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Bodagh N, Williams MC, Vickneson K, Gharaviri A, Niederer S, Williams SE. State of the art paper: Cardiac computed tomography of the left atrium in atrial fibrillation. J Cardiovasc Comput Tomogr 2023; 17:166-176. [PMID: 36966040 PMCID: PMC10689253 DOI: 10.1016/j.jcct.2023.03.002] [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: 10/17/2022] [Revised: 02/06/2023] [Accepted: 03/11/2023] [Indexed: 03/27/2023]
Abstract
The clinical spectrum of atrial fibrillation means that a patient-individualized approach is required to ensure optimal treatment. Cardiac computed tomography can accurately delineate atrial structure and function and could contribute to a personalized care pathway for atrial fibrillation patients. The imaging modality offers excellent spatial resolution and has been utilised in pre-, peri- and post-procedural care for patients with atrial fibrillation. Advances in temporal resolution, acquisition times and analysis techniques suggest potential expanding roles for cardiac computed tomography in the future management of patients with atrial fibrillation. The aim of the current review is to discuss the use of cardiac computed tomography in atrial fibrillation in pre-, peri- and post-procedural settings. Potential future applications of cardiac computed tomography including atrial wall thickness assessment and epicardial fat volume quantification are discussed together with emerging analysis techniques including computational modelling and machine learning with attention paid to how these developments may contribute to a personalized approach to atrial fibrillation management.
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Affiliation(s)
- Neil Bodagh
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | | | - Keeran Vickneson
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ali Gharaviri
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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2
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Abstract
Catheter-based ultrasonography is a widely used tool in cardiac electrophysiology practice, and intracardiac echocardiography is supplanting other forms of imaging to become the dominant imaging modality. Given advances in pericardial access, intrapericardial echocardiography can be performed using ultrasound catheters as well. Intrapericardial echocardiography and echocardiography from the coronary sinus, also an epicardial structure, allows interventionalists to obtain unique views from virtually any vantage point, compared with other forms of echocardiography. Both intrapericardial echocardiography and coronary sinus echocardiography are safe and important alternatives that can be used during complex procedures in the electrophysiology laboratory.
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Affiliation(s)
- Nicholas Palmeri
- Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Andre D'Avila
- Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Eduardo B Saad
- Cardiac Arrhythmia and Pacing, Center for Atrial Fibrillation - Hospital Pró-Cardíaco and Hospital Samaritano Botafogo, Rio de Janeiro, RJ, Brazil.
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3
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Restrepo AJ, Dickfeld TM. Image Integration Using Intracardiac Echography and Three-dimensional Reconstruction for Mapping and Ablation of Atrial and Ventricular Arrhythmias. Card Electrophysiol Clin 2021; 13:365-380. [PMID: 33990275 DOI: 10.1016/j.ccep.2021.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article reviews the basis for image integration of intracardiac echocardiography (ICE) with three-dimensional electroanatomic mapping systems and preprocedural cardiac imaging modalities to enhance anatomic understanding and improve guidance for atrial and ventricular ablation procedures. It discusses the technical aspects of ICE-based integration and the clinical evidence for its use. In addition, it presents the current technical limitations and future directions for this technology. This article also includes figures and videos of clinical representative arrhythmia cases where the use of ICE is key to a safe and successful outcome.
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Affiliation(s)
- Alejandro Jimenez Restrepo
- Section of Cardiology, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449, USA.
| | - Timm Michael Dickfeld
- Section of Cardiac Electrophysiology, Maryland Arrhythmia and Cardiac Imaging Group (MACIG), University of Maryland School of Medicine, 22 South Greene Street, Room N3W77, Baltimore, MD 21201, USA
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4
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Jiang R, Zei PC, Jiang C. Prevention of left atrium esophagus fistula: Appraisal of existing technologies and strategies. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:646-654. [PMID: 32391576 DOI: 10.1111/pace.13939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/27/2020] [Accepted: 05/08/2020] [Indexed: 12/17/2022]
Abstract
Catheter ablation has emerged as an effective treatment for atrial fibrillation (AF). Atrial esophageal fistula (AEF) is a rare, but feared complication. With increasing utilization of ablation therapy for AF, the understanding of the relationship between AEF and ablation has been improved in recent years. Efforts to reduce the risk of AEF have focused on decreasing the risk of severe esophageal injury (EI) and the presumed subsequent progression from EI to AEF, including esophageal temperature monitoring, esophageal cooling systems, esophageal deviation devices, and decreasing and/or curtailing ablation energy delivery. Periprocedural assessment may help identify higher risk patients and detect early esophageal lesions. This review systematically summarizes and evaluates the current strategies and techniques utilized to reduce the risk of AEF in the clinical workflow for AF ablation. We expect that this review will help clinicians to better understand the principles, advantages, and disadvantages of these methods, and to find suitable strategies using current available tools.
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Affiliation(s)
- Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
| | - Paul C Zei
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
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5
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Faletti R, Gatti M, Di Chio A, Fronda M, Anselmino M, Ferraris F, Gaita F, Fonio P. Concentrated pineapple juice for visualisation of the oesophagus during magnetic resonance angiography before atrial fibrillation radiofrequency catheter ablation. Eur Radiol Exp 2018; 2:39. [PMID: 30460417 PMCID: PMC6246758 DOI: 10.1186/s41747-018-0067-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/09/2018] [Indexed: 11/10/2022] Open
Abstract
The purpose of this study was to compare in vitro pineapple juice and a solution of concentrated pineapple juice with a paramagnetic contrast agent in order to determine the feasibility of using the solution of concentrated pineapple juice in vivo for oesophagus visualisation at magnetic resonance angiography (MRA) before the radiofrequency catheter ablation procedure for atrial fibrillation. The pineapple juice was concentrated by a microwave heating evaporation process performed in a domestic microwave oven. Five grams of modified potato starch for every 40 mL of concentrated pineapple juice were added to the concentrated pineapple juice in order to thicken the solution. The solution resulted visually and quantitatively as hyperintense as the contrast agent in vitro (ratio = 1.02). in vivo, no technical difficulties were encountered during the MRA acquisition and a complete enhanced oesophagus was obtained in 37/38 patients (97.4%). The volumetric analysis and the three-dimensional reconstruction were feasible; the quality was rated as diagnostic in every patient. The intensified oesophagus was successfully merged into the electro-anatomical maps in all the patients. In summary, we demonstrated that this technique allows a feasible and safe oesophagus visualisation during MRA.
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Affiliation(s)
- Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy.
| | - Andrea Di Chio
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Marco Fronda
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Federico Ferraris
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
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6
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Yamashita K, Quang C, Schroeder JD, DiBella E, Han F, MacLeod R, Dosdall DJ, Ranjan R. Distance between the left atrium and the vertebral body is predictive of esophageal movement in serial MR imaging. J Interv Card Electrophysiol 2018. [PMID: 29532276 DOI: 10.1007/s10840-018-0348-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE MRI or CT imaging can be used to identify the esophageal location prior to left atrial ablation, but the esophagus may move making the location unreliable when ablating to minimize esophageal injury. The aim of this study was to evaluate esophageal position and movement based on serial MRI imaging with the goal of identifying imaging and clinical characteristics that can predict the esophageal movement. METHODS Fifty patients undergoing 190 MRI scans were analyzed. The relative position of the esophagus in each MRI along with clinical and imaging characteristics was quantified, including the gap between the left atrium (LA) and the vertebral body (GAP), an anatomic space in which the esophagus can move. RESULTS A mean of 3.8 MRIs was analyzed per patient. Sixteen patients (32.0%) experienced significant lateral esophageal movement of more than 10 mm. In the significant movement group, body mass index (BMI) was higher (33.0 ± 6.5 vs 28.8 ± 5.3, p = 0.02) and the GAP was significantly larger (7.1 ± 2.5 vs 4.8 ± 5.1 mm, p = 0.04). Multivariate logistic regression analysis revealed that the GAP ≤ 4.5 mm was the only independent predictor of the esophagus not moving (odds ratio = 9.25, 95% confidence interval = 1.72 to 49.67, p = 0.0095). CONCLUSIONS A GAP of less than 4.5 mm between the LA and the vertebral body is associated with lack of esophageal movement (< 10 mm). This suggests that the measurement of GAP < 4.5 mm may be used to predict the esophageal location in patients undergoing atrial ablation.
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Affiliation(s)
- Kennosuke Yamashita
- Division of Cardiovascular Medicine, University of Utah, 30 N 1900E Rm 4A100, Salt Lake City, UT, USA.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Claire Quang
- Division of Cardiovascular Medicine, University of Utah, 30 N 1900E Rm 4A100, Salt Lake City, UT, USA
| | - Joyce D Schroeder
- Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Edward DiBella
- Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA.,UCAIR, University of Utah, Salt Lake City, UT, USA
| | - Frederick Han
- Division of Cardiovascular Medicine, University of Utah, 30 N 1900E Rm 4A100, Salt Lake City, UT, USA
| | - Robert MacLeod
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA.,Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Derek J Dosdall
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA.,Department of Bioengineering, University of Utah, Salt Lake City, UT, USA.,Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah, 30 N 1900E Rm 4A100, Salt Lake City, UT, USA. .,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA. .,Department of Bioengineering, University of Utah, Salt Lake City, UT, USA.
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7
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Romero J, Avendano R, Grushko M, Diaz JC, Du X, Gianni C, Natale A, Biase LD. Oesophageal Injury During AF Ablation: Techniques for Prevention. Arrhythm Electrophysiol Rev 2018; 7:24-31. [PMID: 29636969 PMCID: PMC5889811 DOI: 10.15420/aer.2017.46.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/15/2018] [Indexed: 11/04/2022] Open
Abstract
Atrial fibrillation remains the most common arrhythmia worldwide, with pulmonary vein isolation (PVI) being an essential component in the treatment of this arrhythmia. In view of the close proximity of the oesophagus with the posterior wall of the left atrium, oesophageal injury prevention has become a major concern during PVI procedures. Oesophageal changes varying from erythema to fistulas have been reported, with atrio-oesophageal fistulas being the most feared as they are associated with major morbidity and mortality. This review article provides a detailed description of the risk factors associated with oesophageal injury during ablation, along with an overview of the currently available techniques to prevent oesophageal injury. We expect that this state of the art review will deliver the tools to help electrophysiologists prevent potential oesophageal injuries, as well as increase the focus on research areas in which evidence is lacking.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Ricardo Avendano
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Michael Grushko
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
| | - Xianfeng Du
- Department of Cardiology, Ningbo First HospitalZhejiang Sheng, China
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St David’s Medical CenterAustin, USA
| | - Andrea Natale
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
- Texas Cardiac Arrhythmia Institute, St David’s Medical CenterAustin, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of MedicineBronx, USA
- Texas Cardiac Arrhythmia Institute, St David’s Medical CenterAustin, USA
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8
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Jhuo SJ, Lo LW, Chang SL, Lin YJ, Chung FP, Chiou CW, Chen SA. Periesophageal vagal plexus injury is a favorable outcome predictor after catheter ablation of atrial fibrillation. Heart Rhythm 2016; 13:1786-93. [PMID: 27236026 DOI: 10.1016/j.hrthm.2016.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Collateral damage to periesophageal vagal plexus associated with symptomatic gastric hypomotility and associated symptoms are not uncommon after catheter ablation of atrial fibrillation (AF). The injury may indicate transmural ablation lesions. OBJECTIVE The purpose of this study was to evaluate the periesophageal vagal plexus injury (PNI) and long-term outcome after catheter ablation of AF. METHODS A total of 441 consecutive patients with AF (mean age 54.71 ± 10.52 years; 134 women) who underwent catheter ablation (paroxysmal AF, n = 312; persistent AF, n = 129) were retrospectively enrolled from 2011 to 2013; group 1 was defined as patients with PNI and associated symptoms (n = 88), and group 2 was defined as patients without PNI or associated symptoms (n = 353). Baseline characteristics and electrophysiological properties were collected to analyze the relationship between PNI and clinical outcome. The association of AF recurrence after catheter ablation and PNI symptoms was also investigated. RESULTS During a mean follow-up period of 37.3 ± 0.94 months, group 1 had longer AF-freedom days in sinus rhythm after AF ablation and had less recurrence after the blanking period compared with group 2 (mean recurrence days, 1254.22 ± 45.26 days vs 1065.21 ± 33.35 days; P < .01). Multivariate analysis also revealed that PNI was an independently protective predictor of AF recurrence (hazard ratio 0.527; 95% confidence interval 0.289-0.959; P = .036). There was no difference in baseline characteristics, CHA2DS2-VASc score, or echocardiography follow-up duration. CONCLUSION PNI and associated symptoms are not uncommon after catheter ablation of AF. A better long-term outcome is thereby independently predicted, suggesting transmural ablation lesions during pulmonary vein isolation.
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Affiliation(s)
- Shih-Jie Jhuo
- Division of Cardiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, College of Medicine, National Yang-Ming Medical University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, College of Medicine, National Yang-Ming Medical University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, College of Medicine, National Yang-Ming Medical University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chuen-Wang Chiou
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, College of Medicine, National Yang-Ming Medical University, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, College of Medicine, National Yang-Ming Medical University, Taipei, Taiwan.
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9
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Mateos JCP, Mateos EIP, Peña TGS, Lobo TJ, Mateos JCP, Vargas RNA, Pachón CTC, Acosta JCZ. Simplified method for esophagus protection during radiofrequency catheter ablation of atrial fibrillation--prospective study of 704 cases. Braz J Cardiovasc Surg 2016; 30:139-47. [PMID: 26107444 PMCID: PMC4462958 DOI: 10.5935/1678-9741.20150009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/02/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction Although rare, the atrioesophageal fistula is one of the most feared
complications in radiofrequency catheter ablation of atrial fibrillation due
to the high risk of mortality. Objective This is a prospective controlled study, performed during regular
radiofrequency catheter ablation of atrial fibrillation, to test whether
esophageal displacement by handling the transesophageal echocardiography
transducer could be used for esophageal protection. Methods Seven hundred and four patients (158 F/546M [22.4%/77.6%];
52.8±14 [17-84] years old), with mean EF of
0.66±0.8 and drug-refractory atrial fibrillation were submitted to
hybrid radiofrequency catheter ablation (conventional pulmonary vein
isolation plus AF-Nests and background tachycardia ablation) with
displacement of the esophagus as far as possible from the radiofrequency
target by transesophageal echocardiography transducer handling. The
esophageal luminal temperature was monitored without and with displacement
in 25 patients. Results The mean esophageal displacement was 4 to 9.1cm (5.9±0.8 cm). In 680
of the 704 patients (96.6%), it was enough to allow complete and safe
radiofrequency delivery (30W/40ºC/irrigated catheter or 50W/60ºC/8 mm
catheter) without esophagus overlapping. The mean esophageal luminal
temperature changes with versus without esophageal displacement were
0.11±0.13ºC versus 1.1±0.4ºC respectively,
P<0.01. The radiofrequency had to be halted in 68% of
the patients without esophageal displacement because of esophageal luminal
temperature increase. There was no incidence of atrioesophageal fistula
suspected or confirmed. Only two superficial bleeding caused by
transesophageal echocardiography transducer insertion were observed. Conclusion Mechanical esophageal displacement by transesophageal echocardiography
transducer during radiofrequency catheter ablation was able to prevent a
rise in esophageal luminal temperature, helping to avoid esophageal thermal
lesion. In most cases, the esophageal displacement was sufficient to allow
safe radiofrequency application without esophagus overlapping, being a
convenient alternative in reducing the risk of atrioesophageal fistula.
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10
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Lin D, Callans DJ. Use of intracardiac echocardiography during atrial fibrillation ablation to avoid complications. Future Cardiol 2015; 11:683-7. [DOI: 10.2217/fca.15.64] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Antral pulmonary vein isolation is the cornerstone of current catheter ablation techniques. As technology and tools for performing the ablations have evolved and improved over the past decade, the safety and efficacy of the procedure have improved. The availability of preprocedure imaging, such as MRI and CT scan and intraprocedure imaging, especially intracardiac echocardiography, gives the operator the ability to have very accurate real-time representations of the cardiac anatomy with visualization of catheter positioning and for assessing for potential complications before they become clinically manifest. Much attention has been paid to decreasing the reliance on use of fluoroscopy and the safety of both the patient as well as the operator. This chapter reviews several aspects of the utility of intracardiac echocardiography imaging in minimizing complications during atrial fibrillation ablation.
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Affiliation(s)
- David Lin
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David J Callans
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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11
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Lakkireddy D, Reddy YM, Atkins D, Rajasingh J, Kanmanthareddy A, Olyaee M, Dusing R, Pimentel R, Bommana S, Dawn B. Effect of atrial fibrillation ablation on gastric motility: the atrial fibrillation gut study. Circ Arrhythm Electrophysiol 2015; 8:531-6. [PMID: 25772541 DOI: 10.1161/circep.114.002508] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 02/22/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Collateral damage to the vagal nerve and the upper gastrointestinal (UGI) system during atrial fibrillation ablation has not been systematically evaluated. METHODS AND RESULTS We performed a prospective, observational study assessing the effect of atrial fibrillation ablation on the function of the vagus nerve/UGI system. All patients underwent esophageal manometry, gastric emptying study, and sham-feeding test (corresponding to esophageal, gastric, and small intestinal function evaluation, respectively) before ablation (baseline) and subsequently at 24 hours, 90 days, and 180 days after the procedure. In addition, UGI symptom assessment using the patient assessment of upper gastrointestinal disorders-symptom severity index (PAGI-SYM) questionnaire was performed at baseline and during each of the subsequent evaluations. Of the 27 patients enrolled in the study, 9 (33%) patients had abnormal UGI function at baseline; defined as at least one of the 3 abnormal tests. At 24 hours after the radiofrequency catheter ablation, 20 (74%) patients had at least 1 new abnormality on the UGI function tests (P<0.001). New onset esophageal dysmotility, delayed gastric emptying time, and abnormal sham-feeding tests were observed in 13 (48%), 13 (48%), and 9 (33%) patients, respectively. Mean PAGI-SYM scores increased from 7.78±6.6 at baseline to 15.56±13.4 (P=0.002) at 24 hours. New onset abnormalities persisted in 9 (33%) patients at 3 months and normalized in all patients at 6 months. CONCLUSIONS Atrial fibrillation ablation results in functional impairment of the UGI system, including the esophagus, stomach, and small intestine. This impairment is transient and is probably mediated by the injury to the components of the vagal nerve. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique Identifier: NCT01396356.
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Affiliation(s)
- Dhanunjaya Lakkireddy
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center.
| | - Yeruva Madhu Reddy
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Donita Atkins
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Johnson Rajasingh
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Arun Kanmanthareddy
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Mojtaba Olyaee
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Reginald Dusing
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Rhea Pimentel
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Sudharani Bommana
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
| | - Buddhadeb Dawn
- From the Cardiovascular Research Institute (D.L., Y.M.R., D.A., J.R., A.K., R.P., S.B., B.D.), Division of Gastroenterology (M.O.), Department of Radiology (R.D.), University of Kansas Hospital & Medical Center
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12
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Gavin AR, Singleton CB, McGavigan AD. Assessment of oesophageal position by direct visualization with luminal contrast compared with segmentation from pre-acquired computed tomography scan-implications for ablation strategy. Europace 2014; 16:1304-8. [PMID: 24820285 DOI: 10.1093/europace/euu062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
AIMS Atrio-oesophageal fistula is a rare but often fatal complication of catheter ablation for atrial fibrillation (AF). Various strategies are employed to evaluate the oesophageal position in relation to the posterior left atrium (LA). These include segmentation of the oesophagus from a pre-acquired computed tomography (CT) scan and direct, real-time assessment of the oesophageal position using contrast at the time of the procedure. METHODS AND RESULTS One hundred and fourteen patients with drug-refractory AF underwent CT scanning prior to AF ablation. The LA and oesophagus were segmented from this scan. The oesophagus was deemed midline, ostial if it crossed directly behind any of the pulmonary vein (PV) ostia, or antral if it passed within 5 mm of a PV ostium. Under general anaesthesia at the time of ablation, the same patients were administered contrast via an oro-gastric tube to outline the oesophagus. Catheters were placed at the PV ostia and oesophageal position in relation to the PVs was established radiographically using a postero-anterior view. Oesophageal position assessed by real-time assessment correlated with the CT scan in only 59% of patients. In 34% the oesophagus was more right sided on direct visualization, while in 7% it was more left sided. CONCLUSION Segmentation of the oesophagus from the CT scan did not correlate the real-time oesophageal position at the time of the procedure in over 40% of patients under general anaesthesia. Reliance on the determination of oesophageal position by previously acquired CT may be misleading at best and provide a false sense of security when ablating in the posterior LA.
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Affiliation(s)
- Andrew R Gavin
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Cameron B Singleton
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Andrew D McGavigan
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia Faculty of Medicine, Flinders University of South Australia, Bedford Park, South Australia, Australia
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RUISI CHRISTOPHERP, BRYSIEWICZ NEIL, ASNES JEREMYD, SUGENG LISSA, MARIEB MARK, CLANCY JUDE, AKAR JOSEPHG. Use of Intracardiac Echocardiography during Atrial Fibrillation Ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:781-8. [DOI: 10.1111/pace.12030] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 08/02/2012] [Accepted: 08/21/2012] [Indexed: 11/30/2022]
Affiliation(s)
- CHRISTOPHER P. RUISI
- Section of Cardiovascular Medicine, Division of Medicine; Yale University School of Medicine; New Haven; Connecticut
| | - NEIL BRYSIEWICZ
- Section of Cardiovascular Medicine, Division of Medicine; Yale University School of Medicine; New Haven; Connecticut
| | - JEREMY D. ASNES
- Section of Cardiovascular Medicine, Division of Medicine; Yale University School of Medicine; New Haven; Connecticut
| | - LISSA SUGENG
- Section of Cardiovascular Medicine, Division of Medicine; Yale University School of Medicine; New Haven; Connecticut
| | - MARK MARIEB
- Section of Cardiovascular Medicine, Division of Medicine; Yale University School of Medicine; New Haven; Connecticut
| | - JUDE CLANCY
- Section of Cardiovascular Medicine, Division of Medicine; Yale University School of Medicine; New Haven; Connecticut
| | - JOSEPH G. AKAR
- Section of Cardiovascular Medicine, Division of Medicine; Yale University School of Medicine; New Haven; Connecticut
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14
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To ACY, Klein AL. Role of Echocardiography in Pulmonary Vein Ablation for Atrial Fibrillation. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Saeed M, Hetts SW, English J, Wilson M. MR fluoroscopy in vascular and cardiac interventions (review). Int J Cardiovasc Imaging 2012; 28:117-37. [PMID: 21359519 PMCID: PMC3275732 DOI: 10.1007/s10554-010-9774-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 12/13/2010] [Indexed: 12/22/2022]
Abstract
Vascular and cardiac disease remains a leading cause of morbidity and mortality in developed and emerging countries. Vascular and cardiac interventions require extensive fluoroscopic guidance to navigate endovascular catheters. X-ray fluoroscopy is considered the current modality for real time imaging. It provides excellent spatial and temporal resolution, but is limited by exposure of patients and staff to ionizing radiation, poor soft tissue characterization and lack of quantitative physiologic information. MR fluoroscopy has been introduced with substantial progress during the last decade. Clinical and experimental studies performed under MR fluoroscopy have indicated the suitability of this modality for: delivery of ASD closure, aortic valves, and endovascular stents (aortic, carotid, iliac, renal arteries, inferior vena cava). It aids in performing ablation, creation of hepatic shunts and local delivery of therapies. Development of more MR compatible equipment and devices will widen the applications of MR-guided procedures. At post-intervention, MR imaging aids in assessing the efficacy of therapies, success of interventions. It also provides information on vascular flow and cardiac morphology, function, perfusion and viability. MR fluoroscopy has the potential to form the basis for minimally invasive image-guided surgeries that offer improved patient management and cost effectiveness.
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Affiliation(s)
- Maythem Saeed
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94107-1701, USA.
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16
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Tognolini A, Al-Ahmad A, Wang PJ, Hsia HH, Herfkens RJ, Girard E, Moore T, Fahrig R. Intraprocedure visualization of the esophagus using interventional C-arm CT as guidance for left atrial radiofrequency ablation. Acad Radiol 2011; 18:850-7. [PMID: 21440465 DOI: 10.1016/j.acra.2011.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 01/28/2011] [Accepted: 01/30/2011] [Indexed: 01/09/2023]
Abstract
RATIONALE AND OBJECTIVES During radiofrequency catheter ablation for atrial fibrillation, the esophagus is at risk for thermal injury. In this study, C-arm computed tomography (CT) was compared to clinical CT, without the administration of oral contrast, to visualize the esophagus and its relationship to the left atrium and the ostia of the pulmonary veins (PVs) during the radiofrequency ablation procedure. MATERIALS AND METHODS Sixteen subjects underwent both cardiac clinical CT and C-arm CT. Computed tomographic scans were performed on a multidetector scanner using a standard electrocardiographically gated protocol. C-arm computed tomographic scans were obtained using either a multisweep protocol with retrospective electrocardiographic gating or a non-gated single-sweep protocol. C-arm and clinical computed tomographic scans were analyzed in a random order and then compared for the following criteria: (1) visualization of the esophagus (yes or no), (2) relationship of esophageal position to the four PVs, and (3) direct contact or absence of a fat pad between the esophagus and the PV antrum. RESULTS The esophagus was identified in all C-arm and clinical computed tomographic scans. In four cases, orthogonal planes were needed on C-arm CT (inferior PV level). In six patients, the esophageal location on C-arm CT was different from that on CT. Direct contact was reported in 19 of 64 of the segments (30%) examined on CT and in 26 of 64 (41%) on C-arm CT. In five of 64 segments (8%), C-arm CT overestimated a direct contact of the esophagus to the left atrium. CONCLUSIONS C-arm computed tomographic image quality without the administration of oral contrast agents was shown to be sufficient for visualization of the esophagus location during a radiofrequency catheter ablation procedure for atrial fibrillation.
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Affiliation(s)
- Alessia Tognolini
- Department of Radiology, The Lucas Center for MR Spectroscopy and Imaging, Palo Alto, CA 94304, USA
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17
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Integrated Imaging of Atrial Fibrillation in 2010. CURRENT CARDIOVASCULAR IMAGING REPORTS 2010. [DOI: 10.1007/s12410-010-9037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Abstract
Catheter ablation is a first-line treatment for many cardiac arrhythmias and is generally performed under X-ray fluoroscopy guidance. However, current techniques for ablating complex arrhythmias such as atrial fibrillation and ventricular tachycardia are associated with sub-optimal success rates and prolonged radiation exposure. Pre-procedure 3-D magnetic resonance imaging (MRI) has improved understanding of the anatomic basis of complex arrhythmias and is being used for planning and guidance of ablation procedures. A particular strength of MRI compared to other imaging modalities is the ability to visualize ablation lesions. Post-procedure MRI is now being applied to assess ablation lesion location and permanence with the goal of identifying factors leading to procedure success and failure. In the future, intra-procedure real-time MRI, together with the ability to image complex 3-D arrhythmogenic anatomy and target additional ablation to regions of incomplete lesion formation, may allow for more successful treatment of even complex arrhythmias without exposure to ionizing radiation. Development of clinical grade MRI-compatible electrophysiology devices is required to transition intra-procedure MRI from preclinical studies to more routine use in patients.
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MUSAT DAN, AZIZ EMADF, KONERU JAYANTHI, ARSHAD AYSHA, KAMATH GANESHS, MITTAL SUNEET, STEINBERG JONATHANS. Computational Method to Predict Esophageal Temperature Elevations During Pulmonary Vein Isolation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1239-48. [DOI: 10.1111/j.1540-8159.2010.02804.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Intracardiac echocardiography in complex cardiac catheter ablation procedures. J Interv Card Electrophysiol 2010; 28:167-84. [DOI: 10.1007/s10840-010-9474-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 02/01/2010] [Indexed: 11/25/2022]
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21
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Relevance of imaging structures adjacent to the left atrium during catheter ablation for atrial fibrillation. Heart Rhythm 2009; 7:269-75. [PMID: 19939740 DOI: 10.1016/j.hrthm.2009.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 09/11/2009] [Indexed: 11/20/2022]
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22
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Kolandaivelu A, Lardo AC, Halperin HR. Cardiovascular magnetic resonance guided electrophysiology studies. J Cardiovasc Magn Reson 2009; 11:21. [PMID: 19580654 PMCID: PMC2719626 DOI: 10.1186/1532-429x-11-21] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Accepted: 07/06/2009] [Indexed: 11/10/2022] Open
Abstract
Catheter ablation is a first line treatment for many cardiac arrhythmias and is generally performed under x-ray fluoroscopy guidance. However, current techniques for ablating complex arrhythmias such as atrial fibrillation and ventricular tachycardia are associated with suboptimal success rates and prolonged radiation exposure. Pre-procedure 3D CMR has improved understanding of the anatomic basis of complex arrhythmias and is being used for planning and guidance of ablation procedures. A particular strength of CMR compared to other imaging modalities is the ability to visualize ablation lesions. Post-procedure CMR is now being applied to assess ablation lesion location and permanence with the goal of indentifying factors leading to procedure success and failure. In the future, intra-procedure real-time CMR, together with the ability to image complex 3-D arrhythmogenic anatomy and target additional ablation to regions of incomplete lesion formation, may allow for more successful treatment of even complex arrhythmias without exposure to ionizing radiation. Development of clinical grade CMR compatible electrophysiology devices is required to transition intra-procedure CMR from pre-clinical studies to more routine use in patients.
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Affiliation(s)
| | - Albert C Lardo
- Johns Hopkins Hospital, Division of Cardiology, Baltimore, MD 21205, USA
| | - Henry R Halperin
- Johns Hopkins Hospital, Division of Cardiology, Baltimore, MD 21205, USA
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23
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Kim SS, Hijazi ZM, Lang RM, Knight BP. The use of intracardiac echocardiography and other intracardiac imaging tools to guide noncoronary cardiac interventions. J Am Coll Cardiol 2009; 53:2117-28. [PMID: 19497437 DOI: 10.1016/j.jacc.2009.01.071] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 01/06/2009] [Accepted: 01/19/2009] [Indexed: 10/20/2022]
Abstract
The limitations of standard fluoroscopy have led to the development of improved imaging techniques to guide noncoronary cardiac interventions. Imaging tools that are used in the interventional laboratory can be categorized as invasive and noninvasive. Noninvasive cardiac imaging tools include ultrasound, computed tomography, and magnetic resonance imaging. These modalities can generate high-resolution images of the heart and are increasingly being used to guide cardiac interventions. Despite these advances, there remains a strong role for invasive imaging tools in the interventional laboratories. Such invasive imaging tools include transesophageal echocardiography, intracardiac echocardiography, intracardiac endoscopy, and electroanatomic mapping systems. Despite the risks inherent to the invasive nature of these tools, these modalities can provide excellent real-time, detailed images that can be invaluable in guiding certain cardiac interventions. This review will propose the features of an ideal intracardiac imaging tool, summarize the intracardiac imaging tools that are currently available or under development to guide noncoronary cardiac interventional procedures, and suggest opportunities for improvement. One opportunity in this field is to couple imaging systems directly with the interventional devices themselves. The use of intracardiac imaging to guide select cardiac procedures including transseptal catheterization, catheter ablation procedures for arrhythmias, and percutaneous placement of cardiac valves and closure devices will also be discussed. Most of this review will be devoted to intracardiac echocardiography, which currently has the broadest number of applications.
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Affiliation(s)
- Susan S Kim
- Department of Internal Medicine, University of Chicago, Illinois, USA
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24
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Awad SM, Cao QL, Hijazi ZM. Intracardiac echocardiography for the guidance of percutaneous procedures. Curr Cardiol Rep 2009; 11:210-5. [DOI: 10.1007/s11886-009-0030-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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Bahnson TD. Strategies to minimize the risk of esophageal injury during catheter ablation for atrial fibrillation. Pacing Clin Electrophysiol 2009; 32:248-60. [PMID: 19170916 DOI: 10.1111/j.1540-8159.2008.02210.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Esophageal injury is a rare but serious complication of catheter ablation for atrial fibrillation using radiofrequency energy. Recent studies have begun to identify variables that may determine heat transfer to and thermal injury of the esophagus. There is significant variability in the relationship between the esophagus and left atrium among individuals. New imaging techniques can facilitate assessment of esophagus position relative to intended ablation targets. Strategies to minimize the risk of esophageal injury include avoidance of ablation near the esophagus, titration of RF energy delivery at the posterior left atrial endocardium, and the use of alternative ablation methods.
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Affiliation(s)
- Tristram D Bahnson
- Division of Cardiology, Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke University Medical Center, Durham, North Carolina 27710, USA.
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26
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Helms A, West JJ, Patel A, Mounsey JP, DiMarco JP, Mangrum JM, Ferguson JD. Real-time rotational ICE imaging of the relationship of the ablation catheter tip and the esophagus during atrial fibrillation ablation. J Cardiovasc Electrophysiol 2008; 20:130-7. [PMID: 18775048 DOI: 10.1111/j.1540-8167.2008.01277.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Atrioesophageal fistula is a rare complication of atrial fibrillation (AF) ablation that should be avoided. We investigated whether rotational intracardiac echocardiography (ICE) can help to minimize ablation close to the esophagus. METHODS AND RESULTS We studied 41 patients referred for catheter ablation of refractory AF. A rotational ICE catheter was inserted into the (LA) to determine the location of the esophagus. The esophagus was identified to be either adjacent to the pulmonary vein (PV) ostium or to a cuff 2 cm outside the ostium. Circumferential ablation was performed at the PV ostium, with the exact ablation location determined by ICE. The relationship of the catheter tip to the esophagus was imaged during energy delivery, allowing interruption when respiration moved the tip closer to the esophagus. Out of 41 patients, the esophagus was seen near left-sided PVs in 32 and near right-sided PVs in three patients. The median distance from LA endocardium to esophagus was 2.2 mm (range, 1.4-6 mm). In 21 of 35 patients with a closely related esophagus, ablation over the esophagus was avoided by ablating either lateral or medial to the esophagus. In 14 patients, the esophagus could not be avoided, and risk was minimized by limiting lesion size. Significant movement (>10 mm) of the esophagus during the procedure occurred in 3/41 cases. CONCLUSION Rotational ICE can accurately determine the distance of ablation sites from the esophagus. Real-time imaging of the relationship of the ablation catheter tip to the esophagus may reduce the incidence of esophageal injury.
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Affiliation(s)
- Adam Helms
- University of Virginia Health System, Charlottesville, Virginia 22908, USA
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27
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Stojanovska J, Cronin P. Computed Tomography Imaging of Left Atrium and Pulmonary Veins for Radiofrequency Ablation of Atrial Fibrillation. Semin Roentgenol 2008; 43:154-66. [DOI: 10.1053/j.ro.2008.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Current World Literature. Curr Opin Cardiol 2008; 23:72-8. [DOI: 10.1097/hco.0b013e3282f40209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aryana A, Heist EK, D'Avila A, Holmvang G, Chevalier J, Ruskin JN, Mansour MC. Pain and anatomical locations of radiofrequency ablation as predictors of esophageal temperature rise during pulmonary vein isolation. J Cardiovasc Electrophysiol 2007; 19:32-8. [PMID: 17900251 DOI: 10.1111/j.1540-8167.2007.00975.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Esophageal temperature rise (ETR) during ablation inside left atrium has been reported as a marker for esophageal thermal injury. We sought to investigate the possible relationships between chest pain and ETR during radiofrequency (RF) ablation, and ETR and locations of RF application, in patients undergoing pulmonary vein (PV) isolation under moderate sedation. METHODS AND RESULTS We analyzed anatomical locations of each RF application and its association with esophageal temperature and presence/absence of pain. Data from 40 consecutive patients (mean age: 56 +/- 10 years) were analyzed. There were a total of 4,071 RF applications resulting in 291 episodes of pain (7.1%) and 223 ETRs (5.5%). Thirty-five patients (87.5%) experienced at least one pain episode and 32 (80.0%) had at least one ETR. While 77.4% of posterior wall applications that caused pain also corresponded to an ETR (P < 0.0001), only 0.8% of pain-free posterior wall applications were associated with ETRs (P < 0.0001). The sensitivity and specificity of pain during ablation for ETR were 94% and 98%, respectively. No ETRs were observed during anterior wall applications. ETRs occurred more frequently during ablation on the left (86.1%) versus the right (13.9%), and in inferior (70.4%) versus superior (29.6%) segments. CONCLUSION In patients undergoing PV isolation, ETR was encountered when ablating in the posterior left atrium with the distribution left > right and inferior > superior. Pain during ablation was associated with ETR, and lack of pain was strongly associated with absence of ETR. Pain during RF ablation may thus serve as a predictor of esophageal heating and potential injury.
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Affiliation(s)
- Arash Aryana
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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Dickfeld T. Magnetic resonance imaging and radiofrequency ablations. Herzschrittmacherther Elektrophysiol 2007; 18:147-56. [PMID: 17891491 DOI: 10.1007/s00399-007-0572-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Accepted: 06/27/2007] [Indexed: 05/17/2023]
Abstract
Cardiac MRI has evolved one of the major imaging technologies in cardiology. Increasingly MRI has also been used for electrophysiological applications. Anatomically based procedures such as the circumferential pulmonary vein ablation emphasized the importance of including the individual's cardiac anatomy in a tailored ablation approach. Today, many centers routinely perform pre-ablation imaging to identify left atrial anatomy. Three-dimensional reconstructions based on MRI are frequently integrated in clinical mapping systems to provide cardiac anatomy during the ablation procedure. Similarly, MRI is a clinically very valuable tool in assessing potential ablation complications such as pulmonary vein stenosis. New innovative use of MRI is likely to occur in three areas over the next several years. During ventricular tachycardia ablations volume rendering/fusion imaging will enable a detailed three-dimensional substrate evaluation and provide supplementary scar characterization using a combination of different imaging approaches. With the ongoing technical improvements real-time MRI will likely emerge as a stand-alone clinical modality to directly guide catheter ablation procedures. The advent of stronger field strength MRI, faster imaging protocols, and improved gating techniques will allow accurate peri- and post-procedural visualization of ablation lesions. These developments should result in shorter procedure times and decreased complications rates. Ultimately, they will enable the development of novel ablation strategies and expand the current indications for electrophysiological ablations.
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Affiliation(s)
- T Dickfeld
- Department of Cardiology, University of Maryland, 22 S. Greene Str., Room N3W77, Baltimore, MD 21201, USA.
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