Integration of Imaging:Impact on Outcome of AF Ablation

Ahmed Abdelaal, MD

CHU Nancy, France

CAIROSTIM NOV 2008

Micro-reentrant atrial circuitsSueda T, Ann Thorac Surg 1997;63:1070-5

Pulmonary vein fociHaïssaguerre M, N Engl J Med 1998;339:659-66

Marshall ligamentHwang C, Circulation 2000;101:1503-5

RotorMandapati R, Circulation 2000;101:194-

99

Cardiac innervationSchauerte P, Circulation 2000;102:2274-

80

Coronary sinusSuperior vena cava Right atrial foci ...

AF: from mechanisms to targets

By courtesy- Christian de Chillou

Left atrium- PV anatomy

LSPV - LAA junction

Common vestibule for both

LPV

4 PV> OR <4 PV77%

20%

23%

Left atrium- PV Imaging

Left atrium- PV Imaging

ICE: 2/6 RPV (33%)

-Venography overestimates PV ostial diamaters- TEE underestimates PV ostial diamaters-ICE is correlated to CT ostial diamaters

Image integration: from real to virtual anatomy

3-D Image integration: back to real anatomy

3-D Image integration: back to real anatomy

3-D Image integration: back to real anatomy

(1) Best landmark registration could be achieved at posterior LA-PV junctions

3-D Image integration: back to real anatomy

(2) Significant landmark shift after surface registration

- Positively correlated to surface registration error

- Surface registration errors were more evident for RPVs

3-D Image integration: back to real life

(1) The effect of respiration:

-Classic splaying effect of PV- Minimal at LA junction

-Maximum at distal PV and MA area

Ector et al, JCE 2008

3-D Image integration: back to real life

(2) The effect of cardiac rhythm:

Patel et al, JICE 2008

3-D Image integration: back to real life

(3) The effect of cardiac rhythm:

Patel et al, JICE 2008

3-D Image integration: back to real life

(2) The effect of cardiac cycle:

Sra el et al, JICE 2008

The need for 3-D image integration

The need for 3-D image integration

10+/-5mm

Superimposed+/-5mm

The need for 3-D image integration

The need for 3-D image integration

The final impact of 3-D image integration on outcome of AF

ablation

StudyStudy No of ptsNo of pts XRTXRT FOLLOW UPFOLLOW UP SUCCESSSUCCESS

Kistler et al Kistler et al 20062006

9494 49 vs 49 vs 6262

25 weeks25 weeks 78 vs 48 %78 vs 48 %

Kai etal 2008Kai etal 2008 8181 99 vs 99 vs 2929

6m6m 78 vs 74 %78 vs 74 %

Kistler etal Kistler etal 20082008

8080 22 22 vs41vs41

6m6m 56 vs 50 %56 vs 50 %

Conclusions

1. PV isolation is still the corner stone in the ablation of atrial fibrillation.

2. Different Cardiac imaging modalities are important for precise delineation of important LA anatomical structures crucial for safe and effective ablation.

3. The use of 3D image integration could be a useful tool taking into consideration its potential limitations during the mapping procedure.

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