Incidental extracardiac findings in cardiac computed tomography performed before radiofrequency ablation of atrial fibrillation

Incidental Cardiac Computed Tomography Findings in Patients Undergoing Atrial Fibrillation Catheter Ablation

Background: Catheter ablation (CA) is an effective technique for the management of atrial fibrillation (AF). Cardiac computed tomography (CCT) is a non-invasive imaging modality that is used as a crucial part of planning before CA procedures which can detect other incidental findings and require further diagnostic investigations.

Objectives: We sought to assess the prevalence and distribution of incidental CCT findings in patients with AF undergoing CA.

Methods: Retrospective analysis over a three-year period (2013-2016) of 218 patients undergoing CCT prior to AF CA. CCT findings were analyzed and incident clinically important findings were reported.

Results: Over the three-year period, 218 patients had undergone CCT. Of these, 28.8% showed clinically significant incidental findings in the chest and upper abdomen. Incidental findings included coronary artery disease (CAD), incomplete cor triatriatum, pericardial effusion, pleural effusion, pulmonary nodules, pulmonary infiltrates, pulmonary mass, thoracic aortic aneurysm, mediastinal nodes, abdominal mass, and liver nodules.

Conclusions: CCT is a cornerstone investigation prior to AF CA and can show multiple incidental findings, thus potentially functioning as a screening method for the detection of other significant conditions. There is still a debate whether further workup is needed or not as most findings will eventually be benign and further investigations could mean financial burden and clinical risks to the patients. Further larger prospective studies are needed with long-term follow-up to determine whether incidental findings on CCT have an impact on the long-term outcomes of patients.

Extracardiac findings on cardiac computed tomography in patients undergoing atrial fibrillation catheter ablation

Abstract Background and Aim

To assess the prevalence of incidental extracardiac findings in patients who underwent cardiac CT for the evaluation of left atrial (LA) anatomy before atrial fibrillation (AF) catheter ablation. We also aimed to determine the independent predictors of relevant extracardiac alterations.

Patients and Methods

We studied consecutive patients who underwent cardiac CT with a 256-slice scanner for the visualization of LA anatomy before AF ablation. Prevalence of clinically significant and not significant extracardiac findings were recorded. Moreover, we determined the variables associated with relevant extracardiac alterations with uni- and multivariate logistic regression analyses.

Results

In total, 1,952 consecutive patients who underwent cardiac CT examination between 2010 and 2020 were included in our study (mean age 61.2±10.6 years; 66.2% male). Incidental extracardiac findings were detected in 820 (42.0%; 95%CI=0.40-0.44%) patients, while clinically significant alterations were reported in 416 (21.3%; 95%CI=20.0-23.2%) patients. When analyzing the predictors of clinically relevant alterations, age (OR=1.04; 95%CI=1.03- 1.05), male sex (OR=1.39; 95%CI=1.12-1.73), chest pain (OR=1.46; 95%CI=1.09-1.93), hypertension (OR=1.42; 95%CI=1.12-1.81), heart failure (OR=1.68; 95%CI=1.09-2.53), obstructive CAD (OR=1.56; 95%CI=1.16-2.09) and prior stroke/TIA (OR=1.56; 95%CI=1.04- 2.30) showed association with clinically significant incidental findings in the univariate analysis (all p<0.05). In the multivariate analysis, age (OR=1.04; 95%CI=1.02-1.06; p<0.001) proved to be the only significant predictor of clinically relevant extracardiac finding.

Conclusion

Cardiac CT performed before AF ablation is not only helpful in understanding LA anatomy, but might also identify clinically significant pathologies. These incidental findings might have further diagnostic or therapeutic consequences.

Major incidental findings on routine cardiovascular magnetic resonance imaging prior to first-time catheter ablation of atrial fibrillation

Introduction

Preprocedural cardiovascular magnetic resonance (CMR) or computed tomography (CT) imaging of the left atrium/pulmonary veins is usually employed to guide catheter ablation of atrial fibrillation (AFCA). Incidental findings (IFs) are common on cardiac imaging prior to AFCA. However, previous studies have mainly focused on extracardiac IFs detected on CT scan. We aimed to assess the prevalence of relevant cardiac and extracardiac IFs on routine preprocedural CMR in a large patient cohort scheduled for first-time AFCA and report its impact on clinical decision-making and management.

Methods and results

We included 2000 consecutive patients (62 ± 10 years; 59% male) who underwent CMR prior to first-time AFCA between April 2015 and March 2019. Among these patients 172 (8.6%) had a total of 184 major IFs. Detection of major IFs resulted in cancellation of the scheduled AFCA procedure in 88 patients (4.4%). Forty-two patients (2.1%) have never been ablated, 46 (2.3%) underwent postponed AFCA after a median time of 83 (32–213) days. The remaining 84 patients (4.2%) underwent an individualized approach to AFCA. The most common major IFs were accessory or anomalous PVs in 76 (3.8%), extracardiac abnormalities suspicious of malignancy in 29 (1.5%), and positive stress perfusion imaging in 19 (7.2% of 261 tested) patients. In 19 patients (1.0%) preprocedural CMR provided the diagnosis of a previously unknown structural cardiac disease.

Conclusions

Unexpected relevant findings on routine preprocedural CMR affected clinical decision-making and management in 8.6% of patients scheduled for first-time AFCA. However, whether preprocedural CMR imaging may improve overall clinical outcome needs to be addressed in future research.

Collateral findings during computed tomography scan for atrial fibrillation ablation: Let’s take a look around

The growing number of atrial fibrillation catheter ablation procedures warranted the development of advanced cardiac mapping techniques, such as image integration between electroanatomical map and cardiac computed tomography. While scanning the chest before catheter ablation, it is frequent to detect cardiac and extracardiac collateral findings. Most collateral findings are promptly recognized as benign and do not require further attention. However, sometimes clinically relevant collateral findings are detected, which often warrant extra diagnostic examinations or even invasive procedure, and sometimes need to be followed-up over time. Even though reporting and further investigating collateral findings has not shown a clear survival benefit, almost all the working groups providing data on collateral findings reported some collateral findings eventually coming out to be malignancies, sometimes at an early stage. Therefore, there is currently no clear agreement about the right strategy to be followed.

Prevalence and clinical relevance of extracardiac findings at cardiac MRI

PURPOSE

To assess the incidence of extracardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart, and to determine the influence of those findings on patient management.

MATERIALS AND METHODS

During 40 months, 854 CMRI were performed at 1.5 T. Extracardiac findings were classified as significant (group A), if recommended for additional diagnostics or therapeutic interventions, and as nonsignificant (group B).

RESULTS

The most frequent indication for CMRI was evaluation of cardiac stress ischemia. In all, 631 CMRI (74% of 854) showed no extracardiac pathologies. In the remaining 223 CMRI (26% of 854), a total of 286 extracardiac findings were detected. Among these findings, 49 were considered significant (group A) and 237 nonsignificant (group B). In group A, the most common findings were suspicious pulmonary nodules or masses. In group B, the most frequent findings were hepatic cysts or hemangiomas. Eight malignancies were observed with certainty at CMRI. Seven of them had been incidentally diagnosed on CMRI for the first time, and subsequently changed the patients' management.

CONCLUSION

Extracardiac findings in clinically indicated CMRI are common (about 26%). Radiologists and cardiologists should be aware of relevant extracardiac findings that might require additional diagnostics or treatment.

[Cardiac computed tomography and ablation of atrial fibrillation]

Both cardiac computed tomography (CT) and interventional electrophysiology (EP) have evolved considerably in recent years. Technical improvements in CT have significantly reduced the radiation dose in cardiac applications. This imaging technology plays an important role in preprocedural planning and guidance of the procedures in many EP centers worldwide. Furthermore, CT is the imaging modality of choice to diagnose relevant complications in ablation of atrial fibrillation, e.g. pulmonary vein stenosis or atrioesophageal fistula. In anatomically driven ablation procedures, such as balloon-based procedures in atrial fibrillation, detailed analysis of the relevant cardiac structures is absolutely crucial not only to reduce radiation exposure and procedure times but also to improve ablation success and to reduce the occurrence of complications. Current software applications enable 3-dimensional reconstruction of cardiac images and the integration into electroanatomical navigation systems. This article reviews the available evidence in this field and highlights recent developments in image guidance for ablation of atrial fibrillation.