Abstract
Atrial fibrillation is the most common arrhythmia worldwide. This disease is associated with structural, functional, and electrical remodeling of left atrium. The end results of these remodeling are diminishing of atrial myocytes and increasing fibrosis. Recently, novel late gadolinium enhancement (LGE) of the left atrium has been developed to identify fibrosis/disease within left atrial wall. Fibrosis within left atrial wall is associated with stroke, atrial fibrillation recurrence after catheter ablation, and cardiomyopathy. These significant imaging markers allow us to personalize and stratify management for patients with atrial fibrillation. In addition to improving treatment efficacy, cardiac LGE is also helping in the detection of post procedural complications, such as esophageal injury. As a result, LGE has become a crucial imaging tool to assess thromboembolic risks, treatment efficacy, and potential complications associated with AF ablation. In this chapter, we will address the imaging protocol, benefit of magnetic resonance imaging-guided atrial fibrillation therapy, and our personalized management of atrial fibrillation based on LGE findings.
Keywords
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ. Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 suppl):429S–56S.
January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC Jr, Cigarroa JE, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;pii: S0735–1097(14):01740–9.
Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Heart Rhythm Society, European Heart Rhythm Association, European Cardiac Arrhythmia Society, American College of Cardiology, American Heart Association, Society of Thoracic Surgeons, et al. HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. Europace. 2007;9:335–79.
Oakes RS, Badger TJ, Kholmovski EG, Akoum N, Burgon NS, Fish EN, et al. Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation. 2009;119:1758–67.
Kato R, Lickfett L, Meininger G, Dickfeld T, Wu R, Juang G, et al. Pulmonary vein anatomy in patients undergoing catheter ablation of atrial fibrillation: lessons learned by use of magnetic resonance imaging. Circulation. 2003;107(15):2004–10.
Hauser TH, Yeon SB, McClennen S, et al. A method for the determination of proximal pulmonary vein size using contrast-enhanced magnetic resonance angiography. J Cardiovasc Magn Reson. 2004;6:927–36.
Hauser TH, Essebag V, Baldessin F, et al. Larger pulmonary vein crosssectional area is associated with recurrent atrial fibrillation after pulmonary vein isolation. Circulation. 2005;112:II–555.
Pappone C, Rosanio S, Augello G, et al. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. J Am Coll Cardiol. 2003;42:185–97.
Zahuranec DB, Mueller GC, Bach DS, et al. Pilot study of cardiac magnetic resonance imaging for detection of embolic source after ischemic stroke. J. Stroke Cerebrovasc Dis. 2012;21:794–800.
Mohrs OK, Nowak B, Petersen SE, et al. Thrombus detection in the left atrial appendage using contrast-enhanced MRI: a pilot study. AJR Am J Roentgenol. 2006;186:198–205.
Ohyama H, Hosomi N, Takahashi T, et al. Comparison of magnetic resonance imaging and transesophageal echocardiography in detection of thrombus in the left atrial appendage. Stroke. 2003;34:2436–9.
Rathi VK, Reddy ST, Anreddy S, et al. Contrast-enhanced CMR is equally effective as TEE in the evaluation of left atrial appendage thrombus in patients with atrial fibrillation undergoing pulmonary vein isolation procedure. Heart Rhythm. 2013;10:1021–7.
Stevens SM, Tung R, Rashid S, Gima J, Cote S, Pavez G, et al. Device artifact reduction for magnetic resonance imaging of patients with implantable cardioverter-defibrillators and ventricular tachycardia: late gadolinium enhancement correlation with electroanatomic mapping. Heart Rhythm. 2014;11(2):289–98.
McGann C, Akoum N, Patel A, Kholmovski E, Revelo P, Damal K, et al. Atrial fibrillation ablation outcome is predicted by left atrial remodeling on MRI. Circ Arrhythmia Electrophysiol. 2014;7(1):23–30.
Expert Panel on MR Safety, Kanal E, Barkovich AJ, Bell C, Borgstede JP, Bradley WG Jr, Froelich JW, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 2013;37(3):501–30.
Spach MS, Boineau JP. Microfibrosis produces electrical load variations due to loss of side-to-side cell connections: a major mechanism of structural heart disease arrhythmias. Pacing Clin Electrophysiol. 1997;20:397–413.
Li D, Fareh S, Leung TK, Nattel S. Promotion of atrial fibrillation by heart failure in dogs: atrial remodeling of a different sort. Circulation. 1999;100:87–95.
Chen MC, Chang JP, Liu WH, Yang CH, Chen YL, Tsai TH, et al. Increased inflammatory cell infiltration in the atrial myocardium of patients with atrial fibrillation. Am J Cardiol. 2008;102:861–5.
Platonov PG, Mitrofanova LB, Orshanskaya V, Ho SY. Structural abnormalities in atrial walls are associated with presence and persistency of atrial fibrillation but not with age. J Am Coll Cardiol. 2011;58:2225–32.
Kainuma S, Masai T, Yoshitatsu M, Miyagawa S, Yamauchi T, Takeda K, et al. Advanced left-atrial fibrosis is associated with unsuccessful maze operation for valvular atrial fibrillation. Eur J Cardiothorac Surg. 2011;40:61–9.
Boldt A, Wetzel U, Lauschke J, Weigl J, Gummert J, Hindricks G, et al. Fibrosis in left atrial tissue of patients with atrial fibrillation with and without underlying mitral valve disease. Heart. 2004;90:400–5.
Akoum N, Daccarett M, McGann C, Segerson N, Vergara G, Kuppahally S, et al. Atrial fibrosis helps select the appropriate patient and strategy in catheter ablation of atrial fibrillation: a DE-MRI guided approach. J Cardiovasc Electrophysiol. 2011;22:16–22.
Marrouche NF, Wilber D, Hindricks G, Jais P, Akoum N, Marchlinski F, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA. 2014;31(5):498–506.
Dulli DA, Stanko H, Levine RL. Atrial fibrillation is associated with severe acute ischemic stroke. Neuroepidemiology. 2003;22(2):118–23.
Coppens M, Eikelboom JW, Hart RG, Yusuf S, Lip GY, Dorian P, et al. The CHA2DS2-VASc score identifies those patients with atrial fibrillation and a CHADS2 score of 1 who are unlikely to benefit from oral anticoagulant therapy. Eur Heart J. 2013;34(3):170–6.
Fang MC, Go AS, Chang Y, Borowsky L, Pomernacki NK, Singer DE. Comparison of risk stratification schemes to predict thromboembolism in people with nonvalvular atrial fibrillation. J Am Coll Cardiol. 2008;51(8):810–5.
Daccarett M, Badger TJ, Akoum N, et al. Association of left atrial fibrosis detected by delayed-enhancement magnetic resonance imaging and the risk of stroke in patients with atrial fibrillation. J Am Coll Cardiol. 2011;57:831–8.
Akoum N, Fernandez G, Wilson B, McGann C, Kholmovski E, Marrouche N. Association of atrial fibrosis quantified using LGE-MRI with atrial appendage thrombus and spontaneous contrast on transesophageal echocardiography in patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2013;24:1104–9.
January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC, Cigarroa JE, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;130(23):2071–104.
Wilber DJ, Pappone C, Neuzil P, De Paola A, Marchlinski F, Natale A, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA. 2010;303(4):333–40.
Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E, et al. Catheter ablation for paroxysmal atrial fibrillation. Circulation. 2003;108(19):2355–60.
Marsan NA, Tops LF, Holman ER, et al. Comparison of left atrial volumes and function by real-time three-dimensional echocardiography in patients having catheter ablation for atrial fibrillation with persistence of sinus rhythm versus recurrent atrial fibrillation three months later. Am J Cardiol. 2008;102:847–53.
Hof IE, Velthuis BK, Chaldoupi SM, et al. Pulmonary vein antrum isolation leads to a significant decrease of left atrial size. Europace. 2011;13(3):371–5.
Jeevanantham V, Ntim W, Navaneethan SD, et al. Meta-analysis of the effect of radio frequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation. Am J Cardiol. 2011;105:1317–26.
Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, et al. A new approach for catheter ablation of atrial fibrillation: Mapping of the electrophysiologic substrate. J Am Coll Cardiol. 2004;43:2044–53.
Sanders P, Berenfeld O, Hocini M, Jais P, Vaidyanathan R, Hsu L, et al. Spectral analysis identifies sites of high frequency activity maintaining atrial fibrillation in humans. Circulation. 2005;112:789–97.
O’Neill M, Jais P, Takahashi Y, Jonsson A, Sacher F, Hocini M, et al. The stepwise ablation approach for chornic atrial fibrillation-evidence for acumulative effect. J Interv Card Electrophysiol. 2006;16:153–67.
Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E, et al. Catheter ablation for paroxysmal atrial fibrillation: Segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation. 2003;108:2355–60.
Lu Z, Scherlag BJ, Lin J, Yu L, Guo J-H, Niu G, et al. Autonomic mechanism for initiation of rapid firing from atria and pulmonary veins: evidence by ablation of ganglionated plexi. Cardiovasc Res. 2009;84:245–52.
Segerson NM, Daccarett M, Badger TJ, Shabaan A, Akoum N, Fish EN, et al. Magnetic resonance imaging-confirmed ablative debulking of the left atrial posterior wall and septum for treatment of persistent atrial fibrillation: rationale and initial experience. J Cardiovasc Electrophysiol. 2010;21(2):126–32.
Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3:32–8.
Cappato R, Calkins H, Chen SA, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005;111:1100–5.
Saad EB, Marrouche NF, Saad CP, Ha E, Bash D, White RD, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome. Ann Intern Med. 2003;138:634–8.
Baranowski B, Saliba W. Our approach to management of patients with pulmonary vein stenosis following AF ablation. J Cardiovasc Electrophysiol. 2011;22(3):364–7.
Goo HW, Al-Otay A, Grosse-Wortmann L, et al. Phase-contrast magnetic resonance quantification of normal pulmonary venous return. J Magn Reson Imaging. 2009;29:588–94.
Nair GM, Nery PB, Redpath CJ, Lam BK, Birnie DH. Atrioesophageal fistula in the era of atrial fibrillation ablation: a review. Can J Cardiol. 2014;30(4):388–95.
Badger TJ, Adjei-Poku YA, Burgon NS, et al. Initial experience of assessing esophageal tissue injury and recovery using delayedenhancement MRI after atrial fibrillation ablation. Circ Arrhythm Electrophysiol. 2009;2:620–5.
Meng J, Peters DC, Hsing JM, Chuang ML, Chan J, Fish A, et al. Late gadolinium enhancement of the esophagus is common on cardiac MR several months after pulmonary vein isolation: preliminary observations. Pacing Clin Electrophysiol. 2010;33(6):661–6.
Vergara GR, Marrouche NF. Tailored management of atrial fibrillation using a LGE-MRI based model: from the clinic to the electrophysiology laboratory. J Cardiovasc Electrophysiol. 2011;22:481–7.
McGann CJ, Kholmovski EG, Oakes RS, Blauer JJ, Daccarett M, Segerson N, et al. New magnetic resonance imaging-based method for defining the extent of left atrial wall injury after the ablation of atrial fibrillation. J Am Coll Cardiol. 2008;52:1263–71.
Ranjan R, Kholmovski EG, Blauer J, Vijayakumar S, Volland NA, Salama ME, et al. Identification and acute targeting of gaps in atrial ablation lesion sets using a real-time magnetic resonance imaging system. Circ Arrhythm Electrophysiol. 2012;5(6):1130–5.
Sommer P, Grothoff M, Eitel C, Gaspar T, Piorkowski C, et al. Feasibility of real-time magnetic resonance imaging-guided electrophysiology studies in humans. Europace. 2013;15(1):101–8.
Grothoff M, Piorkowski C, Eitel C, Gaspar T, Lehmkuhl L, Lücke C, et al. MR imaging-guided electrophysiological ablation studies in humans with passive catheter tracking: initial results. Radiology. 2014;271(3):695–702.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Science+Business Media, LLC, part of Springer Nature
About this chapter
Cite this chapter
Navaravong, L., Marrouche, N. (2019). CMR Guidance of RFA to Atrial Arrhythmias. In: Kwong, R., Jerosch-Herold, M., Heydari, B. (eds) Cardiovascular Magnetic Resonance Imaging. Contemporary Cardiology. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-8841-9_22
Download citation
DOI: https://doi.org/10.1007/978-1-4939-8841-9_22
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4939-8839-6
Online ISBN: 978-1-4939-8841-9
eBook Packages: MedicineMedicine (R0)