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Hopman LHGA, van Pouderoijen N, Mulder MJ, van der Laan AM, Bhagirath P, Nazarian S, Niessen HWM, Ferrari VA, Allaart CP, Götte MJW. Atrial Ablation Lesion Evaluation by Cardiac Magnetic Resonance: Review of Imaging Strategies and Histological Correlations. JACC Clin Electrophysiol 2023; 9:2665-2679. [PMID: 37737780 DOI: 10.1016/j.jacep.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/09/2023] [Indexed: 09/23/2023]
Abstract
Cardiac magnetic resonance (CMR) imaging is a valuable noninvasive tool for evaluating tissue response following catheter ablation of atrial tissue. This review provides an overview of the contemporary CMR strategies to visualize atrial ablation lesions in both the acute and chronic postablation stages, focusing on their strengths and limitations. Moreover, the accuracy of CMR imaging in comparison to atrial lesion histology is discussed. T2-weighted CMR imaging is sensitive to edema and tends to overestimate lesion size in the acute stage after ablation. Noncontrast agent-enhanced T1-weighted CMR imaging has the potential to provide more accurate assessment of lesions in the acute stage but may not be as effective in the chronic stage. Late gadolinium enhancement imaging can be used to detect chronic atrial scarring, which may inform repeat ablation strategies. Moreover, novel imaging strategies are being developed, but their efficacy in characterizing atrial lesions is yet to be determined. Overall, CMR imaging has the potential to provide virtual histology that aids in evaluating the efficacy and safety of catheter ablation and monitoring of postprocedural myocardial changes. However, technical factors, scanning during arrhythmia, and transmurality assessment pose challenges. Therefore, further research is needed to develop CMR strategies to visualize the ablation lesion maturation process more effectively.
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Affiliation(s)
| | | | - Mark J Mulder
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Pranav Bhagirath
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Saman Nazarian
- Penn Cardiovascular Institute, Penn Heart and Vascular Center, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania, USA
| | - Hans W M Niessen
- Department of Pathology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Victor A Ferrari
- Penn Cardiovascular Institute, Penn Heart and Vascular Center, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania, USA
| | | | - Marco J W Götte
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands.
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Mont L, Roca-Luque I, Althoff TF. Ablation Lesion Assessment with MRI. Arrhythm Electrophysiol Rev 2022; 11:e02. [PMID: 35444808 PMCID: PMC9014705 DOI: 10.15420/aer.2021.63] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 12/11/2021] [Indexed: 12/17/2022] Open
Abstract
Late gadolinium enhancement (LGE) MRI is capable of detecting not only native cardiac fibrosis, but also ablation-induced scarring. Thus, it offers the unique opportunity to assess ablation lesions non-invasively. In the atrium, LGE-MRI has been shown to accurately detect and localise gaps in ablation lines. With a negative predictive value close to 100% it can reliably rule out pulmonary vein reconnection non-invasively and thus may avoid unnecessary invasive repeat procedures where a pulmonary vein isolation only approach is pursued. Even LGE-MRI-guided repeat pulmonary vein isolation has been demonstrated to be feasible as a standalone approach. LGE-MRI-based lesion assessment may also be of value to evaluate the efficacy of ventricular ablation. In this respect, the elimination of LGE-MRI-detected arrhythmogenic substrate may serve as a potential endpoint, but validation in clinical studies is lacking. Despite holding great promise, the widespread use of LGE-MRI is still limited by the absence of standardised protocols for image acquisition and post-processing. In particular, reproducibility across different centres is impeded by inconsistent thresholds and internal references to define fibrosis. Thus, uniform methodological and analytical standards are warranted to foster a broader implementation in clinical practice.
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Affiliation(s)
- Lluís Mont
- Arrhythmia Section, Cardiovascular Institute, Clínic - University Hospital Barcelona Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Ivo Roca-Luque
- Arrhythmia Section, Cardiovascular Institute, Clínic - University Hospital Barcelona Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Till F Althoff
- Arrhythmia Section, Cardiovascular Institute, Clínic - University Hospital Barcelona Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Department of Cardiology and Angiology, Charité University Medicine Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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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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Tzeis S, Asvestas D, Vardas P. Atrial Fibrosis: Translational Considerations for the Management of AF Patients. Arrhythm Electrophysiol Rev 2019; 8:37-41. [PMID: 30918665 PMCID: PMC6434500 DOI: 10.15420/aer.2018.79.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Fibrosis plays a fundamental role in the initiation and maintenance of AF, mainly due to enhanced automaticity and anisotropy-related re-entry. The identification and quantification of atrial fibrosis is achieved either preprocedurally by late gadolinium enhancement MRI or intraprocedurally using electroanatomic voltage mapping. The presence and extent of left atrial fibrosis among AF patients may influence relevant decision making regarding the need for anticoagulation, the adoption of rate versus rhythm control and mainly the type of ablation strategy that will be followed during interventional treatment. Several types of individualised substrate modifications targeting atrial fibrotic areas have been proposed, although their impact on patient outcome needs to be further investigated in adequately powered prospective randomised controlled clinical trials.
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Affiliation(s)
- Stylianos Tzeis
- Cardiology Department, Mitera General Hospital, Hygeia Group Athens, Greece
| | - Dimitrios Asvestas
- Cardiology Department, Mitera General Hospital, Hygeia Group Athens, Greece
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals Athens, Greece
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Oltean-Péter B, Korodi S, Benedek I, Lázár E, Kéri J, Pakucs A, Kovács I, Bordi L, Mitre A, Benedek I, Benedek T, Benedek I. Imaging-derived Biomarkers Associated with Atrial FIBROsis, Structural Remodeling and the Risk of Cardioembolic Events in Patients with Atrial Fibrillation – the FIBROS Study. JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Recent studies demonstrated that despite restoration of the sinus rhythm, patients with a positive history of atrial fibrillation (AF) are still at risk of thromboembolic events. The primary objective of this study is to identify new imaging-derived biomarkers provided by modern imaging technologies, such as cardiac computed tomography angiography, delayed enhancement magnetic resonance imaging, or speckle tracking echocardiography, as well as hematological biomarkers, associated with the risk of intracavitary thrombosis in patients with AF, in order to identify the imaging-derived characteristics associated with an increased risk of cardioembolic events. Imaging data collected will be post-processed using advanced techniques of computational modeling, in order to fully characterize the degree of structural remodeling and the amount of atrial fibrosis. The primary endpoint of the study is represented by the rate of thromboembolic events. The rate of cardiovascular death, the rate of major adverse cardiovascular events, and the rate of AF recurrence will also be determined in relation to the degree of structural remodeling and atrial fibrosis.
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Affiliation(s)
- Balázs Oltean-Péter
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
| | - Szilamér Korodi
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - István Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
| | - Erzsébet Lázár
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
| | - Johanna Kéri
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
| | - Annamária Pakucs
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
| | - István Kovács
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Lehel Bordi
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Adriana Mitre
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Imre Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Theodora Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - István Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
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