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Bijvoet GP, Nies HMJM, Holtackers RJ, Martens BM, Smink J, Linz D, Vernooy K, Wildberger JE, Nijveldt R, Chaldoupi SM, Mihl C. Tissue characterization of acute lesions during cardiac magnetic resonance-guided ablation of cavo-tricuspid isthmus-dependent atrial flutter: a feasibility study. Eur Heart J Cardiovasc Imaging 2024; 25:635-644. [PMID: 38156446 PMCID: PMC11057941 DOI: 10.1093/ehjci/jead334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/18/2023] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
AIMS To characterize acute lesions during cardiac magnetic resonance (CMR)-guided radiofrequency (RF) ablation of cavo-tricuspid isthmus (CTI)-dependent atrial flutter by combining T2-weighted imaging (T2WI), T1 mapping, first-pass perfusion, and late gadolinium enhancement (LGE) imaging. CMR-guided catheter ablation offers a unique opportunity to investigate acute ablation lesions. Until present, studies only used T2WI and LGE CMR to assess acute lesions. METHODS AND RESULTS Fifteen patients with CTI-dependent atrial flutter scheduled for CMR-guided RF ablation were prospectively enrolled. Directly after achieving bidirectional block of the CTI line, CMR imaging was performed using: T2WI (n = 15), T1 mapping (n = 10), first-pass perfusion (n = 12), and LGE (n = 12) imaging. In case of acute reconnection, additional RF ablation was performed. In all patients, T2WI demonstrated oedema in the ablation region. Right atrial T1 mapping was feasible and could be analysed with a high inter-observer agreement (r = 0.931, ICC 0.921). The increase in T1 values post-ablation was significantly lower in regions showing acute reconnection compared with regions without reconnection [37 ± 90 ms vs. 115 ± 69 ms (P = 0.014), and 3.9 ± 9.0% vs. 11.1 ± 6.8% (P = 0.022)]. Perfusion defects were present in 12/12 patients. The LGE images demonstrated hyper-enhancement with a central area of hypo-enhancement in 12/12 patients. CONCLUSION Tissue characterization of acute lesions during CMR-guided CTI-dependent atrial flutter ablation demonstrates oedema, perfusion defects, and necrosis with a core of microvascular damage. Right atrial T1 mapping is feasible, and may identify regions of acute reconnection that require additional RF ablation.
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Affiliation(s)
- G P Bijvoet
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center, P.Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - H M J M Nies
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R J Holtackers
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - B M Martens
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J Smink
- Department of Clinical Research, Philips Healthcare, Best, The Netherlands
| | - D Linz
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center, P.Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands
- Faculty of Health and Medical Sciences, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - K Vernooy
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center, P.Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - J E Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S M Chaldoupi
- Department of Cardiology, Maastricht University Medical Center, P.Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - C Mihl
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Kreidieh O, Hunter TD, Goyal S, Varley AL, Thorne C, Osorio J, Silverstein J, Varosy P, Metzl M, Leyton-Mange J, Singh D, Rajendra A, Moretta A, Zei PC. Predictors of first pass isolation of the pulmonary veins in real world ablations: An analysis of 2671 patients from the REAL-AF registry. J Cardiovasc Electrophysiol 2024; 35:440-450. [PMID: 38282445 DOI: 10.1111/jce.16190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION During atrial fibrillation ablation (AFA), achievement of first pass isolation (FPI) reflects effective lesion formation and predicts long-term freedom from arrhythmia recurrence. We aim to determine the clinical and procedural predictors of pulmonary vein FPI. METHODS We reviewed AFA procedures in a multicenter prospective registry of AFA (REAL-AF). A multivariate ordinal logistic regression, weighted by inverse proceduralist volume, was used to determine predictors of FPI. RESULTS A total of 2671 patients were included with 1806 achieving FPI in both vein sides, 702 achieving FPI in one, and 163 having no FPI. Individually, age, left atrial (LA) scar, higher power usage (50 W), greater posterior contact force, ablation index >350 posteriorly, Vizigo™ sheath utilization, nonstandard ventilation, and high operator volume (>6 monthly cases) were all related to improved odds of FPI. Conversely sleep apnea, elevated body mass index (BMI), diabetes mellitus, LA enlargement, antiarrhythmic drug use, and center's higher fluoroscopy use were related to reduced odds of FPI. Multivariate analysis showed that BMI > 30 (OR 0.78 [0.64-0.96]) and LA volume (OR per mL increase = 1.00 [0.99-1.00]) predicted lower odds of achieving FPI, whereas significant left atrial scarring (>20%) was related to higher rates of FPI. Procedurally, the use of high power (50 W) (OR 1.32 [1.05-1.65]), increasing force posteriorly (OR 2.03 [1.19-3.46]), and nonstandard ventilation (OR 1.26 [1.00-1.59]) predicted higher FPI rates. At a site level, high procedural volume (OR 1.89 [1.48-2.41]) and low fluoroscopy centers (OR 0.72 [0.61-0.84]) had higher rates of FPI. CONCLUSION FPI rates are affected by operator experience, patient comorbidities, and procedural strategies. These factors may be postulated to impact acute lesion formation.
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Affiliation(s)
- Omar Kreidieh
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tina D Hunter
- CTI Clinical Trial and Consulting, Covington, Kentucky, USA
| | | | - Allyson L Varley
- Heart Rhythm Clinical Research Solutions, Birmingham, Alabama, USA
| | | | - Jose Osorio
- Heart Rhythm Clinical Research Solutions, Birmingham, Alabama, USA
- Arrhythmia Institute at Grandview, Birmingham, Alabama, USA
| | | | - Paul Varosy
- Medicine-Cardiology, University of Colorado, Denver, Aurora, Colorado, USA
| | - Mark Metzl
- NorthShore University Health System, Bannockburn, Illinois, USA
| | | | - David Singh
- John A Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Anil Rajendra
- Arrhythmia Institute at Grandview, Birmingham, Alabama, USA
| | | | - Paul C Zei
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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Marashly Q, Najjar SN, Hahn J, Rector GJ, Khawaja M, Chelu MG. Innovations in ventricular tachycardia ablation. J Interv Card Electrophysiol 2023; 66:1499-1518. [PMID: 35879516 DOI: 10.1007/s10840-022-01311-z] [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: 02/21/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Catheter ablation of ventricular arrhythmias (VAs) has evolved significantly over the past decade and is currently a well-established therapeutic option. Technological advances and improved understanding of VA mechanisms have led to tremendous innovations in VA ablation. The purpose of this review article is to provide an overview of current innovations in VA ablation. Mapping techniques, such as ultra-high density mapping, isochronal late activation mapping, and ripple mapping, have provided improved arrhythmogenic substrate delineation and potential procedural success while limiting duration of ablation procedure and potential hemodynamic compromise. Besides, more advanced mapping and ablation techniques such as epicardial and intramyocardial ablation approaches have allowed operators to more precisely target arrhythmogenic substrate. Moreover, advances in alternate energy sources, such as electroporation, as well as stereotactic radiation therapy have been proposed to be effective and safe. New catheters, such as the lattice and the saline-enhanced radiofrequency catheters, have been designed to provide deeper and more durable tissue ablation lesions compared to conventional catheters. Contact force optimization and baseline impedance modulation are important tools to optimize VT radiofrequency ablation and improve procedural success. Furthermore, advances in cardiac imaging, specifically cardiac MRI, have great potential in identifying arrhythmogenic substrate and evaluating ablation success. Overall, VA ablation has undergone significant advances over the past years. Innovations in VA mapping techniques, alternate energy source, new catheters, and utilization of cardiac imaging have great potential to improve overall procedural safety, hemodynamic stability, and procedural success.
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Affiliation(s)
- Qussay Marashly
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salim N Najjar
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Joshua Hahn
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Graham J Rector
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Muzamil Khawaja
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Mihail G Chelu
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA.
- Baylor St. Luke's Medical Center, Houston, USA.
- Texas Heart Institute, Houston, USA.
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Rogers T, Campbell-Washburn AE, Ramasawmy R, Yildirim DK, Bruce CG, Grant LP, Stine AM, Kolandaivelu A, Herzka DA, Ratnayaka K, Lederman RJ. Interventional cardiovascular magnetic resonance: state-of-the-art. J Cardiovasc Magn Reson 2023; 25:48. [PMID: 37574552 PMCID: PMC10424337 DOI: 10.1186/s12968-023-00956-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Transcatheter cardiovascular interventions increasingly rely on advanced imaging. X-ray fluoroscopy provides excellent visualization of catheters and devices, but poor visualization of anatomy. In contrast, magnetic resonance imaging (MRI) provides excellent visualization of anatomy and can generate real-time imaging with frame rates similar to X-ray fluoroscopy. Realization of MRI as a primary imaging modality for cardiovascular interventions has been slow, largely because existing guidewires, catheters and other devices create imaging artifacts and can heat dangerously. Nonetheless, numerous clinical centers have started interventional cardiovascular magnetic resonance (iCMR) programs for invasive hemodynamic studies or electrophysiology procedures to leverage the clear advantages of MRI tissue characterization, to quantify cardiac chamber function and flow, and to avoid ionizing radiation exposure. Clinical implementation of more complex cardiovascular interventions has been challenging because catheters and other tools require re-engineering for safety and conspicuity in the iCMR environment. However, recent innovations in scanner and interventional device technology, in particular availability of high performance low-field MRI scanners could be the inflection point, enabling a new generation of iCMR procedures. In this review we review these technical considerations, summarize contemporary clinical iCMR experience, and consider potential future applications.
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Affiliation(s)
- Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA.
- Section of Interventional Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 4B01, Washington, DC, 20011, USA.
| | - Adrienne E Campbell-Washburn
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Rajiv Ramasawmy
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - D Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Christopher G Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Laurie P Grant
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Annette M Stine
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Aravindan Kolandaivelu
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
- Johns Hopkins Hospital, Baltimore, MD, USA
| | - Daniel A Herzka
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Kanishka Ratnayaka
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
- Rady Children's Hospital, San Diego, CA, USA
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA.
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Khan F, Naeem K, Khalid A, Khan MN, Ahmad I. Photoacoustic imaging for characterization of radiofrequency ablated cardiac tissues. Lasers Med Sci 2023; 38:61. [PMID: 36732430 DOI: 10.1007/s10103-023-03723-3] [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: 11/24/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Abstract
Photoacoustic (PA) imaging is an emerging technique being explored for various clinical applications. PA imaging offers a portable, inexpensive, stand-alone modality for evaluating optical contrast agents. PA signals are well-correlated with tissue physical parameters and can quantify various physiological variables (e.g., oxygenation of hemoglobin). Moreover, radiofrequency (RF) ablation is a promising treatment for certain cardiac arrhythmias. Assessment of RF-ablated lesions is of clinical importance. The purpose of this study is to elaborate the PA imaging to characterize RF-ablated cardiac tissues. Specifically, we describe the application of PA imaging to identify, characterize, and quantify cardiac RF lesions, highlighting the fundamental principles and unique benefits of this optical imaging technique. Potential future clinical application of PA imaging that reveals additional information about structural damage in RF-treated cardiac tissue are also anticipated.
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Affiliation(s)
- Farwa Khan
- Services Institute of Medical Sciences, Lahore, Pakistan
| | | | - Amna Khalid
- Nishtar Medical University, Multan, Pakistan
| | | | - Iftikhar Ahmad
- Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan.
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Kawamura I, Reddy VY, Santos-Gallego CG, Wang BJ, Chaudhry HW, Buck ED, Mavroudis G, Jerrell S, Schneider CW, Speltz M, Dukkipati SR, Koruth JS. Electrophysiology, Pathology, and Imaging of Pulsed Field Ablation of Scarred and Healthy Ventricles in Swine. Circ Arrhythm Electrophysiol 2023; 16:e011369. [PMID: 36595634 DOI: 10.1161/circep.122.011369] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) has recently been shown to penetrate ischemic scar, but details on its efficacy, risk of arrhythmias, and imaging insights are lacking. In a porcine model of myocardial scar, we studied the ability of ventricular PFA to penetrate scarred tissue, induce ventricular arrhythmias, and assess the influence of QRS gating during pulse delivery. METHODS Of a total of 6 swine, 5 underwent coronary occlusion and 1 underwent radiofrequency ablation to create infarct scar and iatrogenic scar models, respectively. Two additional swine served as healthy controls. An 8 Fr focal PFA catheter was used to deliver bipolar, biphasic PFA (2.0 kV) lesions guided by electroanatomical mapping, fluoroscopy, and intracardiac echocardiography over both scarred and healthy myocardium. Swine underwent magnetic resonance imaging 2-7 days post-PFA. RESULTS PFA successfully penetrated scar without significant difference in lesion depth between lesion at the infarct border (5.9±1.0 mm, n=41) and healthy myocardium (5.7±1.3 mm, n=26; P=0.53). PFA penetration of both infarct and iatrogenic radiofrequency abalation scar was observed in all examined sections. Sustained ventricular arrhythmias requiring defibrillation occurred in 4 of 187 (2.1%) ungated applications, whereas no ventricular arrhythmias occurred during gated PFA applications (0 of 64 [0%]). Dark-blood late-gadolinium-enhanced sequences allowed for improved endocardial border detection as well as lesion boundaries compared with conventional bright-blood late-gadolinium-enhanced sequences. CONCLUSIONS PFA penetrates infarct and iatrogenic scar successfully to create deep lesions. Gated delivery eliminates the occurrence of ventricular arrhythmias observed with ungated porcine PFA. Optimized magnetic resonance imaging sequences can be helpful in detecting lesion boundaries.
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Affiliation(s)
- Iwanari Kawamura
- Helmsley Electrophysiology Center (I.K., V.Y.R., S.R.D., J.S.K.)
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center (I.K., V.Y.R., S.R.D., J.S.K.)
| | | | - Bingyan J Wang
- Cardiovascular Regenerative Medicine, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (B.J.W., H.W.C.)
| | - Hina W Chaudhry
- Cardiovascular Regenerative Medicine, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (B.J.W., H.W.C.)
| | - Eric D Buck
- FARAPULSE, Menlo Park, CA (E.D.B., G.M., S.J., C.W.S.). R. & M. Speltz, LLC, Pathology Services, Stanchfield, MN
| | - George Mavroudis
- FARAPULSE, Menlo Park, CA (E.D.B., G.M., S.J., C.W.S.). R. & M. Speltz, LLC, Pathology Services, Stanchfield, MN
| | - Samantha Jerrell
- FARAPULSE, Menlo Park, CA (E.D.B., G.M., S.J., C.W.S.). R. & M. Speltz, LLC, Pathology Services, Stanchfield, MN
| | - Christopher W Schneider
- FARAPULSE, Menlo Park, CA (E.D.B., G.M., S.J., C.W.S.). R. & M. Speltz, LLC, Pathology Services, Stanchfield, MN
| | | | | | - Jacob S Koruth
- Helmsley Electrophysiology Center (I.K., V.Y.R., S.R.D., J.S.K.)
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Bhatti HS, Khan S, Zahra M, Mustafa S, Ashraf S, Ahmad I. Characterization of radiofrequency ablated myocardium with optical coherence tomography. Photodiagnosis Photodyn Ther 2022; 40:103151. [PMID: 36228980 DOI: 10.1016/j.pdpdt.2022.103151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022]
Abstract
Certain types of cardiac arrhythmias are best treated with radiofrequency (RF) ablation, in which an electrode is inserted into the targeted area of the myocardium and then RF electrical current is applied to heat and destroy surrounding tissue. The resulting ablation lesion usually consists of a coagulative necrotic core surrounded by a rim region of mixed viable and non-viable cells. The characterization of the RF ablated lesion is of potential clinical importance. Here we aim to elaborate optical coherence tomography (OCT) imaging for the characterization of RF-ablated myocardial tissue. In particular, the underlying principles of OCT and its polarization-sensitive counterpart (PS-OCT) are presented, followed by the knowledge needed to interpret their optical images. Studies focused on real-time monitoring of RF lesion formation in the myocardium using OCT systems are summarized. The design and development of various hybrid probes incorporating both OCT guidance and RF ablation catheters are also discussed. Finally, the challenges related to the transmission of OCT imaging systems to cardiac clinics for real-time monitoring of RF lesions are outlined.
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Affiliation(s)
| | - Shamim Khan
- Department of Physics, Islamia College Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Madeeha Zahra
- Department of Physics, The Women University Multan, Pakistan
| | - Sonia Mustafa
- Department of Physics, The Women University Multan, Pakistan
| | - Sumara Ashraf
- Department of Physics, The Women University Multan, Pakistan
| | - Iftikhar Ahmad
- Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan.
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Ghannam M, Bogun F. Improving Outcomes in Ventricular Tachycardia Ablation Using Imaging to Identify Arrhythmic Substrates. Card Electrophysiol Clin 2022; 14:609-620. [PMID: 36396180 DOI: 10.1016/j.ccep.2022.06.009] [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] [Indexed: 06/16/2023]
Abstract
Ventricular tachycardia (VT) ablation is limited by modest acute and long-term success rates, in part due to the challenges in accurately identifying the arrhythmogenic substrate. The combination of multimodality imaging along with information from electroanatomic mapping allows for a more comprehensive assessment of the arrhythmogenic substrate which facilitates VT ablation, and the use of preprocedural imaging has been shown to improve long-term ablation outcomes. Beyond regional recognition of the arrhythmogenic substrate, advanced imaging techniques can be used to create tailored ablation strategies preprocedurally. This review will focus on how imaging can be used to guide ablation planning and execution with a focus on clinical applications aimed at improving the outcome of VT ablation procedures.
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Affiliation(s)
- Michael Ghannam
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA.
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA
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Alken FA, Scherschel K, Kahle AK, Masjedi M, Meyer C. Combined contact force and local impedance dynamics during repeat atrial fibrillation catheter ablation. Front Physiol 2022; 13:1001719. [PMID: 36311229 PMCID: PMC9606811 DOI: 10.3389/fphys.2022.1001719] [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: 07/23/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Optimal lesion formation during catheter-based radiofrequency current (RFC) ablation depends on electro-mechanical tip-tissue coupling measurable via contact force (CF) and local impedance (LI) monitoring. We aimed to investigate CF and LI dynamics in patients with previous atrial fibrillation (AF) ablation who frequently present with heterogenous arrhythmia substrate. Methods: Data from consecutive patients presenting for repeat AF or atrial tachycardia ablation using a novel open-irrigated single-tip ablation catheter were studied. RFC applications were investigated regarding CF, LI and the maximum LI drop (∆LI) for evaluation of ablation efficacy. ∆LI > 20 Ω was defined as a successful RFC application. Results: A total of 730 RFC applications in 20 patients were analyzed. Baseline CF was not associated with baseline LI (R = 0.06, p = 0.17). A mean CF < 8 g during ablation resulted in lower ∆LI (<8 g: 13 Ω vs. ≥ 8 g: 16 Ω, p < 0.001). Baseline LI showed a better correlation with ∆LI (R = 0.35, p < 0.001) compared to mean CF (R = 0.17, p < 0.001). Mean CF correlated better with ∆LI in regions of low (R = 0.31, p < 0.001) compared to high (R = 0.21, p = 0.02) and intermediate voltage (R = 0.17, p = 0.004). Combined CF and baseline LI predicted ∆LI > 20 Ω (area under the receiver operating characteristic curve (AUC) 0.75) better compared to baseline LI (AUC 0.72), mean CF (AUC 0.60), force-time integral (AUC 0.59) and local bipolar voltage (0.55). Conclusion: Combination of CF and LI may aid monitoring real-time catheter-tissue electro-mechanical coupling and lesion formation within heterogenous atrial arrhythmia substrate in patients with repeat AF or atrial tachycardia ablation.
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Affiliation(s)
- Fares-Alexander Alken
- Division of Cardiology, Angiology and Intensive Care, cNEP, Cardiac Neuro- and Electrophysiology Research Group, EVK Düsseldorf, Düsseldorf, Germany
| | - Katharina Scherschel
- Division of Cardiology, Angiology and Intensive Care, cNEP, Cardiac Neuro- and Electrophysiology Research Group, EVK Düsseldorf, Düsseldorf, Germany
- Department of Neurophysiology, Heinrich-Heine-University Düsseldorf, Medical Faculty, cNEP, Cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
| | - Ann-Kathrin Kahle
- Division of Cardiology, Angiology and Intensive Care, cNEP, Cardiac Neuro- and Electrophysiology Research Group, EVK Düsseldorf, Düsseldorf, Germany
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mustafa Masjedi
- Division of Cardiology, Angiology and Intensive Care, cNEP, Cardiac Neuro- and Electrophysiology Research Group, EVK Düsseldorf, Düsseldorf, Germany
- Department of Neurophysiology, Heinrich-Heine-University Düsseldorf, Medical Faculty, cNEP, Cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
| | - Christian Meyer
- Division of Cardiology, Angiology and Intensive Care, cNEP, Cardiac Neuro- and Electrophysiology Research Group, EVK Düsseldorf, Düsseldorf, Germany
- Department of Neurophysiology, Heinrich-Heine-University Düsseldorf, Medical Faculty, cNEP, Cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- *Correspondence: Christian Meyer,
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Sung E, Prakosa A, Zhou S, Berger RD, Chrispin J, Nazarian S, Trayanova NA. Fat infiltration in the infarcted heart as a paradigm for ventricular arrhythmias. NATURE CARDIOVASCULAR RESEARCH 2022; 1:933-945. [PMID: 36589896 PMCID: PMC9802586 DOI: 10.1038/s44161-022-00133-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Infiltrating adipose tissue (inFAT) has been recently found to co-localize with scar in infarcted hearts and may contribute to ventricular arrhythmias (VAs), a life-threatening heart rhythm disorder. However, the contribution of inFAT to VA has not been well-established. We investigated the role of inFAT versus scar in VA through a combined prospective clinical and mechanistic computational study. Using personalized computational heart models and comparing the results from simulations of VA dynamics with measured electrophysiological abnormalities during the clinical procedure, we demonstrate that inFAT, rather than scar, is a primary driver of arrhythmogenic propensity and is frequently present in critical regions of the VA circuit. We determined that, within the VA circuitry, inFAT, as opposed to scar, is primarily responsible for conduction slowing in critical sites, mechanistically promoting VA. Our findings implicate inFAT as a dominant player in infarct-related VA, challenging existing paradigms and opening the door for unexplored anti-arrhythmic strategies.
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Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Shijie Zhou
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Ronald D. Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Saman Nazarian
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Natalia A. Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova.,Correspondence and requests for materials should be addressed to Natalia A. Trayanova.
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11
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Lu Y, Zei PC, Jiang C. Current Understanding of Atrial Fibrillation Recurrence After Atrial Fibrillation Ablation: From Pulmonary Vein to Epicardium. Pacing Clin Electrophysiol 2022; 45:1216-1224. [PMID: 35998211 DOI: 10.1111/pace.14581] [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] [Received: 03/10/2022] [Revised: 06/18/2022] [Accepted: 08/05/2022] [Indexed: 11/29/2022]
Abstract
Recurrence of atrial fibrillation (AF) after catheter ablation is common, with pulmonary vein (PV) reconnection considered the most likely cause. However, technologies such as contact force-sensing, irrigated catheters, and ablation index (AI)-guided ablation strategies have resulted in more durable PV isolation. As a result, it is difficult to predict which patients will develop AF recurrence despite durable PV isolation, with evolving non-PV atrial substrates thought to be a key contributor to late recurrences. Deciphering the complex mechanisms of AF recurrence beyond the cornerstone of PV isolation therefore remains challenging. Recently, there have been several important advances that may lead to better understanding and treatment of this challenging clinical entity: percutaneous epicardial access and mapping, late gadolinium enhancement magnetic resonance imaging (LGE-MRI), improvements in high-resolution electroanatomic mapping, and new ablation energy sources, specifically pulsed-field ablation. This review aims to synthesize the current literature in an effort to better understand arrhythmia mechanisms and treatment targets in patients with AF/Atrial tachycardia (AT) recurrence post-ablation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yu Lu
- Department of Cardiology, Sir Run Shaw Hospital, Hangzhou, China
| | - Paul C Zei
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Shaw Hospital, Hangzhou, China
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12
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Ghannam M, Liang J, Attili A, Cochet H, Jais P, Latchamsetty R, Jongnarangsin K, Morady F, Gordon D, Bogun F. Magnetic Resonance Imaging and Histopathology of Catheter Ablation Lesions after Ventricular Tachycardia Ablation in Patients with Nonischemic Cardiomyopathy. Heart Rhythm 2022; 19:1642-1649. [PMID: 35772697 DOI: 10.1016/j.hrthm.2022.06.027] [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] [Received: 04/24/2022] [Revised: 06/07/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Late gadolinium enhanced cardiac magnetic resonance (LGE-CMR) imaging may help identify radiofrequency ablation lesions. This has been poorly described in patients with non-ischemic cardiomyopathy (NICM). OBJECTIVES To describe LGE-CMR characteristics of ablation lesions in patients with NICM and correlate with histopathology. METHODS Twenty-six patients (24 males, 38±14 ejection fraction, 61±9 age), with CMR imaging after VT ablation were included. Areas of both dark and bright core lesions correlating with prior radiofrequency ablation lesions were identified. Histology was performed on an explanted heart. RESULTS The mean time between the ablation procedure and the LGE-CMR study was 8[2-20] months. Twenty-three/26 patients demonstrated dark-core lesions (volume 2.16±1.8 cm3, thickness 3.6±1.3 mm) with a transmurality of 42±16%, overlaying areas of intramural or transmural LGE. Fourteen/26 patients demonstrated bright core lesions (volume 0.8±0.6 cm3, depth 4.15±1.76 mm) with a transmurality of 34±14%, which was located in areas without underlying LGE in 11/13 patients. Both dark and bright core lesions were visualized on standard clinical LGE-CMR imaging obtained in the acute setting and chronic settings (within 3 days and up to 2090 days post ablation). Histopathologic analysis demonstrated coagulation necrosis in the area that corresponded to dark core lesions in the post ablation CMR. CONCLUSION Ablation lesions can be detected by LGE-CMR after VT ablation in NICM patients and have a different appearance than scar tissue. These lesions can be observed in the acute and chronic settings after ablations.
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Affiliation(s)
| | | | | | - Hubert Cochet
- Bordeaux University Hospital and University of Bordeaux, Bordeaux, France; INRIA, Sophia Antipolis, France
| | - Pierre Jais
- Bordeaux University Hospital and University of Bordeaux, Bordeaux, France; INRIA, Sophia Antipolis, France
| | | | | | | | - David Gordon
- Department of Pathology University of Michigan, Ann Arbor, MI, USA
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13
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Marrouche NF, Wazni O, McGann C, Greene T, Dean JM, Dagher L, Kholmovski E, Mansour M, Marchlinski F, Wilber D, Hindricks G, Mahnkopf C, Wells D, Jais P, Sanders P, Brachmann J, Bax JJ, Morrison-de Boer L, Deneke T, Calkins H, Sohns C, Akoum N. Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The DECAAF II Randomized Clinical Trial. JAMA 2022; 327:2296-2305. [PMID: 35727277 PMCID: PMC9214588 DOI: 10.1001/jama.2022.8831] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/11/2022] [Indexed: 11/14/2022]
Abstract
Importance Ablation of persistent atrial fibrillation (AF) remains a challenge. Left atrial fibrosis plays an important role in the pathophysiology of AF and has been associated with poor procedural outcomes. Objective To investigate the efficacy and adverse events of targeting atrial fibrosis detected on magnetic resonance imaging (MRI) in reducing atrial arrhythmia recurrence in persistent AF. Design, Setting, and Participants The Efficacy of Delayed Enhancement-MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation of Atrial Fibrillation trial was an investigator-initiated, multicenter, randomized clinical trial involving 44 academic and nonacademic centers in 10 countries. A total of 843 patients with symptomatic or asymptomatic persistent AF and undergoing AF ablation were enrolled from July 2016 to January 2020, with follow-up through February 19, 2021. Interventions Patients with persistent AF were randomly assigned to pulmonary vein isolation (PVI) plus MRI-guided atrial fibrosis ablation (421 patients) or PVI alone (422 patients). Delayed-enhancement MRI was performed in both groups before the ablation procedure to assess baseline atrial fibrosis and at 3 months postablation to assess for ablation scar. Main Outcomes and Measures The primary end point was time to first atrial arrhythmia recurrence after a 90-day blanking period postablation. The primary safety composite outcome was defined by the occurrence of 1 or more of the following events within 30 days postablation: stroke, PV stenosis, bleeding, heart failure, or death. Results Among 843 patients who were randomized (mean age 62.7 years; 178 [21.1%] women), 815 (96.9%) completed the 90-day blanking period and contributed to the efficacy analyses. There was no significant difference in atrial arrhythmia recurrence between groups (fibrosis-guided ablation plus PVI patients, 175 [43.0%] vs PVI-only patients, 188 [46.1%]; hazard ratio [HR], 0.95 [95% CI, 0.77-1.17]; P = .63). Patients in the fibrosis-guided ablation plus PVI group experienced a higher rate of safety outcomes (9 [2.2%] vs 0 in PVI group; P = .001). Six patients (1.5%) in the fibrosis-guided ablation plus PVI group had an ischemic stroke compared with none in PVI-only group. Two deaths occurred in the fibrosis-guided ablation plus PVI group, and the first one was possibly related to the procedure. Conclusions and Relevance Among patients with persistent AF, MRI-guided fibrosis ablation plus PVI, compared with PVI catheter ablation only, resulted in no significant difference in atrial arrhythmia recurrence. Findings do not support the use of MRI-guided fibrosis ablation for the treatment of persistent AF. Trial Registration ClinicalTrials.gov Identifier: NCT02529319.
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Affiliation(s)
- Nassir F. Marrouche
- Cardiology Department, Tulane University School of Medicine, New Orleans, Louisiana
| | | | | | | | | | - Lilas Dagher
- Cardiology Department, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Moussa Mansour
- Cardiology Department, Massachusetts General Hospital, Boston
| | | | - David Wilber
- Cardiology Department, Loyola University Chicago, Chicago, Illinois
| | | | | | | | - Pierre Jais
- Cardiology Department, Segalen University, Bordeaux, France
| | | | | | - Jeroen J. Bax
- Cardiology Department, Leiden University Medical Center, Leiden, the Netherlands
- Cardiology Department, Turku Heart Center, Turku, Finland
| | | | | | - Hugh Calkins
- Cardiology Department, Johns Hopkins University, Baltimore, Maryland
| | | | - Nazem Akoum
- Cardiology Department, University of Washington Medical Center, Seattle
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14
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Schmidt EJ, Olson G, Tokuda J, Alipour A, Watkins RD, Meyer EM, Elahi H, Stevenson WG, Schweitzer J, Dumoulin CL, Johnson T, Kolandaivelu A, Loew W, Halperin HR. Intracardiac MR imaging (ICMRI) guiding-sheath with amplified expandable-tip imaging and MR-tracking for navigation and arrythmia ablation monitoring: Swine testing at 1.5 and 3T. Magn Reson Med 2022; 87:2885-2900. [PMID: 35142398 PMCID: PMC8957513 DOI: 10.1002/mrm.29168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/30/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Develop a deflectable intracardiac MR imaging (ICMRI) guiding-sheath to accelerate imaging during MR-guided electrophysiological (EP) interventions for radiofrequency (500 kHz) ablation (RFA) of arrythmia. Requirements include imaging at three to five times surface-coil SNR in cardiac chambers, vascular insertion, steerable-active-navigation into cardiac chambers, operation with ablation catheters, and safe levels of MR-induced heating. METHODS ICMRI's 6 mm outer-diameter (OD) metallic-braided shaft had a 2.6 mm OD internal lumen for ablation-catheter insertion. Miniature-Baluns (MBaluns) on ICMRI's 1 m shaft reduced body-coil-induced heating. Distal section was a folded "star"-shaped imaging-coil mounted on an expandable frame, with an integrated miniature low-noise-amplifier overcoming cable losses. A handle-activated movable-shaft expanded imaging-coil to 35 mm OD for imaging within cardiac-chambers. Four MR-tracking micro-coils enabled navigation and motion-compensation, assuming a tetrahedron-shape when expanded. A second handle-lever enabled distal-tip deflection. ICMRI with a protruding deflectable EP catheter were used for MR-tracked navigation and RFA using a dedicated 3D-slicer user-interface. ICMRI was tested at 3T and 1.5T in swine to evaluate (a) heating, (b) cardiac-chamber access, (c) imaging field-of-view and SNR, and (d) intraprocedural RFA lesion monitoring. RESULTS The 3T and 1.5T imaging SNR demonstrated >400% SNR boost over a 4 × 4 × 4 cm3 FOV in the heart, relative to body and spine arrays. ICMRI with MBaluns met ASTM/IEC heating limits during navigation. Tip-deflection allowed navigating ICMRI and EP catheter into atria and ventricles. Acute-lesion long-inversion-time-T1-weighted 3D-imaging (TWILITE) ablation-monitoring using ICMRI required 5:30 min, half the time needed with surface arrays alone. CONCLUSION ICMRI assisted EP-catheter navigation to difficult targets and accelerated RFA monitoring.
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Affiliation(s)
- Ehud J. Schmidt
- Medicine (Cardiology)Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Gregory Olson
- Cardiac Arrhythmia and Heart Failure DivisionAbbott LaboratoriesMinnetonkaMinnesotaUSA
| | - Junichi Tokuda
- RadiologyBrigham and Women’s HospitalBostonMassachusettsUSA
| | - Akbar Alipour
- Medicine (Cardiology)Johns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Eric M. Meyer
- Medicine (Cardiology)Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Hassan Elahi
- Medicine (Cardiology)Johns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Jeffrey Schweitzer
- Cardiac Arrhythmia and Heart Failure DivisionAbbott LaboratoriesMinnetonkaMinnesotaUSA
| | | | | | | | - Wolfgang Loew
- RadiologyCincinnati Children’s Hospital Medical CenterCincinnatiOhioUSA
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15
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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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16
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Krahn PRP, Biswas L, Ferguson S, Ramanan V, Barry J, Singh SM, Pop M, Wright GA. MRI-Guided Cardiac RF Ablation for Comparing MRI Characteristics of Acute Lesions and Associated Electrophysiologic Voltage Reductions. IEEE Trans Biomed Eng 2022; 69:2657-2666. [PMID: 35171765 DOI: 10.1109/tbme.2022.3152145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Objective: Radiofrequency (RF) energy delivered to cardiac tissue produces a core ablation lesion with surrounding edema, the latter of which has been implicated in acute procedural failure of Ventricular Tachycardia (VT) ablation and late arrhythmia recurrence. This study sought to investigate the electrophysiological characteristics of acute RF lesions in the left ventricle (LV) visualized with native-contrast Magnetic Resonance Imaging (MRI). Methods: An MR-guided electrophysiology system was used to deliver RF ablation in the LV of 8 swine (9 RF lesions in total), then perform MRI and electroanatomic mapping. The permanent RF lesions and transient edema were delineated via native-contrast MRI segmentation of T1-weighted images and T2 maps respectively. Bipolar voltage measurements were matched with image characteristics of pixels adjacent to the catheter tip. Native-contrast MR visualization was verified with 3D late gadolinium enhanced MRI and histology. Results: The T2-derived edema was significantly larger than the T1-derived RF lesion (2.11.5 mL compared to 0.580.34 mL; p=0.01). Bipolar voltage was significantly reduced in the presence of RF lesion core (p<0.05) and edema (p<0.05), with similar trends suggesting that both the permanent lesion and transient edema contributed to the region of reduced voltage. While bipolar voltage was significantly decreased where RF lesions are present (p<0.05), voltage did not change significantly with lesion transmurality (p>0.05). Conclusion: Permanent RF lesions and transient edema are distinct in native-contrast MR images, but not differentiable using bipolar voltage. Significance: Intraprocedural native-contrast MRI may provide valuable lesion assessment in MR-guided ablation, whose clinical application is now feasible.
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17
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Ghannam M, Liang J, Attili A, Cochet H, Jais P, Latchamsetty R, Jongnarangsin K, Morady F, Bogun F. Late Gadolinium Enhancement Cardiac Magnetic Resonance Imaging of Ablation Lesions after Post‐Infarction Ventricular Tachycardia Ablation:Implications for VT Recurrence. J Cardiovasc Electrophysiol 2022; 33:715-721. [DOI: 10.1111/jce.15386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/06/2021] [Accepted: 12/09/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Michael Ghannam
- Division of Cardiovascular Medicine, Department of RadiologyUniversity of MichiganAnn ArborMIUSA
| | - Jackson Liang
- University of Michigan, CardiologyAnn ArborMichiganUnited States
| | - Anil Attili
- Division of Cardiovascular Medicine, Department of RadiologyUniversity of MichiganAnn ArborMIUSA
| | - Hubert Cochet
- Bordeaux University Hospital and University of BordeauxBordeauxFrance
| | - Pierre Jais
- Bordeaux University Hospital and University of BordeauxBordeauxFrance
| | - Rakesh Latchamsetty
- Division of Cardiovascular Medicine, Department of RadiologyUniversity of MichiganAnn ArborMIUSA
| | | | - Fred Morady
- University of Michigan, Internal medicineAnn ArborMichiganUnited States
| | - Frank Bogun
- University of Michigan, ElectrophysiologyAnn ArborMichiganUnited States
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18
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Mulder MJ, Kemme MJB, Allaart CP. Radiofrequency ablation to achieve durable pulmonary vein isolation. Europace 2021; 24:874-886. [PMID: 34964469 DOI: 10.1093/europace/euab279] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Indexed: 11/13/2022] Open
Abstract
Pulmonary vein isolation (PVI) by radiofrequency (RF) ablation is an important alternative to antiarrhythmic drugs in the treatment of symptomatic atrial fibrillation. However, the inability to consistently achieve durable isolation of the pulmonary veins hampers the long-term efficacy of PVI procedures. The large number of factors involved in RF lesion formation and the complex interplay of these factors complicate reliable creation of durable and transmural ablation lesions. Various surrogate markers of ablation lesion formation have been proposed that may provide information on RF lesion completeness. Real-time assessment of these surrogates may aid in the creation of transmural ablation lesions, and therefore, holds potential to decrease the risk of PV reconnection and consequent post-PVI arrhythmia recurrence. Moreover, titration of energy delivery until lesions is transmural may prevent unnecessary ablation and subsequent adverse events. Whereas several surrogate markers of ablation lesion formation have been described over the past decades, a 'gold standard' is currently lacking. This review provides a state-of-the-art overview of ablation strategies that aim to enhance durability of RF-PVI, with special focus on real-time available surrogates of RF lesion formation in light of the biophysical basis of RF ablation.
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Affiliation(s)
- Mark J Mulder
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Michiel J B Kemme
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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19
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Chu GS, Calvert P, Futyma P, Ding WY, Snowdon R, Gupta D. Local impedance for the optimization of radiofrequency lesion delivery: A review of bench and clinical data. J Cardiovasc Electrophysiol 2021; 33:389-400. [PMID: 34921465 DOI: 10.1111/jce.15335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/11/2021] [Accepted: 12/05/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Radiofrequency catheter ablation is a cornerstone of treatment for many cardiac arrhythmias. Progression in three-dimensional mapping and contact-force sensing technologies have improved our capability to achieve success, but challenges still remain. METHODS In this article, we discuss the importance of overall circuit impedance in radiofrequency lesion formation. This is followed by a review of the literature regarding recently developed "local impedance" technology and its current and future potential applications and limitations, in the context of established surrogate markers currently used to infer effective ablation. RESULTS We discuss the role of local impedance in assessing myocardial substrate, as well as its role in clinical studies of ablation. We also discuss safety considerations, limitations and ongoing research. CONCLUSION Local impedance is a novel tool which has the potential to tailor ablation in a manner distinct from other established metrics.
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Affiliation(s)
- Gavin S Chu
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Peter Calvert
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Research Unit, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Piotr Futyma
- Department of Cardiology, Medical College of the University of Rzeszów, St. Joseph's Heart Rhythm Center, Rzeszów, Poland, Rzeszów, Poland
| | - Wern Yew Ding
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Research Unit, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Richard Snowdon
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Research Unit, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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20
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Kanjwal K, Kichloo A, Mohiuddin Mir K, Haji AQ. Left-sided Macro-reentry or Right-sided Focal Tachycardia in Patients with Prior Pulmonary Vein Isolation: A Tale of Two Atria. J Innov Card Rhythm Manag 2021; 12:4764-4768. [PMID: 34858670 PMCID: PMC8631371 DOI: 10.19102/icrm.2021.121104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022] Open
Abstract
We report on three patients with prior pulmonary vein isolation who presented with atrial tachycardia/atrial flutter. During electrophysiology study, the whole tachycardia cycle length was mapped to the left atrium. Multiple ablation attempts failed to terminate the tachycardia and, subsequently, right atrial mapping revealed a focal early site of origin near the superior vena cava–right atrial junction in two patients and outside the coronary sinus ostium in one patient. In this report, we discuss the probable mechanism of these tachycardias.
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Affiliation(s)
- Khalil Kanjwal
- Department of Electrophysiology, McLaren Greater Lansing Hospital, Lansing, MI, USA
| | - Asim Kichloo
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA.,Department of Internal Medicine, Central Michigan University, Saginaw, MI, USA
| | | | - Abdul Qadir Haji
- Department of Cardiology, Martinsburg VA Medical Center, Martinsburg, WV, USA
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21
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Roberts WC, Kietzman AT, Rao PK. Malignant Ventricular Tachycardia, Ventricular Wall Ablation, and Orthotopic Heart Transplantation. Am J Cardiol 2021; 149:150-154. [PMID: 33753037 DOI: 10.1016/j.amjcard.2021.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/26/2021] [Accepted: 03/12/2021] [Indexed: 11/16/2022]
Abstract
Described herein are three patients with refractory ventricular tachycardia and one or more unsuccessful ablation procedures finally leading to orthotropic heart transplantation (OHT). The latter procedure allowed examination of the ventricular ablation sites, an unusual opportunity reported previously in few patients (all case reports). The acute ablation lesions are unique, with necrosis of the myocardial fibers adjacent to the endocardium and encircled by layers of extravasated erythrocytes in the deeper myocardial wall. All 3 patients returned to normal activities following the OHT.
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Affiliation(s)
- William C Roberts
- Baylor Scott and White Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas; Department of Medicine (Division of Cardiology), Dallas, Texas; Department of Pathology, Baylor University Medical Center, Dallas, Texas.
| | - Alexander T Kietzman
- Baylor Scott and White Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Praveen K Rao
- Department of Medicine (Division of Cardiology), Dallas, Texas
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Kolandaivelu A, Bruce CG, Ramasawmy R, Yildirim DK, O'Brien KJ, Schenke WH, Rogers T, Campbell-Washburn AE, Lederman RJ, Herzka DA. Native contrast visualization and tissue characterization of myocardial radiofrequency ablation and acetic acid chemoablation lesions at 0.55 T. J Cardiovasc Magn Reson 2021; 23:50. [PMID: 33952312 PMCID: PMC8101152 DOI: 10.1186/s12968-020-00693-1] [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] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/09/2020] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Low-field (0.55 T) high-performance cardiovascular magnetic resonance (CMR) is an attractive platform for CMR-guided intervention as device heating is reduced around 7.5-fold compared to 1.5 T. This work determines the feasibility of visualizing cardiac radiofrequency (RF) ablation lesions at low field CMR and explores a novel alternative method for targeted tissue destruction: acetic acid chemoablation. METHODS N = 10 swine underwent X-ray fluoroscopy-guided RF ablation (6-7 lesions) and acetic acid chemoablation (2-3 lesions) of the left ventricle. Animals were imaged at 0.55 T with native contrast 3D-navigator gated T1-weighted T1w) CMR for lesion visualization, gated single-shot imaging to determine potential for real-time visualization of lesion formation, and T1 mapping to measure change in T1 in response to ablation. Seven animals were euthanized on ablation day and hearts imaged ex vivo. The remaining animals were imaged again in vivo at 21 days post ablation to observe lesion evolution. RESULTS Chemoablation lesions could be visualized and displayed much higher contrast than necrotic RF ablation lesions with T1w imaging. On the day of ablation, in vivo myocardial T1 dropped by 19 ± 7% in RF ablation lesion cores, and by 40 ± 7% in chemoablation lesion cores (p < 4e-5). In high resolution ex vivo imaging, with reduced partial volume effects, lesion core T1 dropped by 18 ± 3% and 42 ± 6% for RF and chemoablation, respectively. Mean, median, and peak lesion signal-to-noise ratio (SNR) were all at least 75% higher with chemoablation. Lesion core to myocardium contrast-to-noise (CNR) was 3.8 × higher for chemoablation. Correlation between in vivo and ex vivo CMR and histology indicated that the periphery of RF ablation lesions do not exhibit changes in T1 while the entire extent of chemoablation exhibits T1 changes. Correlation of T1w enhancing lesion volumes indicated in vivo estimates of lesion volume are accurate for chemoablation but underestimate extent of necrosis for RF ablation. CONCLUSION The visualization of coagulation necrosis from cardiac ablation is feasible using low-field high-performance CMR. Chemoablation produced a more pronounced change in lesion T1 than RF ablation, increasing SNR and CNR and thereby making it easier to visualize in both 3D navigator-gated and real-time CMR and more suitable for low-field imaging.
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Affiliation(s)
- Aravindan Kolandaivelu
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chris G Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Rajiv Ramasawmy
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
- Biophysics and Biochemistry Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Dursun Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
- Institute of Biomedical Engineering, Bogazici University, Istanbul, Turkey
| | - Kendall J O'Brien
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - William H Schenke
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
- Medstar Washington Hospital Center, Washington, DC, USA
| | - Adrienne E Campbell-Washburn
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
- Biophysics and Biochemistry Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Daniel A Herzka
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA.
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23
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Chu GS, Gupta D. Local impedance to guide focal radiofrequency ablation: There is life in the old dog yet. J Cardiovasc Electrophysiol 2021; 32:1549-1552. [PMID: 33851472 DOI: 10.1111/jce.15039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/11/2021] [Indexed: 01/06/2023]
Affiliation(s)
- Gavin S Chu
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Department of Cardiology, Liverpool Center for Cardiovascular Science, University of Liverpool, Liverpool, UK
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24
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Updating the Risk Stratification for Sudden Cardiac Death in Cardiomyopathies: The Evolving Role of Cardiac Magnetic Resonance Imaging. An Approach for the Electrophysiologist. Diagnostics (Basel) 2020; 10:diagnostics10080541. [PMID: 32751773 PMCID: PMC7460122 DOI: 10.3390/diagnostics10080541] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
The prevention of sudden cardiac death (SCD) in cardiomyopathies (CM) remains a challenge. The current guidelines still favor the implantation of devices for the primary prevention of SCD only in patients with severely reduced left ventricular ejection fraction (LVEF) and heart failure (HF) symptoms. The implantation of an implantable cardioverter-defibrillator (ICD) is a protective barrier against arrhythmic events in CMs, but the benefit does not outweigh the cost in low risk patients. The identification of high risk patients is the key to an individualized prevention strategy. Cardiac magnetic resonance (CMR) provides reliable and reproducible information about biventricular function and tissue characterization. Furthermore, late gadolinium enhancement (LGE) quantification and pattern of distribution, as well as abnormal T1 mapping and extracellular volume (ECV), representing indices of diffuse fibrosis, can enhance our ability to detect high risk patients. CMR can also complement electro-anatomical mapping (EAM), a technique already applied in the risk evaluation and in the ventricular arrhythmias ablation therapy of CM patients, providing a more accurate assessment of fibrosis and arrhythmic corridors. As a result, CMR provides a new insight into the pathological substrate of CM. CMR may help identify high risk CM patients and, combined with EAM, can provide an integrated evaluation of scar and arrhythmic corridors in the ablative therapy of ventricular arrhythmias.
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25
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Ali RL, Hakim JB, Boyle PM, Zahid S, Sivasambu B, Marine JE, Calkins H, Trayanova NA, Spragg DD. Arrhythmogenic propensity of the fibrotic substrate after atrial fibrillation ablation: a longitudinal study using magnetic resonance imaging-based atrial models. Cardiovasc Res 2020; 115:1757-1765. [PMID: 30977811 DOI: 10.1093/cvr/cvz083] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/31/2019] [Accepted: 04/08/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS Inadequate modification of the atrial fibrotic substrate necessary to sustain re-entrant drivers (RDs) may explain atrial fibrillation (AF) recurrence following failed pulmonary vein isolation (PVI). Personalized computational models of the fibrotic atrial substrate derived from late gadolinium enhanced (LGE)-magnetic resonance imaging (MRI) can be used to non-invasively determine the presence of RDs. The objective of this study is to assess the changes of the arrhythmogenic propensity of the fibrotic substrate after PVI. METHODS AND RESULTS Pre- and post-ablation individualized left atrial models were constructed from 12 AF patients who underwent pre- and post-PVI LGE-MRI, in six of whom PVI failed. Pre-ablation AF sustained by RDs was induced in 10 models. RDs in the post-ablation models were classified as either preserved or emergent. Pre-ablation models derived from patients for whom the procedure failed exhibited a higher number of RDs and larger areas defined as promoting RD formation when compared with atrial models from patients who had successful ablation, 2.6 ± 0.9 vs. 1.8 ± 0.2 and 18.9 ± 1.6% vs. 13.8 ± 1.5%, respectively. In cases of successful ablation, PVI eliminated completely the RDs sustaining AF. Preserved RDs unaffected by ablation were documented only in post-ablation models of patients who experienced recurrent AF (2/5 models); all of these models had also one or more emergent RDs at locations distinct from those of pre-ablation RDs. Emergent RDs occurred in regions that had the same characteristics of the fibrosis spatial distribution (entropy and density) as regions that harboured RDs in pre-ablation models. CONCLUSION Recurrent AF after PVI in the fibrotic atria may be attributable to both preserved RDs that sustain AF pre- and post-ablation, and the emergence of new RDs following ablation. The same levels of fibrosis entropy and density underlie the pro-RD propensity in both pre- and post-ablation substrates.
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Affiliation(s)
- Rheeda L Ali
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Joe B Hakim
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Patrick M Boyle
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Sohail Zahid
- Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Bhradeev Sivasambu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph E Marine
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Natalia A Trayanova
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - David D Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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26
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Guttman MA, Tao S, Fink S, Tunin R, Schmidt EJ, Herzka DA, Halperin HR, Kolandaivelu A. Acute enhancement of necrotic radio-frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non-contrast-enhanced T 1 -weighted MRI. Magn Reson Med 2020; 83:1368-1379. [PMID: 31565818 PMCID: PMC6949368 DOI: 10.1002/mrm.28001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate non-contrast-enhanced MRI of acute radio-frequency ablation (RFA) lesions in the left atrium (LA) and pulmonary vein (PV) ostia. The goal is to provide a method for discrimination between necrotic (permanent) lesions and reversible injury, which is associated with recurrence after treatment of atrial fibrillation. METHODS Fifteen normal swine underwent RFA around the right-superior PV ostia. Electrical pulmonary vein isolation (PVI) was verified by electro-anatomic mapping (EAM) and pacing. MRI was carried out using a 3D respiratory-gated T1 -weighted long inversion time (TWILITE) sequence without contrast agent. Key settings were: inversion time 700 ms, triggering over 2 cardiac cycles, pixel size 1.1 mm3 . Contrast-enhanced imaging and T2 -weighted imaging were carried out for comparison. Six animals were sacrificed on ablation day for TTC-stained gross pathology, 9 animals were sacrificed after 2-3 mo after repeat EAM and MRI. Image intensity ratio (IIR) was used to measure lesion enhancement, and gross pathology was used to validate image enhancement patterns and compare lesion widths. RESULTS RFA lesions exhibited unambiguous enhancement in acute TWILITE imaging (IIR = 2.34 ± 0.49 at 1.5T), and the enhancement patterns corresponded well with gross pathology. Lesion widths in MRI correlated well with gross pathology (R2 = 0.84), with slight underestimation by 0.9 ± 0.5 mm. Lesion enhancement subsided chronically. CONCLUSION TWILITE imaging allowed acute detection of permanent RFA lesions in swine LA and PV ostia, without the need for contrast agent. Lesion enhancement pattern showed good correspondence to gross pathology and was well visualized by volume rendering. This method may provide valuable intra- or post-procedural assessment of RFA treatment.
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Affiliation(s)
- Michael A Guttman
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Susumu Tao
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sarah Fink
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Rick Tunin
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ehud J Schmidt
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Daniel A Herzka
- Cardiovascular Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Henry R Halperin
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Aravindan Kolandaivelu
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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