Changes in Left Atrial and Pulmonary Venous Anatomy During Respiration
2007; Lippincott Williams & Wilkins; Volume: 115; Issue: 23 Linguagem: Inglês
10.1161/circulationaha.107.688457
ISSN1524-4539
AutoresJoris Ector, Dirk Loeckx, Walter Coudijzer, Stijn De Buck, Frederik Maes, Steven Dymarkowski, Jan Bogaert, H. Heidbuchel,
Tópico(s)Atrial Fibrillation Management and Outcomes
ResumoHomeCirculationVol. 115, No. 23Changes in Left Atrial and Pulmonary Venous Anatomy During Respiration Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBChanges in Left Atrial and Pulmonary Venous Anatomy During RespirationA 4-Dimensional Computed Tomography–Based Assessment and Implications for Atrial Fibrillation Ablation Joris Ector, MD, Dirk Loeckx, MSc, Walter Coudijzer, MS, Stijn De Buck, MSc, Frederik Maes, MSc, PhD, Steven Dymarkowski, MD, PhD, Jan Bogaert, MD, PhD and Hein Heidbüchel, MD, PhD Joris EctorJoris Ector From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. , Dirk LoeckxDirk Loeckx From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. , Walter CoudijzerWalter Coudijzer From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. , Stijn De BuckStijn De Buck From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. , Frederik MaesFrederik Maes From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. , Steven DymarkowskiSteven Dymarkowski From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. , Jan BogaertJan Bogaert From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. and Hein HeidbüchelHein Heidbüchel From the Departments of Cardiology (J.E., H.H.), Radiology (W.C., S.D., J.B.), and Electrical Engineering (D.L., S.D.B., F.M.), University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. Originally published12 Jun 2007https://doi.org/10.1161/CIRCULATIONAHA.107.688457Circulation. 2007;115:e617–e619The possibility of integrating 3D models of the left atrium (LA) and pulmonary veins (PVs) in 3D mapping systems has recently provided a detailed anatomic reference for electrophysiologists performing atrial fibrillation (AF) ablations. Single-breathhold contrast-enhanced computed tomography (CT) or MRI images are reconstructed to a static 3D surface and registered to the LA geometry acquired by a roving catheter during the procedure. Respiratory changes in LA and PV anatomy, however, can reduce registration accuracy, especially when preprocedural CT images are acquired during inspiration.1A 46-year-old man was referred for catheter ablation of drug-resistant paroxysmal AF. One day before the procedure, 64-slice cardiac CT was performed during both held inspiration and end-expiration. Images were not gated to the cardiac cycle to reduce patient radiation exposure. Nonrigid image registration2 between inspiratory and expiratory data sets with custom software resulted in a dynamic 3D (ie, 4D) sequence of the combined changes in LA, PV, and pulmonary anatomy during the respiratory cycle. Automatic intensity-based segmentation and surface reconstruction was performed with commercial software (Amira 4.0, TGS Template Graphics Software, Inc, Chelmsford, Mass).Figure 1 shows the 3D anatomy of the LA and surrounding pulmonary anatomy (upper pane) and the changes in left atrial geometry during respiration (middle and lower panes). The remarkable absolute and relative anatomic changes during respiration are illustrated as a 4D sequence in the supplemental movie file. During inspiration, the inferior PVs show a larger downward movement than the superior PVs, which results in splaying of the ipsilateral PVs. Download figureDownload PowerPointFigure 1. Top, CT-based 3D reconstruction of the LA, PVs (pink, solid surface), and surrounding pulmonary anatomy (yellow, semitransparent surface) acquired during held inspiration. Middle and Bottom, Changes in LA geometry during respiration. "X-ray images" on the left are calculated from the inspiratory and expiratory CT data and show the actual position of the LA relative to the cardiac silhouette. Cardiac CT was not gated to the cardiac cycle to reduce patient radiation exposure. c indicates carina; d, diaphragmatic pleural surface; RSPV, right superior PV; RIPV, right inferior PV; LSPV, left superior PV; and LIPV, left inferior PV.One day later, lasso-guided electrical isolation of the 4 PVs was performed under general anesthesia with propofol and mechanical ventilation. Merging of the LA 3D surfaces with biplane fluoroscopic imaging was performed as outlined previously3 to assist catheter navigation and ablation. In brief, LA 3D models are shown as an overlay on the fluoroscopic images after registration with a combined angiographic image of the 4 PVs acquired during apnea (ie, expiration; Figure 2). Although the 3D surface acquired during expiration resulted in a near-perfect registration with the angiographic images, the inspiratory 3D surface could not be registered correctly owing to the relative changes in PV and LA geometry, especially in the region of the inferior PVs (yellow dotted circles). Download figureDownload PowerPointFigure 2. Merging of CT-based 3D models of the LA and PVs with biplane fluoroscopic images during AF ablation procedure. Left, Selective angiography of the 4 PVs is performed during apnea (expiration). End-diastolic angiographic images of the 4 PVs are then combined into a single digital subtraction angiographic image that shows the anatomy of the 4 PVs and LA in right anterior oblique (RAO) and left anterior oblique (LAO) views. Middle and Right, Combined angiographic image is used to register the 3D surfaces during the procedure. Although the 3D surface acquired during expiration results in a near-perfect registration with the angiographic images (middle), the inspiratory 3D surface could not be registered correctly because of relative changes in PV and LA geometry, especially in the region of the inferior PVs (yellow dotted circles, right). RSPV indicates right superior PV; RIPV, right inferior PV; LSPV, left superior PV; and LIPV, left inferior PV.The observed respiratory changes in LA-PV anatomy are concordant with observations made by other authors1 and include splaying of the PVs during inspiration, with larger variability in the position of inferior PVs during respiration. The present 4D analysis for the first time directly relates these changes to the respiratory movements of surrounding pulmonary and diaphragmatic structures.The online-only Data Supplement, consisting of a movie, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/23/e617/DC1.Sources of FundingDr Ector is a research assistant of the Fund for Scientific Research, Flanders. Stijn De Buck acknowledges the support of the IWT OZM 080511 research project.DisclosuresDr Heidbüchel is a member of the scientific advisory board of Biosense Webster, Inc, and is holder of the AstraZeneca Chair in Cardiac Electrophysiology, University of Leuven. The remaining authors have nothing to disclose.FootnotesCorrespondence to Joris Ector, MD, Cardiology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. E-mail [email protected]References1 Noseworthy PA, Malchano ZJ, Ahmed J, Holmvang G, Ruskin JN, Reddy VY. The impact of respiration on left atrial and pulmonary venous anatomy: implications for image-guided intervention. Heart Rhythm. 2005; 2: 1173–1178.CrossrefMedlineGoogle Scholar2 Loeckx D, Maes F, Vandermeulen D, Suetens P. Nonrigid image registration using free-form deformations with a local rigidity constraint. In: Barillot C, Haynor DR, Hellier P, eds. Lecture Notes in Computer Science: Medical Image Computing and Computer-Assisted Intervention: MICCAI 2004. 7th International Conference, Saint-Malo, France, September 26–29, 2004. Proceedings, Part I. Berlin, Germany: Springer; 2004; 3216: 639–646.Google Scholar3 Ector J, De Buck S, Adams J, Dymarkowski S, Bogaert J, Maes F, Heidbuchel H. Cardiac three-dimensional magnetic resonance imaging and fluoroscopy merging: a new approach for electroanatomic mapping to assist catheter ablation. Circulation. 2005; 112: 3769–3776.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Beinart R, Kabra R, Heist K, Blendea D, Barrett C, Danik S, Collins R, Ruskin J and Mansour M (2011) Respiratory compensation improves the accuracy of electroanatomic mapping of the left atrium and pulmonary veins during atrial fibrillation ablation, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-011-9583-z, 32:2, (105-110), Online publication date: 1-Nov-2011. Manzke R, Meyer C, Ecabert O, Peters J, Noordhoek N, Thiagalingam A, Reddy V, Chan R and Weese J Automatic Segmentation of Rotational X-Ray Images for Anatomic Intra-Procedural Surface Generation in Atrial Fibrillation Ablation Procedures, IEEE Transactions on Medical Imaging, 10.1109/TMI.2009.2021946, 29:2, (260-272) June 12, 2007Vol 115, Issue 23 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.688457PMID: 17562962 Originally publishedJune 12, 2007 PDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorComputerized Tomography (CT)Electrophysiology
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