Hybrid solid-state SPECT/CT left atrial innervation imaging for identification of left atrial ganglionated plexi: Technique and validation in patients with atrial fibrillation
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Ablating left atrial (LA) ganglionated plexi (GP), identified invasively by high-frequency stimulation (HFS) during pulmonary vein isolation (PVI), may reduce atrial fibrillation (AF) recurrence. 123I-metaiodobenzylguanidine (123I-mIBG) solid-state SPECT LA innervation imaging (LAII) has the spatial resolution to detect LAGP non-invasively but this has never been demonstrated in clinical practice.
20 prospective patients with paroxysmal AF scheduled for PVI underwent 123I-mIBG LAII. High-resolution tomograms, reconstructed where possible using cardiorespiratory gating, were co-registered with pre-PVI cardiac CT. Location and reader confidence (1 [low] to 3 [high]) in discrete 123I-mIBG LA uptake areas (DUAs) were recorded and correlated with HFS.
A total of 73 DUAs were identified, of which 59 (81%) were HFS positive (HFS +). HFS + likelihood increased with reader confidence (92% [score 3]). 64% of HFS-negative DUAs occurred over the lateral and inferior LA. Cardiorespiratory gating reduced the number of DUAs per patient (4 vs 7, P = .001) but improved: HFS + predictive value (76% vs 49%); reader confidence (2 vs 1, P = .02); and inter-observer, intra-observer, and inter-study agreement (κ = 0.84 vs 0.68; 0.82 vs 0.74; 0.64 vs 0.53 respectively).
123I-mIBG SPECT/CT LAII accurately and reproducibly identifies GPs verified by HFS, particularly when reconstructed with cardiorespiratory gating.
KeywordsNuclear medicine imaging nervous system, autonomic atrial fibrillation ganglionated plexi mapping catheter ablation mIBG, SPECT/CT, CZT
Discrete uptake area
Single-photon emission computed tomography
Left atrial innervation imaging
Pulmonary vein isolation
The authors wish to thank U. Voss, Department of Nuclear Medicine, Royal Brompton and Harefield NHS Foundation Trust, United Kingdom for contributing to data collection; and Samy Bross, Spectrum Dynamics Medical, Caesarea, Isarel, for contribution to the development of the phantom model.
JS, SE, DA, and SRU receive consultancy fees from Spectrum Dynamics Medical. JS receives speaker honoraria from Canon Medical Systems Europe (previously Toshiba Medical Systems Europe). UV was employed by a restricted research grant while NR, RB, and CB are employees of Spectrum Dynamics Medical.
All procedures performed were in accordance with the ethical standards of the local Research Ethics Committee (London—Camberwell St Giles REC, reference 14/LO/2207) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards (Clinicatrials.gov Identifier NCT02267889).
Informed consent was obtained from all individual participants included in the study.
- 4.Fink T, Schlüter M, Heeger C-H, Lemes C, Maurer T, Reissmann B, et al. Stand-alone pulmonary vein isolation versus pulmonary vein isolation with additional substrate modification as index ablation procedures in patients with persistent and long-standing persistent atrial fibrillation: The randomized alster-lost-af trial (ablation at St. Georg Hospital for long-standing persistent atrial fibrillation). Circ Arrhythm Electrophysiol 2017;10:e005114.CrossRefGoogle Scholar
- 15.Jacobson AF, Senior R, Cerqueira MD, Wong ND, Thomas GS, Lopez VA, et al. Myocardial iodine-123 meta-iodobenzylguanidine imaging and cardiac events in heart failure: Results of the prospective ADMIRE-HF (AdreView myocardial imaging for risk evaluation in heart failure) study. J Am Coll Cardiol 2010;55:2212-21.CrossRefGoogle Scholar
- 19.Flotats A, Carrió I, Agostini D, Le Guludec D, Marcassa C, Schäfers M, et al. Proposal for standardization of 123I-metaiodobenzylguanidine (MIBG) cardiac sympathetic imaging by the EANM Cardiovascular Committee and the European Council of Nuclear Cardiology. Eur J Nucl Med Mol Imaging 2010;37:1802-12.CrossRefGoogle Scholar
- 20.Bellevre D, Manrique A, Legallois D, Bross S, Baavour R, Roth N, et al. First determination of the heart-to-mediastinum ratio using cardiac dual isotope (123I-MIBG/99mTc-tetrofosmin) CZT imaging in patients with heart failure: The ADRECARD study. Eur J Nucl Med Mol Imaging 2015;42:1912-9.CrossRefGoogle Scholar
- 24.Administration of Radioactive Substances Advisory Committee. Notes for guidance on the clinical administration of radiopharmaceuticals and use of sealed radioactive sources. Chilton: NRPB; 2017. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/590649/ARSAC_NfG_2017.pdf. Accessed 28 Dec 2017.
- 27.Joint Committee for Guides in Metrology. Evaluation of measurement data—Guide to the expression of uncertainty in measurement (GUM). JCGM 2008. https://www.bipm.org/en/publications/guides/gum. Accessed 29 Aug 2018.
- 33.Verschure DO, Veltman CE, Manrique A, Somsen GA, Koutelou M, Katsikis A, et al. For what endpoint does myocardial 123I-MIBG scintigraphy have the greatest prognostic value in patients with chronic heart failure? Results of a pooled individual patient data meta-analysis. Eur Heart J Cardiovasc Imaging 2014;15:996-1003.CrossRefGoogle Scholar
- 37.Boogers MJ, Borleffs CJW, Henneman MM, van Bommel RJ, van Ramshorst J, Boersma E, et al. Cardiac sympathetic denervation assessed with 123-iodine metaiodobenzylguanidine imaging predicts ventricular arrhythmias in implantable cardioverter-defibrillator patients. J Am Coll Cardiol 2010;55:2769-77.CrossRefGoogle Scholar
- 43.Biermann J, Bode C, Asbach S. Intracardiac echocardiography during catheter-based ablation of atrial fibrillation. Cardiol Res Pract 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368317/. Accessed 29 Aug 2018.