Electroanatomic reconstruction of the left atrium, pulmonary veins, and esophagus compared with the “true anatomy” on multislice computed tomography in patients undergoing catheter ablation of atrial fibrillation

doi:10.1016/j.hrthm.2005.11.027

Heart Rhythm

Volume 3, Issue 3, March 2006, Pages 317-327

https://doi.org/10.1016/j.hrthm.2005.11.027 Get rights and content

Background

Current concepts of catheter ablation for atrial fibrillation (AF) commonly use three-dimensional (3D) reconstructions of the left atrium (LA) for orientation, catheter navigation, and ablation line placement.

Objectives

The purpose of this study was to compare the 3D electroanatomic reconstruction (Carto) of the LA, pulmonary veins (PVs), and esophagus with the true anatomy displayed on multislice computed tomography (CT).

Methods

In this prospective study, 100 patients undergoing AF catheter ablation underwent contrast-enhanced spiral CT scan with barium swallow and subsequent multiplanar and 3D reconstructions. Using Carto, circumferential plus linear LA lesions were placed. The esophagus was tagged and integrated into the Carto map.

Results

Compared with the true anatomy on CT, the electroanatomic reconstruction accurately displayed the true distance between the lower PVs; the distances between left upper PV, left lower PV, right lower PV, and center of the esophagus; the longitudinal diameter of the encircling line around the funnel of the left PVs; and the length of the mitral isthmus line. Only the distances between the upper PVs, the distance between the right upper PV and esophagus, and the diameter of the right encircling line were significantly shorter on the electroanatomic reconstructions. Furthermore, electroanatomic tagging of the esophagus reliably visualized the true anatomic relationship to the LA. On multiple tagging and repeated CT scans, the LA and esophagus showed a stable anatomic relationship, without relevant sideward shifting of the esophagus.

Conclusion

Electroanatomic reconstruction can display with high accuracy the true 3D anatomy of the LA and PVs in most of the regions of interest for AF catheter ablation. In addition, Carto was able to visualize the true anatomic relationship between the esophagus and LA. Both structures showed a stable anatomic relationship on Carto and CT without relevant sideward shifting of the esophagus.

Section snippets

Patient selection and characteristics

One hundred patients (75 men and 25 women, mean age 53 ± 10 years) with highly symptomatic AF were included in this prospective study. Inclusion criteria were a history of AF for more than 18 months, previously ineffective antiarrhythmic drug therapy (at least one antiarrhythmic drug), and at least three documented AF episodes together with corresponding symptoms. Eighty-five (85%) patients had paroxysmal AF and 15 (15%) had persistent AF. Persistent AF was defined as continuous arrhythmia

LA anatomy on Carto and CT

Table 1 summarizes the parameters measured on Carto and CT. The electroanatomic LA reconstruction accurately displayed the true distance between the lower PVs (46 ± 8 mm vs 46 ± 7 mm); the distance between the left upper PV, left lower PV, right lower PV, and center of the esophagus (18 ± 8 mm vs 18 ± 8 mm; 20 ± 10 mm vs 19 ± 8 mm; 27 ± 9 mm vs 26 ± 8 mm); the longitudinal diameter of the encircling line around the funnel of the left PVs (41 ± 7 mm vs 41 ± 8 mm); and the length of the mitral

Main findings

The results of our study show that electroanatomic reconstruction can display with high accuracy the true anatomy of the LA, PVs, and esophagus in most of the regions of interest for AF catheter ablation. No significant differences between the Carto and CT parameters could be found, especially in the area around the left PVs, at the mitral annulus, and at the posterior LA wall. In addition, Carto was able to visualize the true anatomic relationship between the esophagus and LA. Furthermore, the

References (14)

H. Kottkamp et al.
Specific linear left atrial lesions in atrial fibrillationintraoperative radiofrequency ablation using minimally invasive surgical techniques
J Am Coll Cardiol
(2002)
S. Ernst et al.
Catheter-induced linear lesions in the left atrium in patients with atrial fibrillation
J Am Coll Cardiol
(2003)
H. Kottkamp et al.
Time courses and quantitative analysis of atrial fibrillation episode number and duration after circular plus linear left atrial lesions: trigger elimination or substrate modification: early or delayed cure?
J Am Coll Cardiol
(2004)
D. Schwartzman et al.
Characterization of left atrium and distal pulmonary vein morphology using multidimensional computed tomography
J Am Coll Cardiol
(2003)
C.R. Vasamreddy et al.
Pulmonary vein occlusionAn unanticipated complication of catheter ablation of atrial fibrillation using the anatomic circumferential approach
Heart Rhythm
(2004)
C.R. Vasamreddy et al.
Safety and efficacy of circumferential pulmonary vein catheter ablation of atrial fibrillation
Heart Rhythm
(2005)
S.J. Asirvatham
Methods to identify the pulmonary vein ostium
Heart Rhythm
(2005)

There are more references available in the full text version of this article.

Cited by (91)

Relationship between the posterior atrial wall and the esophagus: Esophageal position during atrial fibrillation ablation
2022, Heart Rhythm O2
Atrial fibrillation ablation implies a risk of esophageal thermal injury. Esophageal position can be analyzed with imaging techniques, but evidence for esophageal mobility is inconsistent.
The purpose of this study was to analyze esophageal position stability from one procedure to another and during a single procedure.
Esophageal position was compared in 2 patient groups. First, preprocedural multidetector computerized tomography (MDCT) of first pulmonary vein isolation and redo intervention (redo group) was segmented with ADAS 3D™ to compare the stability of the atrioesophageal isodistance prints. Second, 3 imaging modalities were compared for the same procedure (multimodality group): (1) preprocedural MDCT; (2) intraprocedural fluoroscopy obtained with the transesophageal echocardiographic probe in place with CARTOUNIVU™; and (3) esophageal fast anatomic map (FAM) at the end of the procedure. Esophageal position correlation between different imaging techniques was computed in MATLAB using semiautomatic segmentation analysis.
Thirty-five redo patients were analyzed and showed a mean atrioesophageal distance of 1.2 ± 0.6 mm and a correlation between first and redo procedure esophageal fingerprint of 91% ± 5%. Only 3 patients (8%) had a clearly different position. The multi-imaging group was composed of 100 patients. Esophageal position correlation between MDCT and CARTOUNIVU was 82% ± 10%; between MDCT and esophageal FAM was 80% ± 12%; and between esophageal FAM and CARTOUNIVU was 83% ± 15%.
There is high stability of esophageal position between procedures and from the beginning to the end of a procedure. Further research is undergoing to test the clinical utility of the esophageal fingerprinted isodistance map to the posterior atrial wall.
Detection of oesophageal course during left atrial catheter ablation
2020, Indian Pacing and Electrophysiology Journal
Oesophageal changes and injuries were recorded after atrial fibrillation(AF) ablation procedures. The reduction of power in the posterior left atrial(LA) wall(closest to the oesophagus) and the monitoring of temperature in the oesophagus(OE) reduced oesophageal injuries. The intracardiac-echocardiography(ICE) with a Cartosound module provides two-dimensional imaging (2D) to assess detailed cardiac anatomy and its relationship with the OE. The aim of this study was to highlight the safety and feasibility of 3D-reconstruction of the oesophageal course in left atrial catheter ablation(CA) procedures without OE temperature probe or quadripolar catheter to guide ICE OE reconstruction.
180 patients(PT) underwent left atrial ablation. AF ablation were 125(69.5%); incisional left atrial tachycardias(IAFL) were 37(20.6%); left atrial tachycardias(LAT) were 19(10.6%). The LA and pulmonary vein anatomies were rendered by traditional electroanatomic mapping(EAM) and merged with an ICE anatomic map. In 109 PT ICE imaging was used to create a geometry of the OE(group A). A quadripolar catheter was used in 71 PT to show OE course associated to ICE(group B).
Ablation energy delivery was performed outside the broadest OE anatomy borders. The duration of procedures was longer in group B vs group A Fluoroscopy time was lower in Group A than Group B(Group A 7 ± 3.2 vs 19.2 ± 2.4 min; p < 0.01).
OE monitoring with ICE is safe and feasible. Oesophageal anatomy is complex and variable. Many PT will have a broad oesophageal boundary, which increases the risk of untoward thermal injury during posterior LA ablation. ICE with 3D construction of the OE enhances border detection of the OE, and as such, should decrease the risk of oesophageal injury by improving avoidance strategies without intra-oesophageal catheter visualization.
Analysis for the primary predictive factor for the incidence of esophageal injury after ablation of atrial fibrillation
2018, Journal of Cardiology
Esophageal injury (EI) is a serious complication that occurs after catheter ablation of atrial fibrillation (AF), however predictable factor of EI is unclear.
Among 308 patients who underwent AF ablation, upper gastrointestinal tract endoscopy was performed the next day after ablation to examine for EI. To define the primary factor that predicts EI, patients’ characteristics, number and amount of radiofrequency energy applied to the posterior wall, ablation procedure, and the shortest distance between esophagus and posterior left atrium measured on contrast computed tomography (SD-CT) were analyzed.
EI was found in 27 patients (8.8%). There were no significant differences in the patient characteristics, number and amount of radiofrequency energy applied to posterior wall or ablation procedure between patients with (Injury Group) and without EI (Non-Injury Group). However, SD-CT in the Injury Group was significantly shorter than that in Non-Injury Group (2.3 ± 0.6 mm vs 4.1 ± 0.9 mm, p < 0.001). The area under a receiver operating characteristic curve using SD-CT as a predictive marker in EI patients was 0.988 (p < 0.001). When the cut-off value of SD-CT was set at 2.9 mm, the sensitivity and specificity for EI diagnosis were 92.3% and 96.8%, and the positive predictive value and negative predictive value were 0.75 and 0.99, respectively.
EI observed after catheter ablation of AF was closely associated with the SD-CT. Patients with SD-CT below 2.9 mm have a potential risk of EI and thus must be strictly followed.
EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: Definition, characterization, and clinical implication
2017, Heart Rhythm
EHRA/HRS/APHRS/SOLAECE expert consensus on Atrial cardiomyopathies: Definition, characterisation, and clinical implication
2016, Journal of Arrhythmia
Esophageal luminal temperature monitoring using a multi-sensor probe lowers the risk of esophageal injury in cryo and radiofrequency catheter ablation for atrial fibrillation
2023, Journal of Interventional Cardiac Electrophysiology

View all citing articles on Scopus

View full text

Original-clinicalElectroanatomic reconstruction of the left atrium, pulmonary veins, and esophagus compared with the “true anatomy” on multislice computed tomography in patients undergoing catheter ablation of atrial fibrillation

Background

Objectives

Methods

Results

Conclusion

Section snippets

Patient selection and characteristics

LA anatomy on Carto and CT

Main findings

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Heart Rhythm

Heart Rhythm

Heart Rhythm

Original-clinical
Electroanatomic reconstruction of the left atrium, pulmonary veins, and esophagus compared with the “true anatomy” on multislice computed tomography in patients undergoing catheter ablation of atrial fibrillation