobes, and multiple lobes. The correlation between morphological feature of LAA and the recurrence rate of AF after RFA was analyzed. Results: During follow-up, 12 patients (50%) and 10 patients (16.7%) had AF recurrence in persistent and paroxysmal AF, respectively. The LAA morphology was associated with the recurrence of AF after RFA with the chicken-wing highest recurrence risk (68.2%). The structure type of LAA was also related to the AF recurrence rate (p < 0.01). Compared with one lobe and multiple lobes, two lobes (recurrence, 47.6%) were more likely associated with the recurrence of AF (p < 0.02). Logistic regression analysis showed that the chicken-wing group had a higher risk of recurrence after RFA (OR = 8.13, p = 0.004), and the windsock group had a lower risk of recurrence (OR = 0.17, p = 0.002). Conclusion: The morphological feature of LAA is related to the recurrence risk of AF after RFA. LAA morphology assessment can predict the risk of AF recurrence.
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Affiliation(s)
- Shiyu Gong
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jian Zhou
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Bingyu Li
- Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Sheng Kang
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoye Ma
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ying Cai
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yang Guo
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rui Hu
- Department of Laboratory, Taiyuan Hospital Health Center for Woman and Children, Taiyuan, China
| | - Xumin Zhang
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
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20
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Markman TM, Khoshknab M, Nazarian S. Catheter ablation of atrial fibrillation: cardiac imaging guidance as an adjunct to the electrophysiological guided approach. Europace 2021; 23:520-528. [PMID: 33555014 DOI: 10.1093/europace/euaa249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/07/2020] [Accepted: 08/23/2020] [Indexed: 11/12/2022] Open
Abstract
Catheter ablation is increasingly utilized to treat patients with atrial fibrillation (AF). Despite progress in technology and procedural strategy, there remain significant limitations with suboptimal outcomes. The role of imaging has continued to evolve, and multimodality imaging now presents an important opportunity to make substantial progress in the safety and efficacy of ablation. In this review, we discuss the history of imaging in the ablation of AF with a specific focus on the ability of cardiac computed tomography and magnetic resonance imaging to characterize anatomy, arrhythmogenic substrate, and guide ablation strategy. We will review the progress that has been made and highlight many of the limitations as well as future directions for the field.
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Affiliation(s)
- Timothy M Markman
- Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9118, Philadelphia, PA, USA
| | - Mirmilad Khoshknab
- Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9118, Philadelphia, PA, USA
| | - Saman Nazarian
- Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9118, Philadelphia, PA, USA
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21
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Ghafouri K, Franke KB, Foo FS, Stiles MK. Clinical utility of cardiac magnetic resonance imaging to assess the left atrium before catheter ablation for atrial fibrillation - A systematic review and meta-analysis. Int J Cardiol 2021; 339:192-202. [PMID: 34303756 DOI: 10.1016/j.ijcard.2021.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/04/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Abstract
AIMS This systematic review and meta-analysis aims to clarify the role of pre-procedural cardiac magnetic resonance imaging (MRI) in identifying the association between left atrial (LA) characteristics and post-ablation atrial fibrillation (AF) recurrence. These characteristics include LA fibrosis, emptying function, sphericity, volume, volume index, peak strain and post-contrast T1 relaxation time. METHODS PubMed, EMBASE, and Cochrane were searched up to July 2020 for English language articles reporting the use of cardiac MRI in catheter ablation for AF. Studies reporting the prognostic value of pre-ablation cardiac MRI were included. All references and citations were filtered for relevant manuscripts. RESULTS Twenty-four publications were identified. Every 10% increase in LA fibrosis was associated with a 1.54-fold increase in post-ablation AF recurrence (95%CI: 1.39-1.70, I2 = 50.1%). Every 10 ml increase in LA volume resulted in a hazard ratio of 1.07 (95%CI:1.03-1.12; I2 = 41.4%) for post-ablation AF recurrence. For LA sphericity, there was no significant association with post-ablation AF recurrence (HR: 1.032 [95%CI: 0.962-1.103, I2 = 49.6%). Egger's test was non-significant for publication bias in all meta-analyses. LA volume index, emptying function, peak strain and post-contrast LA T1 relaxation time had insufficient compatible publications to conduct a meta-analysis. CONCLUSION LA fibrosis quantified by cardiac MRI is associated with risk of AF recurrence after AF ablation, while increased LA volume is associated with AF recurrence to a lesser extent. There remains insufficient evidence to support the routine measurement of LA sphericity, LA volume index, LA emptying function, peak strain and LA T1 relaxation time to predict AF recurrence after AF ablation.
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Affiliation(s)
- Khashayar Ghafouri
- The university of Auckland, Faculty of Medical and Health Sciences, 85 Park Road, Grafton, 1023 Auckland, New Zealand..
| | - Kyle B Franke
- The University of Adelaide, Adelaide Medical School, North Terrace, Adelaide, South Australia 5005, Australia
| | - Fang Shawn Foo
- Peter Rothwell Academic Centre, Waikato Hospital, Pembroke Street, 3240 Hamilton, New Zealand; North Shore Hospital, 124 Shakespeare Road, Takapuna, 0620 Auckland, New Zealand
| | - Martin K Stiles
- The university of Auckland, Faculty of Medical and Health Sciences, 85 Park Road, Grafton, 1023 Auckland, New Zealand.; Peter Rothwell Academic Centre, Waikato Hospital, Pembroke Street, 3240 Hamilton, New Zealand
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22
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Dagher L, Shi H, Zhao Y, Mitlacher M, Schnupp S, Ajmi I, Forkmann M, Marrouche N, Mahnkopf C. Atrial fibrosis progression in patients with no history of atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:2140-2147. [PMID: 34191382 DOI: 10.1111/jce.15140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 05/24/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unexpected high levels of atrial fibrosis are found in individuals with no history of atrial fibrillation (AF). The temporal behavior of atrial fibrosis in this population is still unknown. We sought to investigate the progression and predictors of atrial fibrosis in non-AF individuals. METHODS Non-AF individuals at baseline who underwent late gadolinium enhancement magnetic resonance imaging (LGE-MRI) for assessment of left atrial (LA) fibrosis at least twice were retrospectively included in this study. The incidence of AF was assessed using review of medical records. RESULTS In 42 non-AF patients (15 females, 65.9 ± 8.6 years old), all patients had a detectable level of LA fibrosis at baseline, ranging from 4.5% to 28.8%, with a mean of 12.9 ± 5.9%. LA fibrosis in the second LGE-MRI was significantly higher in all patients compared to the first measurement (mean value of 12.9 ± 5.9% vs. 17.34 ± 6.8%; p < .05). Congestive heart failure was a significant clinical predictor of atrial fibrosis progression. The seven patients (16.6%) who developed new-onset AF during follow-up showed a significantly higher degree of LA fibrosis on their second MRI, compared to individuals who stayed in sinus rhythm (20.5 ± 6.9% vs. 16.7 ± 6.7%, p < .05). CONCLUSION Atrial fibrotic remodeling is a dynamic process that is progressively increasing in non-AF patients, accentuated by congestive heart failure. The higher extent of LA remodeling observed in patients who developed AF could highlight either the fact that AF is an expression of a highly dynamic left atrial substrate, or that remodeling processes are accelerated by AF.
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Affiliation(s)
- Lilas Dagher
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Hanyuan Shi
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Yan Zhao
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | | | | | | | | | - Nassir Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
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23
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Szilágyi J, Sághy L. Atrial Remodeling in Atrial Fibrillation. Comorbidities and Markers of Disease Progression Predict Catheter Ablation Outcome. Curr Cardiol Rev 2021; 17:217-229. [PMID: 32693769 PMCID: PMC8226201 DOI: 10.2174/1573403x16666200721153620] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 01/19/2023] Open
Abstract
Atrial fibrillation is the most common supraventricular arrhythmia affecting an increasing proportion of the population in which mainstream therapy, i.e. catheter ablation, provides freedom from arrhythmia in only a limited number of patients. Understanding the mechanism is key in order to find more effective therapies and to improve patient selection. In this review, the structural and electrophysiological changes of the atrial musculature that constitute atrial remodeling in atrial fibrillaton and how risk factors and markers of disease progression can predict catheter ablation outcome will be discussed in detail.
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Affiliation(s)
- Judit Szilágyi
- 2nd Department of Internal Medicine and Cardiology Centre, University of Szeged, Szeged, Hungary
| | - László Sághy
- 2nd Department of Internal Medicine and Cardiology Centre, University of Szeged, Szeged, Hungary
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24
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Vermeersch G, Abugattas J, Varnavas V, De Cocker J, Schwagten B, Sieira J, de Asmundis C, Chierchia G, De Greef Y. Efficacy and safety of the second-generation cryoballoon ablation for the treatment of persistent atrial fibrillation in elderly patients. J Arrhythm 2021; 37:626-634. [PMID: 34141015 PMCID: PMC8207396 DOI: 10.1002/joa3.12531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/22/2021] [Accepted: 03/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND It is expected that ablation procedures will be increasingly offered to a more aged population affected with persistent AF (persAF); however, the clinical outcomes of ablation in this specific population are not well described. We aimed to analyze the efficacy and safety of CB-A in this group of patients compared with a younger cohort. METHODS AND RESULTS Eighty-three patients with (persAF) aged ≥75 years (group 1; mean age 78.2 ± 3.1 years) and 166 patients also affected with persAF aged <75 years (group 2; mean age 64.3 ± 6.6 years) were included in the study. The primary outcome was freedom from recurrent sustained (>30 seconds) atrial arrhythmias without anti-arrhythmic medication after a blanking period of 3 months. At 2 years, clinical success was achieved in 108 out of 249 patients (43.4%). Median follow-up was 24 months (IQR: 18.4-25.5 months). Older patients suffered from more recurrences than those in the younger cohort ((53/83 patients, 63.9% vs 88/166 patients, 53.0%; P = .03). Thirty (12.0%) patients suffered a complication, but the incidence of complications was not different between both groups. The most frequent complication was transient phrenic nerve injury. CONCLUSIONS The global 2 years efficacy of CB-A PVI in persAF is 43.4%. A lower success rate is achieved in the older patients (36.1%) compared to the younger age group (47.0%). However, the complication rate was not different between age groups.
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Affiliation(s)
| | - Juan‐Pablo Abugattas
- Electrophysiology UnitZNA Heart Centre MiddelheimAntwerpenBelgium
- Department of CardiologyElectrophysiology UnitHôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
- Heart Rhythm Management CentreUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Varnavas Varnavas
- Electrophysiology UnitZNA Heart Centre MiddelheimAntwerpenBelgium
- Heart Rhythm Management CentreUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Jeroen De Cocker
- Electrophysiology UnitZNA Heart Centre MiddelheimAntwerpenBelgium
| | - Bruno Schwagten
- Electrophysiology UnitZNA Heart Centre MiddelheimAntwerpenBelgium
- Heart Rhythm Management CentreUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Juan Sieira
- Heart Rhythm Management CentreUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Carlo de Asmundis
- Heart Rhythm Management CentreUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Gian‐Battista Chierchia
- Heart Rhythm Management CentreUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
| | - Yves De Greef
- Electrophysiology UnitZNA Heart Centre MiddelheimAntwerpenBelgium
- Heart Rhythm Management CentreUniversitair Ziekenhuis BrusselVrije Universiteit BrusselBrusselsBelgium
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25
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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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26
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Tan H, Chen Z, Chen F, Xu W, Liu X. CKAP4 participates in tryptase-induced phenotypic conversion in atrial fibroblasts through PAR2/p38/JNK pathway. Am J Transl Res 2021; 13:2270-2282. [PMID: 34017388 PMCID: PMC8129387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/20/2021] [Indexed: 06/12/2023]
Abstract
Our previous study found that tryptase activated atrial fibroblasts, increased collagen synthesis in atrial fibroblasts through protease activated receptor-2 (PAR2) receptors. Recent studies showed that cytoskeleton-associated protein 4 (CKAP4) played an important role in ventricular fibroblast activation. The present study aimed to investigate the role of CKAP4 in tryptase-induced atrial fibroblast activation, atrial fibrosis, and molecular regulatory mechanisms. We cultured atrial fibroblasts in vitro, gave cells tryptase stimulation, then overexpressed or silenced PAR2 and CKAP4 genes in the cells. Their effects on atrial fibroblast proliferation, migration, extracellular matrix remodeling (Collagen I and fibronectin) and downstream key molecules (TGF-β1, c-jun and c-fos, JNK, p38) were investigated. The results showed that the expression of CKAP4 was significantly increased by tryptase and further increased by pcDNA3.1-PAR2, but decreased by FALLRY-NH2 and PAR2 siRNA. CKAP4 overexpression significantly increased the cell proliferation, migration and levels of Collagen I and fibronectin, matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of metalloproteinases-1 (TIMP-1) levels in atrial fibroblasts, while CKAP4 siRNA significantly reduced them. CKAP4 overexpression significantly increased the expression of TGF-β1, c-jun and c-fos, and activated the JNK/p38 pathway, which were suppressed by CKAP4 siRNA. In conclusion, CKAP4 is involved in tryptase-induced phenotypic conversion in atrial fibroblasts through PAR2/p38/JNK pathway, which may provide novel targets in the prevention of atrial fibrosis.
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Affiliation(s)
- Hongwei Tan
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine Shanghai 200065, China
| | - Zhisong Chen
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine Shanghai 200065, China
| | - Fei Chen
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine Shanghai 200065, China
| | - Wenjun Xu
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine Shanghai 200065, China
| | - Xuebo Liu
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine Shanghai 200065, China
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27
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Cirasa A, La Greca C, Pecora D. Catheter Ablation of Atrial Fibrillation in Heart Failure: from Evidences to Guidelines. Curr Heart Fail Rep 2021; 18:153-162. [PMID: 33817773 DOI: 10.1007/s11897-021-00508-z] [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] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Catheter ablation of atrial fibrillation in heart failure seems to be the way to improve the quality of life, life expectance, and prognosis. In this review, we outline the growing role of this therapy and which patients can benefit from it. RECENT FINDINGS While previous studies comparing rate control and rhythm control had not demonstrated the superiority of rhythm control in the prognosis of patients with atrial fibrillation and heart failure, recent findings seem to demonstrate that catheter ablation of atrial fibrillation reduces mortality and hospitalization for heart failure and improves the quality of life, when compared to medical therapy alone. An early rhythm-control strategy in atrial fibrillation may reduce cardiovascular death, stroke, hospitalization for HF, or acute coronary syndrome. Catheter ablation in heart failure is an effective and safe solution to obtain a rhythm control and, therefore, to improve outcomes. A better selection of the patients could help to avoid futile procedures and to identify patients requiring a closer follow-up, to redo procedures, or the addition of antiarrhythmic drugs.
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Affiliation(s)
- Arianna Cirasa
- Cardiovascular Department, "E. Muscatello" Hospital, C.da Granatello, 96011, Augusta, Italy.
| | - Carmelo La Greca
- Electrophysiology Unit, Cardiovascular Department, Poliambulanza Institute Hospital Foundation, Brescia, Italy
| | - Domenico Pecora
- Electrophysiology Unit, Cardiovascular Department, Poliambulanza Institute Hospital Foundation, Brescia, Italy
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28
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Marrouche NF, Greene T, Dean JM, Kholmovski EG, Boer LMD, Mansour M, Calkins H, Marchlinski F, Wilber D, Hindricks G, Mahnkopf C, Jais P, Sanders P, Brachmann J, Bax J, Dagher L, Wazni O, Akoum N. Efficacy of LGE-MRI-guided fibrosis ablation versus conventional catheter ablation of atrial fibrillation: The DECAAF II trial: Study design. J Cardiovasc Electrophysiol 2021; 32:916-924. [PMID: 33600025 DOI: 10.1111/jce.14957] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment. We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes. METHODS The DECAAF II trial (ClinicalTrials. gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first-time ablation procedure were randomized in a 1:1 fashion to receive conventional pulmonary vein isolation (PVI) ablation (Group 1) or PVI + fibrosis-guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3-12 months postablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia postablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90-day postablation blanking period. Patients were followed for a period of 12-18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc.). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint. RESULTS AND CONCLUSION The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden.
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Affiliation(s)
- Nassir F Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tom Greene
- University of Utah, Salt Lake City, Utah, USA
| | | | | | | | - Moussa Mansour
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Francis Marchlinski
- Department of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Wilber
- Department of Cardiology, Loyola University Medical Center, Chicago, Illinois, USA
| | | | | | - Pierre Jais
- Department of Cardiology, Segalen University, Bordeaux, France
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | | | - Jereon Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilas Dagher
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Oussama Wazni
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nazem Akoum
- Department of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
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29
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Nakamura T, Kiuchi K, Fukuzawa K, Takami M, Watanabe Y, Izawa Y, Suehiro H, Akita T, Takemoto M, Sakai J, Yatomi A, Sonoda Y, Takahara H, Nakasone K, Yamamoto K, Negi N, Kono A, Ashihara T, Hirata KI. Late-gadolinium enhancement properties associated with atrial fibrillation rotors in patients with persistent atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:1005-1013. [PMID: 33556994 DOI: 10.1111/jce.14933] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/12/2021] [Accepted: 01/21/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND A computational model demonstrated that atrial fibrillation (AF) rotors could be distributed in patchy late-gadolinium enhancement (LGE) areas and play an important role in AF drivers. However, this was not validated in humans. OBJECTIVE The purpose of this study was to evaluate the LGE properties of AF rotors in patients with persistent AF. METHODS A total of 287 segments in 15 patients with persistent AF (long-standing persistent AF in 9 patients) that underwent AF ablation were assessed. Non-passively activated areas (NPAs), where rotational activation (AF rotor) was frequently observed, were detected by the novel real-time phase mapping (ExTRa Mapping). The properties of the LGE areas were assessed using the LGE heterogeneity and the density which was evaluated by the entropy (LGE-entropy) and the volume ratio of the enhancement voxel (LGE-volume ratio), respectively. RESULTS NPAs were found in 61 (21%) of 287 segments and were mostly found around the pulmonary vein antrum. A receiver operating characteristic curve analysis yielded an optimal cutoff value of 5.7% and 10% for the LGE-entropy and LGE-volume ratio, respectively. The incidence of NPAs was significantly higher at segments with an LGE-entropy of >5.7 and LGE-volume ratio of >10% than at the other segments (38 [30%] of 126 vs. 23 [14%] of 161 segments; p = .001). No NPAs were found at segments with an LGE-volume ratio of >50% regardless of the LGE-entropy. Of five patients with AF recurrence, NPAs outside the PV antrum were not ablated in three patients and the remaining NPAs were ablated, but their LGE-entropy and LGE-volume ratio were low. CONCLUSION AF rotors are mostly distributed in relatively weak and much more heterogenous LGE areas.
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Affiliation(s)
- Toshihiro Nakamura
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kunihiko Kiuchi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Mitsuru Takami
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiaki Watanabe
- Division of Radiology, Center for Radiology and Radiation Oncology, Kobe University Hospital, Kobe, Japan
| | - Yu Izawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideya Suehiro
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomomi Akita
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Makoto Takemoto
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jun Sakai
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsusuke Yatomi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Sonoda
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Takahara
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazutaka Nakasone
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kyoko Yamamoto
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Noriyuki Negi
- Division of Radiology, Center for Radiology and Radiation Oncology, Kobe University Hospital, Kobe, Japan
| | - Atsushi Kono
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Ashihara
- Department of Medical Informatics and Biomedical Engineering, Shiga University of Medical Science, Otsu, Japan
| | - Ken-Ichi Hirata
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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30
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Barletta V, Mazzocchetti L, Parollo M, Spatafora D, Bongiorni M, Zucchelli G. Multimodality imaging for atrial fibrosis detection in the era of precision medicine. J Cardiovasc Echogr 2021; 31:189-197. [PMID: 35284213 PMCID: PMC8893107 DOI: 10.4103/jcecho.jcecho_61_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 08/09/2021] [Indexed: 11/04/2022] Open
Abstract
In recent years, atrial fibrillation (AF) has increasingly become a focus of attention because it represents the most encountered arrhythmia in clinical practice and a major cause of morbidity and mortality. Issues underlying AF have long been debated; nevertheless, electrical, contractile, and structural remodeling is demonstrated to be the pivotal contributor to arrhythmic substrate. Fibrosis is a hallmark of arrhythmogenic structural remodeling, resulting from an accumulation of fibrillar collagen deposits, as a reparative process to replace degenerating myocardium with concomitant reactive fibrosis, which causes interstitial expansion. Although the precise role of fibrosis in AF initiation and maintenance remains to be fully elucidated, a better definition of its extent and distribution may assist in designing individually tailored ablation approaches and improving procedure outcomes by targeting the fibrotic substrates with an organized strategy employing imaging resources. A deep comprehension of the mechanisms underlying atrial fibrosis could be crucial to setting up improved strategies for preventing AF-promoting structural remodeling. Imaging modalities such as echocardiography, cardiac computed tomography, and cardiac magnetic resonance, combined sometimes with invasive electroanatomical mapping, could provide valuable information for the optimal patients’ management if their use is not limited to cardiac anatomy study but extended to characterize abnormal left atrial substrate. Although pulmonary vein isolation is usually efficacious in treating paroxysmal AF, it is not sufficient for many patients with nonparoxysmal arrhythmias, particularly those with longstanding persistent AF. Noninvasive imaging techniques play a pivotal role in the planning of arrhythmic substrates ablation and show a strong correlation with electro-anatomic mapping, whose novel multipolar mapping catheters allow nowadays a more precise comprehension of atrial substrate. This review aims to explore the impact of the various imaging modalities for the detection of atrial fibrosis and their role in the management of AF.
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31
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Habibi M, Lima JAC, Gucuk Ipek E, Spragg D, Ashikaga H, Marine JE, Berger RD, Calkins H, Nazarian S. Short- and long-term associations of atrial fibrillation catheter ablation with left atrial structure and function: A cardiac magnetic resonance study. J Cardiovasc Electrophysiol 2020; 32:316-324. [PMID: 33350536 DOI: 10.1111/jce.14842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effects of atrial fibrillation (AF) catheter ablation on the left atrium (LA) are poorly understood. OBJECTIVES To examine short- and long-term associations of AF catheter ablation with LA function using cardiac magnetic resonance (CMR). METHODS Fifty-one AF patients (mean age 56 ± 8 years) underwent CMR at baseline, 1 day (n = 17) and 11 ± 2 months after ablation (n = 38). LA phasic volumes, emptying fractions (LAEF), and longitudinal strain were measured using feature-tracking CMR. LA fibrosis was quantified using late gadolinium enhancement (LGE). RESULTS There were no acute changes in volume; however, active, total LAEF, and peak LA strain decreased significantly compared to the baseline. During long-term follow-up, there was a decrease in maximum but not minimum LA volume (from 99 ± 5.2 ml to 89 ± 4.7 ml; p = .009) and a decrease in total LAEF (from 43 ± 1.8% to 39 ± 2.0%; p = .001). In patients with AF recurrence, LA volumes were unchanged. However, total LAEF decreased from 38 ± 3% to 33 ± 3%; p = .015. Patients without AF recurrence had no changes in LA functional parameters during follow-up. The amount of LA LGE at long-term follow-up was higher compared to the baseline, however, was significantly less compared to immediately post-procedure (37 ± 1.9% vs. 47 ± 2.8%; p = .015). A higher increase in LA LGE extent compared to the baseline was associated with a greater decrease in total LAEF (r = -.59; p < .001). CONCLUSIONS LA function is impaired acutely following AF catheter ablation. However, long-term changes of LA function are associated positively with the successful restoration of sinus rhythm and inversely with increased LA LGE.
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Affiliation(s)
- Mohammadali Habibi
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Valley Health System and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey, USA
| | - Joao A C Lima
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Esra Gucuk Ipek
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Spragg
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hiroshi Ashikaga
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph E Marine
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald D Berger
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hugh Calkins
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saman Nazarian
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Cardiology, Section for Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
AF is the most common arrhythmia in clinical practice. In addition to the severe effect on quality of life, patients with AF are at higher risk of stroke and mortality. Recent studies have suggested that atrial and ventricular substrate play a major role in the development and maintenance of AF. Cardiac MRI has emerged as a viable tool for interrogating the underlying substrate in AF patients. Its advantage includes localisation and quantification of structural remodelling. Cardiac MRI of the atrial substrate is not only a tool for management and treatment of arrhythmia, but also to individualise the prevention of stroke and major cardiovascular events. This article provides an overview of atrial imaging using cardiac MRI and its clinical implications in the AF population.
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Affiliation(s)
- Yan Zhao
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Lilas Dagher
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Chao Huang
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Peter Miller
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Nassir F Marrouche
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
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Ezeani M, Hagemeyer CE, Lal S, Niego B. Molecular imaging of atrial myopathy: Towards early AF detection and non-invasive disease management. Trends Cardiovasc Med 2020; 32:20-31. [DOI: 10.1016/j.tcm.2020.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/07/2020] [Accepted: 12/07/2020] [Indexed: 12/14/2022]
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34
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Bisbal F, Benito E, Teis A, Alarcón F, Sarrias A, Caixal G, Villuendas R, Garre P, Soto N, Cozzari J, Guasch E, Juncà G, Prat-Gonzalez S, Perea RJ, Bazán V, Tolosana JM, Arbelo E, Bayés-Genís A, Mont L. Magnetic Resonance Imaging-Guided Fibrosis Ablation for the Treatment of Atrial Fibrillation. Circ Arrhythm Electrophysiol 2020; 13:e008707. [DOI: 10.1161/circep.120.008707] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Myocardial fibrosis is key for atrial fibrillation maintenance. We aimed to test the efficacy of ablating cardiac magnetic resonance (CMR)-detected atrial fibrosis plus pulmonary vein isolation (PVI).
Methods:
This was an open-label, parallel-group, randomized, controlled trial. Patients with symptomatic drug-refractory atrial fibrillation (paroxysmal and persistent) undergoing first or repeat ablation were randomized in a 1:1 basis to receive PVI plus CMR-guided fibrosis ablation (CMR group) or PVI alone (PVI-alone group). The primary end point was the rate of recurrence (>30 seconds) at 12 months of follow-up using a 12-lead ECG and Holter monitoring at 3, 6, and 12 months. The analysis was conducted by intention-to-treat.
Results:
In total, 155 patients (71% male, age 59±10, CHA
2
DS
2
-VASc 1.3±1.1, 54% paroxysmal atrial fibrillation) were allocated to the PVI-alone group (N=76) or CMR group (N=79). First ablation was performed in 80% and 71% of patients in the PVI-alone and CMR groups, respectively. The mean atrial fibrosis burden was 12% (only ≈50% of patients had fibrosis outside the pulmonary vein area). One hundred percent and 99% of patients received the assigned intervention in the PVI-alone and CMR group, respectively. The primary outcome was achieved in 21 patients (27.6%) in the PVI-alone group and 22 patients (27.8%) in the CMR group (odds ratio: 1.01 [95% CI, 0.50–2.04];
P
=0.976). There were no differences in the rate of adverse events (3 in the CMR group and 2 in the PVI-alone group;
P
=0.68).
Conclusions:
A pragmatic ablation approach targeting CMR-detected atrial fibrosis plus PVI was not more effective than PVI alone in an unselected population undergoing atrial fibrillation ablation with low fibrosis burden.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02698631.
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Affiliation(s)
- Felipe Bisbal
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
- CIBERCV, Instituto de Salud Carlos III, Madrid (F.B., A.B.-G., L.M.)
| | - Eva Benito
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Albert Teis
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
| | - Francisco Alarcón
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Axel Sarrias
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
| | - Gala Caixal
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Roger Villuendas
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
| | - Paz Garre
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Nina Soto
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
| | - Jennifer Cozzari
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Eduard Guasch
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
- Institut d’Investigació Biomèdica August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain (E.G, L.M.)
| | - Gladys Juncà
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
| | - Susanna Prat-Gonzalez
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Rosario J. Perea
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Victor Bazán
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
| | - José María Tolosana
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Elena Arbelo
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
| | - Antoni Bayés-Genís
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Badalona, Catalonia (F.B., A.T., A.S., R.V., N.S., G.J., V.B., A.B.-G.)
- CIBERCV, Instituto de Salud Carlos III, Madrid (F.B., A.B.-G., L.M.)
| | - Lluis Mont
- CIBERCV, Instituto de Salud Carlos III, Madrid (F.B., A.B.-G., L.M.)
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain (E.B., F.A., G.C., P.G., J.C., E.G., S.P.-G., R.J.P., J.M.T., E.A., L.M.)
- Institut d’Investigació Biomèdica August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain (E.G, L.M.)
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Gunasekaran S, Haji-Valizadeh H, Lee DC, Avery RJ, Wilson BD, Ibrahim M, Markl M, Passman RS, Kholmovski EG, Kim D. Accelerated 3D Left Atrial Late Gadolinium Enhancement in Patients with Atrial Fibrillation at 1.5 T: Technical Development. Radiol Cardiothorac Imaging 2020; 2:e200134. [PMID: 33154994 PMCID: PMC7605361 DOI: 10.1148/ryct.2020200134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To develop an accelerated three-dimensional (3D) late gadolinium enhancement (LGE) pulse sequence using balanced steady-state free precession readout with stack-of-stars k-space sampling and extra motion-state golden-angle radial sparse parallel (XD-GRASP) reconstruction and test the performance for detecting atrial scar and fibrosis in patients with atrial fibrillation (AF). MATERIALS AND METHODS Twenty-five patients with AF (20 paroxysmal and five persistent; 65 years ± 7 [standard deviation]; 18 men) were imaged at 1.5 T using the proposed LGE sequence with 1.3 mm × 1.3 mm × 2-mm spatial resolution and predictable imaging time. The resulting images were compared with historic images of 25 patients with AF (18 paroxysmal and seven persistent; 67 years ± 10; 14 men) obtained using a reference 3D left atrial (LA) LGE sequence with 1.3 mm × 1.3 mm × 2.5-mm spatial resolution. Two readers visually graded the 3D LGE images (conspicuity, artifact, noise) on a five-point Likert scale (1 = worst, 3 = acceptable, 5 = best), in which the summed visual score (SVS) of 9 or greater was defined as clinically acceptable. Appropriate statistical analyses (Cohen κ coefficient, Mann-Whitney U test, t tests, and intraclass correlation) were performed, where a P value < .05 was considered significant. RESULTS Mean imaging time was significantly shorter (P < .01) for the proposed pulse sequence (5.9 minutes ± 1.3) than for the reference pulse sequence (10.6 minutes ± 2). Median SVS was significantly higher (P < .01) for the proposed (SVS = 11) than reference (SVS = 9.5) 3D LA LGE images. Interrater reproducibility in visual scores was higher for the proposed (κ = 0.78-1) than reference 3D LA LGE (κ = 0.44-0.75). Intrareader repeatability in fibrosis quantification was higher for the reference cohort (intraclass correlation coefficient [ICC] = 0.94) than the prospective cohort (ICC = 0.79). CONCLUSION The proposed 3D LA LGE method produced clinically acceptable image quality with 1.5 mm × 1.5 mm × 2-mm nominal spatial resolution and 6-minute predictable imaging time for quantification of LA scar and fibrosis in patients with AF. Supplemental material is available for this article. © RSNA, 2020.
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Affiliation(s)
- Suvai Gunasekaran
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Hassan Haji-Valizadeh
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Daniel C. Lee
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Ryan J. Avery
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Brent D. Wilson
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Mark Ibrahim
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Michael Markl
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Rod S. Passman
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Eugene G. Kholmovski
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
| | - Daniel Kim
- From the Department of Radiology (S.G., D.C.L., R.J.A., M.M., D.K.) and Department of Internal Medicine, Division of Cardiology (D.C.L., R.S.P.), Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611; Department of Biomedical Engineering, Northwestern University, Evanston, Ill (S.G., M.M., D.K.); Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass (H.H.V.); and Department of Internal Medicine, Division of Cardiovascular Medicine (B.D.W., M.I.), and Department of Radiology and Imaging Sciences (E.G.K.), University of Utah, Salt Lake City, Utah
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Ghannam M, Yun HJ, Ficaro EP, Ghanbari H, Lazarus JJ, Konerman M, Shah RV, Weinberg R, Corbett JR, Oral H, Murthy VL. Multiparametric assessment of left atrial remodeling using 18F-FDG PET/CT cardiac imaging: A pilot study. J Nucl Cardiol 2020; 27:1547-1562. [PMID: 30191438 PMCID: PMC6411463 DOI: 10.1007/s12350-018-1429-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 08/08/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Left atrial (LA) remodeling is associated with structural, electric, and metabolic LA changes. Integrated evaluation of these features in vivo is lacking. METHODS Patients undergoing 18F-fluorodeoxyglucose (FDG) PET-CT during a hyperinsulinemic-euglycemic clamp were classified into sinus rhythm (SR), paroxysmal AF (PAF), and persistent AF (PerAF). The LA was semiautomatically segmented, and global FDG uptake was quantified using standardized uptake values (SUVmax and SUVmean) in gated, attenuation-corrected images and normalized to LA blood pool activity. Regression was used to relate FDG data to AF burden and critical patient factors. Continuous variables were compared using t-tests or Mann-Whitney tests. RESULTS 117 patients were included (76% men, age 66.4 ± 11.0, ejection fraction (EF) 25[22-35]%) including those with SR (n = 48), PAF (n = 55), and PerAF (n = 14). Patients with any AF had increased SUVmean (2.3[1.5-2.4] vs 2.0[1.5-2.5], P = 0.006), SUVmax (4.4[2.8-6.7] vs 3.2[2.3-4.3], P < 0.001), uptake coefficient of variation (CoV) 0.28[0.22-0.40] vs 0.25[0.2-0.33], P < 0.001), and hypometabolic scar (32%[14%-53%] vs 16.5%[0%-38.5%], P = 0.01). AF burden correlated with increased SUVmean, SUVmax, CoV, and scar independent of age, gender, EF, or LA size (P < 0.03 for all). CONCLUSIONS LA structure and metabolism can be assessed using FDG PET/CT. Greater AF burden correlates with the increased LA metabolism and scar.
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Affiliation(s)
- Michael Ghannam
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Hong Jun Yun
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Edward P Ficaro
- INVIA Medical Imaging Solutions, Ann Arbor, MI, USA
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Hamid Ghanbari
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - John J Lazarus
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Matthew Konerman
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Ravi V Shah
- Department of Medicine (Division of Cardiovascular Medicine), Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Weinberg
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - James R Corbett
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
- INVIA Medical Imaging Solutions, Ann Arbor, MI, USA
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Hakan Oral
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Venkatesh L Murthy
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA.
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.
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37
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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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Tidbury N, Preston J, Ding WY, Rivera-Caravaca JM, Marín F, Lip GYH. Utilizing biomarkers associated with cardiovascular events in atrial fibrillation: informing a precision medicine response. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2020. [DOI: 10.1080/23808993.2020.1804864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Nicola Tidbury
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Joshua Preston
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, University of Murcia, Instituto Murciano De Investigación Biosanitaria (Imib-arrixaca), CIBERCV, Murcia, Spain
| | - Francisco Marín
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, University of Murcia, Instituto Murciano De Investigación Biosanitaria (Imib-arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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39
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Obeng-Gyimah E, Nazarian S. Advancements in Imaging for Atrial Fibrillation Ablation: Is There a Potential to Improve Procedural Outcomes? J Innov Card Rhythm Manag 2020; 11:4172-4178. [PMID: 32724708 PMCID: PMC7377648 DOI: 10.19102/icrm.2020.110701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/06/2020] [Indexed: 12/30/2022] Open
Abstract
Since the introduction of atrial fibrillation (AF) ablation in the 1990s, the procedure has continuously evolved, with gradual improvements in outcomes and safety. Recent technological advancements include the introduction of contact force catheters and high-resolution electroanatomical mapping systems, while imaging modalities including transesophageal echocardiography and fluoroscopy have become integral parts of AF ablation procedures. Further, intraprocedural intracardiac echocardiography and the integration of cardiac magnetic resonance and computed tomography images with electroanatomical mapping have shown promise to improve procedural outcomes by reducing radiation exposure and procedural times. However, available data on procedural utility and the reduction in AF recurrence rates associated with these modalities are mixed. This review therefore aims to discuss the current common imaging modalities used in AF ablation and their potential impact on outcomes. In particular, imaging is discussed with respect to the important information it offers before, during, and after the procedure. Perspectives on the future of imaging in AF ablation are also shared.
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Affiliation(s)
- Edmond Obeng-Gyimah
- Perelman Clinical Electrophysiology Section, Cardiovascular Division, Department of Medicine, School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Saman Nazarian
- Perelman Clinical Electrophysiology Section, Cardiovascular Division, Department of Medicine, School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Ciuffo L, Bruña V, Martínez-Sellés M, de Vasconcellos HD, Tao S, Zghaib T, Nazarian S, Spragg DD, Marine J, Berger RD, Lima JAC, Calkins H, Bayés-de-Luna A, Ashikaga H. Association between interatrial block, left atrial fibrosis, and mechanical dyssynchrony: Electrocardiography-magnetic resonance imaging correlation. J Cardiovasc Electrophysiol 2020; 31:1719-1725. [PMID: 32510679 DOI: 10.1111/jce.14608] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Advanced interatrial block (IAB) on a 12-lead electrocardiogram (ECG) is a predictor of stroke, incident atrial fibrillation (AF), and AF recurrence after catheter ablation. The objective of this study was to determine which features of IAB structural remodeling is associated with left atrium (LA) magnetic resonance imaging structure and function. METHODS/RESULTS We included 152 consecutive patients (23% nonparoxysmal AF) who underwent preprocedural ECG and cardiac magnetic resonance (CMR) in sinus rhythm before catheter ablation of AF. IAB was defined as P-wave duration ≥120 ms, and was considered partial if P-wave was positive and advanced if P-wave had a biphasic morphology in inferior leads. From cine CMR and late gadolinium enhancement, we derived LA maximum and minimum volume indices, strain, LA fibrosis, and LA dyssynchrony. A total of 77 patients (50.7% paroxysmal) had normal P-wave, 52 (34.2%) partial IAB, and 23 (15.1%) advanced IAB. Patients with advanced IAB had significantly higher LA minimum volume index (25.7 vs 19.9 mL/m2 , P = .010), more LA fibrosis (21.9% vs 13.1%, P = .020), and lower LA maximum strain rate (0.99 vs 1.18, P = .007) than those without. Advanced IAB was independently associated with LA (minimum [P = .032] and fibrosis [P = .009]). P-wave duration was also independently associated with LA fibrosis (β = .33; P = .049) and LA mechanical dyssynchrony (β = 2.01; P = .007). CONCLUSION Advanced IAB is associated with larger LA volumes, lower emptying fraction, and more fibrosis. Longer P-wave duration is also associated with more LA fibrosis and higher LA mechanical dyssynchrony.
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Affiliation(s)
- Luisa Ciuffo
- Division of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Vanesa Bruña
- Servicio de Cardiología, CIBERCV, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, CIBERCV, Hospital Universitario Gregorio Marañón, Madrid, Spain.,Facultad de Ciencias Biomédicas, Universidad Europea, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | | | - Susumu Tao
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tarek Zghaib
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saman Nazarian
- Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David D Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Marine
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald D Berger
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joao A C Lima
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antonio Bayés-de-Luna
- Cardiovascular Research Foundation, Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Hiroshi Ashikaga
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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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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Habibi M, Chrispin J, Spragg DD, Zimmerman SL, Tandri H, Nazarian S, Halperin H, Trayanova N, Calkins H. Utility of Cardiac MRI in Atrial Fibrillation Management. Card Electrophysiol Clin 2020; 12:131-139. [PMID: 32451098 DOI: 10.1016/j.ccep.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Advances in cardiac magnetic resonance (CMR) techniques and image acquisition have made it an excellent tool in the assessment of atrial myopathy. Remolding of the left atrium is the mainstay of atrial fibrillation (AF) development and its progression. CMR can detect phasic atrial volumes, atrial function, and atrial fibrosis using cine, and contrast-enhanced or non-contrast-enhanced images. These abilities make CMR a versatile and extraordinary tool in management of patients with AF including for risk stratification, ablation prognostication and planning, and assessment of stroke risk. We review the latest advancements in utility of CMR in management of patients with AF.
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Affiliation(s)
- Mohammadali Habibi
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan Chrispin
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - David D Spragg
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Harikrishna Tandri
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - Saman Nazarian
- Division of Cardiology, Section for Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henry Halperin
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA.
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43
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Daimee UA, Berger RD. Freezing left atrial scar: The new Ice Age? J Cardiovasc Electrophysiol 2020; 31:1595-1596. [PMID: 32412121 DOI: 10.1111/jce.14549] [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: 05/10/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Usama A Daimee
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald D Berger
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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44
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Kim Y, Chen S, Ernst S, Guzman CE, Han S, Kalarus Z, Labadet C, Lin Y, Lo L, Nogami A, Saad EB, Sapp J, Sticherling C, Tilz R, Tung R, Kim YG, Stiles MK. 2019 APHRS expert consensus statement on three-dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRA, and LAHRS. J Arrhythm 2020; 36:215-270. [PMID: 32256872 PMCID: PMC7132207 DOI: 10.1002/joa3.12308] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/20/2020] [Indexed: 12/24/2022] Open
Affiliation(s)
- Young‐Hoon Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
| | - Shih‐Ann Chen
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Sabine Ernst
- Department of CardiologyRoyal Brompton and Harefield HospitalImperial College LondonLondonUK
| | | | - Seongwook Han
- Division of CardiologyDepartment of Internal MedicineKeimyung University School of MedicineDaeguRepublic of Korea
| | - Zbigniew Kalarus
- Department of CardiologyMedical University of SilesiaKatowicePoland
| | - Carlos Labadet
- Cardiology DepartmentArrhythmias and Electrophysiology ServiceClinica y Maternidad Suizo ArgentinaBuenos AiresArgentina
| | - Yenn‐Jian Lin
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Li‐Wei Lo
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Akihiko Nogami
- Department of CardiologyFaculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Eduardo B. Saad
- Center for Atrial FibrillationHospital Pro‐CardiacoRio de JaneiroBrazil
| | - John Sapp
- Division of CardiologyDepartment of MedicineQEII Health Sciences CentreDalhousie UniversityHalifaxNSCanada
| | | | - Roland Tilz
- Medical Clinic II (Department of Cardiology, Angiology and Intensive Care Medicine)University Hospital Schleswig‐Holstein (UKSH) – Campus LuebeckLuebeckGermany
| | - Roderick Tung
- Center for Arrhythmia CarePritzker School of MedicineUniversity of Chicago MedicineChicagoILUSA
| | - Yun Gi Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
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Abstract
Left atrial fibrosis plays an important role in the pathophysiology of atrial fibrillation. Left atrial ablation is an effective and increasingly used strategy to restore and maintain sinus rhythm in patients with atrial fibrillation. Late gadolinium enhancement (LGE) MRI and custom image analysis software have been used to visualize and quantify preablation atrial fibrosis and postablation scar and new fibrosis formation. This article reviews technical aspects of imaging atrial fibrosis/scar by LGE-MRI; use of atrial fibrosis and scar in predicting outcomes; applications of LGE-MRI to assess ablation lesions and optimize ablation parameters while avoiding collateral damage.
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Affiliation(s)
- Eugene G Kholmovski
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA; Utah Center for Advanced Imaging Research (UCAIR), University of Utah, Salt Lake City, UT, USA; Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Alan K Morris
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA
| | - Mihail G Chelu
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA; Division of Cardiovascular Medicine, Section of Electrophysiology, University of Utah, Salt Lake City, UT, USA.
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46
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Left Atrial Structural Remodelling in Non-Valvular Atrial Fibrillation: What Have We Learnt from CMR? Diagnostics (Basel) 2020; 10:diagnostics10030137. [PMID: 32131455 PMCID: PMC7151417 DOI: 10.3390/diagnostics10030137] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/20/2020] [Accepted: 02/27/2020] [Indexed: 12/28/2022] Open
Abstract
Left atrial structural, functional and electrical remodelling are linked to atrial fibrillation (AF) pathophysiology and mirror the phrase “AF begets AF”. A structurally remodelled left atrium (LA) is fibrotic, dysfunctional and enlarged. Fibrosis is the hallmark of LA structural remodelling and is associated with increased risk of stroke, heart failure development and/or progression and poorer catheter ablation outcomes with increased recurrence rates. Moreover, increased atrial fibrosis has been associated with higher rates of stroke even in sinus-rhythm individuals. As such, properly assessing the fibrotic atrial cardiomyopathy in AF patients becomes necessary. In this respect, late-gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging is the gold standard in imaging myocardial fibrosis. LA structural remodelling extension offers both diagnostic and prognostic information and influences therapeutic choices. LGE-CMR scans can be used before the procedure to better select candidates and to aid in choosing the ablation technique, during the procedure (full CMR-guided ablations) and after the ablation (to assess the ablation scar). This review focuses on imaging several LA structural remodelling CMR parameters, including size, shape and fibrosis (both extension and architecture) and their impact on procedure outcomes, recurrence risk, as well as their utility in relation to the index procedure timing.
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Kuo L, Zado E, Frankel D, Santangelli P, Arkles J, Han Y, Marchlinski FE, Nazarian S, Desjardins B. Association of Left Atrial High-Resolution Late Gadolinium Enhancement on Cardiac Magnetic Resonance With Electrogram Abnormalities Beyond Voltage in Patients With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2020; 13:e007586. [PMID: 31940244 PMCID: PMC7031051 DOI: 10.1161/circep.119.007586] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Conflicting data have been reported on the association of left atrial (LA) late gadolinium enhancement (LGE) with atrial voltage in patients with atrial fibrillation. The association of LGE with electrogram fractionation and delay remains to be examined. We sought to examine the association between LA LGE on cardiac magnetic resonance and electrogram abnormalities in patients with atrial fibrillation. METHODS High-resolution LGE cardiac magnetic resonance was performed before electrogram mapping and ablation in atrial fibrillation patients. Cardiac magnetic resonance features were quantified using LA myocardial signal intensity Z score (SI-Z), a continuous normalized variable, as well as a dichotomous LGE variable based on previously validated methodology. Electrogram mapping was performed pre-ablation during sinus rhythm or LA pacing, and electrogram locations were coregistered with cardiac magnetic resonance images. Analyses were performed using multilevel patient-clustered mixed-effects regression models. RESULTS In the 40 patients with atrial fibrillation (age, 63.2±9.2 years; 1312.3±767.3 electrogram points per patient), lower bipolar voltage was associated with higher SI-Z in patients who had undergone previous ablation (coefficient, -0.049; P<0.001) but not in ablation-naive patients (coefficient, -0.004; P=0.7). LA electrogram activation delay was associated with SI-Z in patients with previous ablation (SI-Z: coefficient, 0.004; P<0.001 and LGE: coefficient, 0.04; P<0.001) but not in ablation-naive patients. In contrast, increased LA electrogram fractionation was associated with SI-Z (coefficient, 0.012; P=0.03) and LGE (coefficient, 0.035; P<0.001) only in ablation-naive patients. CONCLUSIONS The association of LA LGE with voltage is modified by ablation. Importantly, in ablation-naive patients, atrial LGE is associated with electrogram fractionation even in the absence of voltage abnormalities.
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Affiliation(s)
- Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan;,Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Erica Zado
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - David Frankel
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Pasquale Santangelli
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Jeffrey Arkles
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Yuchi Han
- Cardiovascular Division, Department of Medicine, University of Pennsylvania School of Medicine
| | - Francis E. Marchlinski
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Saman Nazarian
- Electrophysiology Section, Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Benoit Desjardins
- Department of Radiology, Hospital of Pennsylvania Medical Center, Philadelphia, PA
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Kis Z, Hendriks AA, Muka T, Bramer WM, Kovacs I, Szili-Torok T. The Role of Atrial Fibrosis Detected by Delayed - Enhancement MRI in Atrial Fibrillation Ablation. Curr Med Imaging 2020; 16:135-144. [DOI: 10.2174/1573405614666180806130327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 11/04/2017] [Accepted: 03/19/2018] [Indexed: 11/22/2022]
Abstract
Introduction:
Atrial Fibrillation (AF) is associated with remodeling of the atrial tissue,
which leads to fibrosis that can contribute to the initiation and maintenance of AF. Delayed-
Enhanced Cardiac Magnetic Resonance (DE-CMR) imaging for atrial wall fibrosis detection was
used in several studies to guide AF ablation. The aim of present study was to systematically review
the literature on the role of atrial fibrosis detected by DE-CMR imaging on AF ablation outcome.
Methods:
Eight bibliographic electronic databases were searched to identify all published relevant
studies until 21st of March, 2016. Search of the scientific literature was performed for studies describing
DE-CMR imaging on atrial fibrosis in AF patients underwent Pulmonary Vein Isolation
(PVI).
Results:
Of the 763 citations reviewed for eligibility, 5 articles (enrolling a total of 1040 patients)
were included into the final analysis. The overall recurrence of AF ranged from 24.4 - 40.9% with
median follow-up of 324 to 540 days after PVI. With less than 5-10% fibrosis in the atrial wall
there was a maximum of 10% recurrence of AF after ablation. With more than 35% fibrosis in the
atrial wall there was 86% recurrence of AF after ablation.
Conclusion:
Our analysis suggests that more extensive left atrial wall fibrosis prior ablation predicts
the higher arrhythmia recurrence rate after PVI. The DE-CMR imaging modality seems to be
a useful method for identifying the ideal candidate for catheter ablation. Our findings encourage
wider usage of DE-CMR in distinct AF patients in a pre-ablation setting.
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Affiliation(s)
- Zsuzsanna Kis
- Department of Clinical Electrophysiology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Astrid Amanda Hendriks
- Department of Clinical Electrophysiology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Taulant Muka
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Wichor M. Bramer
- Medical Library, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Istvan Kovacs
- Department of Internal Medicine, Clinic of Cardiology, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania
| | - Tamas Szili-Torok
- Department of Clinical Electrophysiology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
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Integrative analysis reveals essential mRNA, long non-coding RNA (lncRNA), and circular RNA (circRNA) in paroxysmal and persistent atrial fibrillation patients. Anatol J Cardiol 2020; 25:414-428. [PMID: 34100729 DOI: 10.14744/anatoljcardiol.2020.57295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the functions of mRNA, long non-coding RNA (lncRNA), and circular RNA (circRNA) in paroxysmal and persistent atrial fibrillation (AF) patients. METHODS A total of 9 left atrial appendage (LAA) tissues were collected from patients with AF (ParoAF patients = 3 and PersAF patients = 3) and donors (n=3). Genes and circRNAs were identified by per kilobase per million reads (RPKM) and number of circular reads/number of mapped reads/read length (SRPBM), respectively. Differentially expressed mRNAs (DE mRNAs), lncRNAs (DE lncRNAs), and circRNAs (DE circRNAs) were identified by | log2 (Fold Change) | ≥ 2 and p-value < 0.05. Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed. Protein-protein, mRNA-lncRNA, and circRNA-miRNA interaction networks were constructed. In addition, logistic analysis was conducted among AF and circRNAs. RESULTS A total of 285 (116 up-regulated and 169 down-regulated) and 275 (110 up-regulated and 165 down-regulated) DE mRNAs, 575 (276 up-regulated and 299 down-regulated) and 583 (330 up-regulated and 253 down-regulated) DE lncRNAs, and 83 (48 up-regulated and 35 down-regulated) and 99 (58 up-regulated and 41 down-regulated) circRNAs were detected in ParoAF and PersAF, respectively, as compared with control. MAPK signal pathway as well as voltage-dependent, L type, and alpha 1C subunit calcium channel (CACNA1C) might participate in AF occurrence by preventing atrial parasympathetic remodeling. Collagen type I alpha 1 (COL1A1) and COL1A2 mostly participated in the enriched GO and KEGG terms and connected with most of the DE mRNAs. The expression of chr10: 69902697|69948883 was a protective factor against PersAF after adjusting for age (p=0.022, 95% CI: 0.003-0.634). CONCLUSION We found that some mRNAs, lncRNAs, circRNAs, and pathways play essential roles in AF pathogenesis and development. Moreover, one protective factor against PersAF was detected.
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50
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Bertelsen L, Alarcón F, Andreasen L, Benito E, Olesen MS, Vejlstrup N, Mont L, Svendsen JH. Verification of threshold for image intensity ratio analyses of late gadolinium enhancement magnetic resonance imaging of left atrial fibrosis in 1.5T scans. Int J Cardiovasc Imaging 2019; 36:513-520. [PMID: 31748945 PMCID: PMC7080681 DOI: 10.1007/s10554-019-01728-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/03/2019] [Indexed: 11/25/2022]
Abstract
The use of cardiovascular magnetic resonance imaging left atrial late gadolinium enhancement (LA LGE) is increasing for fibrosis evaluation though the use is still limited to specialized centres due to complex image acquisition and lack of consensus on image analyses. Analysis of LA LGE with image intensity ratio (IIR) (pixel intensity of atrial wall normalized by blood pool intensity) provides an objective method to obtain quantitative data on atrial fibrosis. A threshold between healthy myocardium and fibrosis of 1.2 has previously been established in 3T scans. The aim of the study was to reaffirm this threshold in 1.5T scans. LA LGE was performed using a 1.5T magnetic resonance scanner on: 11 lone-AF patients, 11 age-matched healthy volunteers (aged 27-44) and 11 elderly patients without known history of AF but varying degrees of comorbidities. Mean values of IIR for all healthy volunteers +2SD were set as upper limit of normality and was reproduced to 1.21 and the original IIR-threshold of 1.20 was maintained. The degree of fibrosis in lone-AF patients [median 9.0% (IQR 3.9-12.0)] was higher than in healthy volunteers [2.8% (1.3-8.3)] and even higher in elderly non-AF [20.1% (10.2-35.8), p = 0.001]. The previously established IIR-threshold of 1.2 was reaffirmed in 1.5T LA LGE scans. Patients with lone AF presented with increased degrees of atrial fibrosis compared to healthy volunteers in the same age-range. Elderly patients with no history of AF showed significantly higher degrees of fibrosis compared to both groups with younger individuals.
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Affiliation(s)
- Litten Bertelsen
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Francisco Alarcón
- Department of Cardiology, Unitat de Fibril.lació Auricular (UFA) Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Andreasen
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Eva Benito
- Department of Cardiology, Unitat de Fibril.lació Auricular (UFA) Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Niels Vejlstrup
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lluis Mont
- Department of Cardiology, Unitat de Fibril.lació Auricular (UFA) Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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