Portal de Periódicos da CAPES

Cardiac Magnetic Resonance for Lesion Assessment in the Electrophysiology Laboratory

2017; Lippincott Williams & Wilkins; Volume: 10; Issue: 11 Linguagem: Inglês

10.1161/circep.117.005839

1941-3149

Timothy M. Markman, Saman Nazarian,

Cardiac Imaging and Diagnostics

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 10, No. 11Cardiac Magnetic Resonance for Lesion Assessment in the Electrophysiology Laboratory Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCardiac Magnetic Resonance for Lesion Assessment in the Electrophysiology Laboratory Timothy M. Markman, MD and Saman Nazarian, MD, PhD Timothy M. MarkmanTimothy M. Markman From the Division of Cardiology (T.M.M., S.N.) and Section for Cardiac Electrophysiology (S.N.), Hospital of the University of Pennsylvania, Philadelphia. and Saman NazarianSaman Nazarian From the Division of Cardiology (T.M.M., S.N.) and Section for Cardiac Electrophysiology (S.N.), Hospital of the University of Pennsylvania, Philadelphia. Originally published27 Oct 2017https://doi.org/10.1161/CIRCEP.117.005839Circulation: Arrhythmia and Electrophysiology. 2017;10:e005839See Article by Ghafoori et alCardiac magnetic resonance imaging (CMR) is of growing importance in cardiac electrophysiology. This imaging modality is clinically used for the diagnosis of arrhythmogenic substrates, prognosis of sudden cardiac death, preprocedural planning, and procedural image integration.1–3 Because of the increasing use of CMR in the electrophysiology environment, interest in the use of real-time CMR for electrophysiology procedural guidance has amplified in recent years. This is an attractive option for many reasons. Currently, there is considerable radiation exposure to both patients and providers during electrophysiology procedures, and CMR offers a welcome radiation-free alternative to fluoroscopy.4 The other fundamental advantage of CMR over other imaging techniques is enhanced visualization of soft tissue structures with excellent spatial and temporal resolution. The enhanced soft tissue resolution with CMR promises not only to enhance the identification of arrhythmogenic substrates during the procedure but also to augment lesion assessment to distinguish acute edema in the setting of an ablation from the chronic lesion that ultimately results.5 This distinction may be critical because a significant proportion of long-term arrhythmia recurrences after acutely successful pulmonary vein isolation or other substrate or trigger ablations are likely attributable to resolution of acute edema that does not persist as a chronic lesion.6,7 These advantages present the exciting possibility of real-time CMR-guided ablation procedures, in which imaging assists both the identification of ablation targets and the evaluation of a successful ablation. Nevertheless, several limitations persist in the development of a real-time CMR-guided ablation system. Ongoing academic and industry endeavors are beginning to overcome the significant electromagnetic interference and safety issues.8 However, the use of CMR for real-time characterization of ablation lesions has also been challenged by the delayed nature of lesion formation.9 Multiple CMR imaging techniques are possible, including T2-weighted sequences to evaluate edema, as well as T1-weighted sequences to evaluate scar formation using the native T1 characteristics or late gadolinium enhancement (LGE).3 Each of these methodologies offers advantages and disadvantages. Therefore, studies that characterize the diagnostic accuracy of each sequence in different tissues, and depending on the modality of ablation, and timing of image acquisition after ablation are timely.In this issue of Circulation: Arrhythmia and Electrophysiology, Ghafoori et al10 report findings from 10 canines that underwent serial ventricular radiofrequency ablation followed by CMR at a magnetic strength of 3 Tesla with LGE and T2-weighted sequences and repeat imaging at 1, 2, 4, and 8 weeks after ablation. Histology was performed to definitively characterize the chronic lesions. By reacquiring LGE sequences at different time points, they demonstrate the dependence of lesion imaging characteristics on time after ablation and time from contrast injection to image acquisition. Areas of microvascular obstruction (dark region in the middle of the area of enhancement) and edema (bright region around area of enhancement with lower degree of enhancement) were manually identified on LGE images based on prior work by this group and others.11,12 Based on generalized estimating equations modeling of microvascular obstruction volume to chronic lesions size versus time to image acquisition, the authors found that LGE image acquisition at 26 minutes after contrast injection optimally predicted the chronic lesion size. In addition, the authors showed a close association between the extent of edema estimated by LGE and T2-weighted images. Although it is important to recognize that potentially different contrast kinetics in canines compared with humans limits the applicability of specific timing intervals in humans, these results demonstrate that periprocedural LGE on CMR can reliably estimate the size of chronic ventricular lesions. However, the timing of image acquisition after contrast administration seems to be of critical importance in this process.Successful catheter ablation requires accurate localization of the arrhythmogenic substrate or trigger, permanent ablation of critical portions of the substrate, trigger, or isolation thereof, and ultimately determination of whether the intervention effect will be durable.13 CMR has the potential to aide the electrophysiologist in each of these requirements. Before ablation procedures, CMR has been shown to predict and localize arrhythmogenic substrate, identifying patients at risk for arrhythmia and aiding in preprocedural planning.2,14–16 Ablation to destroy or isolate the abnormal substrate or trigger is generally achieved through radiofrequency ablation, which is critically dependent on catheter position in contact with the target myocardium and stability during ablation.17 CMR has been shown to accurately localize catheter position, and real-time CMR-guided procedures could facilitate assurance of effective, stable catheter position during ablation and adequate contact with the intended target.8,18,19 The current standard for determining the success of ablation is functional assays to identify persistent or dormant conduction to the isolated tissue.13 Although these techniques are used for a variety of ablation procedures, including both supraventricular and ventricular tachycardia, recurrence of arrhythmias after ablations is not uncommon and is often secondary to re-establishment of conduction through acutely stunned tissue.6,7 Current techniques to establish the durability of ablation are imperfect for identification of edema that commonly occurs with radiofrequency ablation but resolves. By distinguishing temporary edema from chronic, electrically nonconducting lesions, CMR has the potential to redefine ablation success in real-time.The results presented here by Ghafoori et al10 are encouraging as we formulate a standard workflow for real-time CMR-guided electrophysiology interventions. As CMR-guided electrophysiology interventions become a reality and evolve, future studies are needed to calibrate the recent findings from animal studies in humans, including the results discussed here. We are just beginning to realize the full potential of CMR because many of the technical hurdles of its use in an electrophysiology laboratory are gradually overcome by the development of specialized hardware and monitoring equipment, as well as improved imaging systems and techniques.19–21 The prospective impact of CMR-guided electrophysiology procedures is substantial and justifies continued research and technical innovation.DisclosuresDr Nazarian has a research grant and receives honoraria from Biosense Webster. He also is a consultant for Biosense Wevster, Siemens, and CardioSolv. The other author reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org.Correspondence to: Saman Nazarian, MD, PhD, Hospital of the University of Pennsylvania 3400 Spruce St, Founders 9118, Philadelphia, PA 19104. E-mail [email protected]References1. Dickfeld T, Kato R, Zviman M, Nazarian S, Dong J, Ashikaga H, Lardo AC, Berger RD, Calkins H, Halperin H. Characterization of acute and subacute radiofrequency ablation lesions with nonenhanced magnetic resonance imaging.Heart Rhythm. 2007; 4:208–214. doi: 10.1016/j.hrthm.2006.10.019.CrossrefMedlineGoogle Scholar2. Halliday BP, Gulati A, Ali A, Guha K, Newsome S, Arzanauskaite M, Vassiliou VS, Lota A, Izgi C, Tayal U, Khalique Z, Stirrat C, Auger D, Pareek N, Ismail TF, Rosen SD, Vazir A, Alpendurada F, Gregson J, Frenneaux MP, Cowie MR, Cleland JGF, Cook SA, Pennell DJ, Prasad SK. Association between midwall late gadolinium enhancement and sudden cardiac death in patients with dilated cardiomyopathy and mild and moderate left ventricular systolic dysfunction.Circulation. 2017; 135:2106–2115. doi 10.1161/CIRCULATIONAHA.116.026910.LinkGoogle Scholar3. Saeed M, Liu H, Liang CH, Wilson MW. Magnetic resonance imaging for characterizing myocardial diseases.Int J Cardiovasc Imaging. 2017; 33:1395–1414. doi: 10.1007/s10554-017-1127-x.CrossrefMedlineGoogle Scholar4. Nair GM, Nery PB, Redpath CJ, Sadek MM, Birnie DH. Radiation safety and ergonomics in the electrophysiology laboratory: update on recent advances.Curr Opin Cardiol. 2016; 31:11–22. doi: 10.1097/HCO.0000000000000246.CrossrefMedlineGoogle Scholar5. Kim RJ, Fieno DS, Parrish TB, Harris K, Chen EL, Simonetti O, Bundy J, Finn JP, Klocke FJ, Judd RM. Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function.Circulation. 1999; 100:1992–2002.LinkGoogle Scholar6. Ranjan R, Kato R, Zviman MM, Dickfeld TM, Roguin A, Berger RD, Tomaselli GF, Halperin HR. Gaps in the ablation line as a potential cause of recovery from electrical isolation and their visualization using MRI.Circ Arrhythm Electrophysiol. 2011; 4:279–286. doi: 10.1161/CIRCEP.110.960567.LinkGoogle Scholar7. Cheema A, Dong J, Dalal D, Marine JE, Henrikson CA, Spragg D, Cheng A, Nazarian S, Bilchick K, Sinha S, Scherr D, Almasry I, Halperin H, Berger R, Calkins H. Incidence and time course of early recovery of pulmonary vein conduction after catheter ablation of atrial fibrillation.J Cardiovasc Electrophysiol. 2007; 18:387–391. doi: 10.1111/j.1540-8167.2007.00760.x.CrossrefMedlineGoogle Scholar8. Nazarian S, Kolandaivelu A, Zviman MM, Meininger GR, Kato R, Susil RC, Roguin A, Dickfeld TL, Ashikaga H, Calkins H, Berger RD, Bluemke DA, Lardo AC, Halperin HR. Feasibility of real-time magnetic resonance imaging for catheter guidance in electrophysiology studies.Circulation. 2008; 118:223–229. doi: 10.1161/CIRCULATIONAHA.107.742452.LinkGoogle Scholar9. Lardo AC, McVeigh ER, Jumrussirikul P, Berger RD, Calkins H, Lima J, Halperin HR. Visualization and temporal/spatial characterization of cardiac radiofrequency ablation lesions using magnetic resonance imaging.Circulation. 2000; 102:698–705.LinkGoogle Scholar10. Ghafoori E, Kholmovski EG, Thomas S, Silvernagel J, Angel N, Hu N, Dosdall DJ, MacLeod R, Ranjan R. Characterization of gadolinium contrast-enhancement of radiofrequency ablation lesions in predicting edema and chronic lesion size.Circ Arrhythm Electrophysiol. 2017; 10:e005599. doi: 10.1161/CIRCEP.117.005599.LinkGoogle Scholar11. McGann C, Kholmovski E, Blauer J, Vijayakumar S, Haslam T, Cates J, DiBella E, Burgon N, Wilson B, Alexander A, Prastawa M, Daccarett M, Vergara G, Akoum N, Parker D, MacLeod R, Marrouche N. Dark regions of no-reflow on late gadolinium enhancement magnetic resonance imaging result in scar formation after atrial fibrillation ablation.J Am Coll Cardiol. 2011; 58:177–185. doi: 10.1016/j.jacc.2011.04.008.CrossrefMedlineGoogle Scholar12. Judd RM, Lugo-Olivieri CH, Arai M, Kondo T, Croisille P, Lima JA, Mohan V, Becker LC, Zerhouni EA. Physiological basis of myocardial contrast enhancement in fast magnetic resonance images of 2-day-old reperfused canine infarcts.Circulation. 1995; 92:1902–1910.LinkGoogle Scholar13. Josephson MEClinical Cardiac Electrophysiology. 5thed. Philadelphia, PA: Lippincott Williams and Wilkins; 2016.Google Scholar14. Markman TM, Nazarian S. Risk stratification for sudden cardiac death: is it too late to establish a role for cardiac MRI?Circulation. 2017; 135:2116–2118. doi: 10.1161/CIRCULATIONAHA.117.027958.LinkGoogle Scholar15. Nazarian S, Bluemke DA, Lardo AC, Zviman MM, Watkins SP, Dickfeld TL, Meininger GR, Roguin A, Calkins H, Tomaselli GF, Weiss RG, Berger RD, Lima JA, Halperin HR. Magnetic resonance assessment of the substrate for inducible ventricular tachycardia in nonischemic cardiomyopathy.Circulation. 2005; 112:2821–2825. doi: 10.1161/CIRCULATIONAHA.105.549659.LinkGoogle Scholar16. Sasaki T, Miller CF, Hansford R, Zipunnikov V, Zviman MM, Marine JE, Spragg D, Cheng A, Tandri H, Sinha S, Kolandaivelu A, Zimmerman SL, Bluemke DA, Tomaselli GF, Berger RD, Halperin HR, Calkins H, Nazarian S. Impact of nonischemic scar features on local ventricular electrograms and scar-related ventricular tachycardia circuits in patients with nonischemic cardiomyopathy.Circ Arrhythm Electrophysiol. 2013; 6:1139–1147. doi: 10.1161/CIRCEP.113.000159.LinkGoogle Scholar17. Reddy VY, Shah D, Kautzner J, Schmidt B, Saoudi N, Herrera C, Jaïs P, Hindricks G, Peichl P, Yulzari A, Lambert H, Neuzil P, Natale A, Kuck KH. The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study.Heart Rhythm. 2012; 9:1789–1795. doi: 10.1016/j.hrthm.2012.07.016.CrossrefMedlineGoogle Scholar18. Wang W. Magnetic resonance-guided active catheter tracking.Magn Reson Imaging Clin N Am. 2015; 23:579–589. doi: 10.1016/j.mric.2015.05.009.CrossrefMedlineGoogle Scholar19. Dumoulin CL, Souza SP, Darrow RD. Real-time position monitoring of invasive devices using magnetic resonance.Magn Reson Med. 1993; 29:411–415.CrossrefMedlineGoogle Scholar20. Chubb H, Williams SE, Whitaker J, Harrison JL, Razavi R, O'Neill M. Cardiac electrophysiology under MRI guidance: an emerging technology.Arrhythm Electrophysiol Rev. 2017; 6:85–93. doi: 10.15420/aer.2017.1.2.CrossrefMedlineGoogle Scholar21. Hilbert S, Sommer P, Gutberlet M, Gaspar T, Foldyna B, Piorkowski C, Weiss S, Lloyd T, Schnackenburg B, Krueger S, Fleiter C, Paetsch I, Jahnke C, Hindricks G, Grothoff M. Real-time magnetic resonance-guided ablation of typical right atrial flutter using a combination of active catheter tracking and passive catheter visualization in man: initial results from a consecutive patient series.Europace. 2016; 18:572–577. doi: 10.1093/europace/euv249.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Guttman M, Tao S, Fink S, Tunin R, Schmidt E, Herzka D, Halperin H and Kolandaivelu A (2019) Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T 1 ‐weighted MRI , Magnetic Resonance in Medicine, 10.1002/mrm.28001, 83:4, (1368-1379), Online publication date: 1-Apr-2020. Candemir B, Ozyurek E, Vurgun K, Turan N, Duzen V, Goksuluk H, Ozyuncu N, Kurklu S, Altin T, Akyurek O and Erol C (2018) Effect of radiofrequency on epicardial myocardium after ablation of ventricular arrhythmias from within coronary sinus, Pacing and Clinical Electrophysiology, 10.1111/pace.13429, 41:9, (1060-1068), Online publication date: 1-Sep-2018. Floria M, Radu S, Gosav E, Cozma D, Mitu O, Ouatu A, Tanase D, Scripcariu V and Serban L (2020) Left Atrial Structural Remodelling in Non-Valvular Atrial Fibrillation: What Have We Learnt from CMR?, Diagnostics, 10.3390/diagnostics10030137, 10:3, (137) November 2017Vol 10, Issue 11 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.117.005839PMID: 29079665 Manuscript receivedSeptember 28, 2017Manuscript acceptedSeptember 29, 2017Originally publishedOctober 27, 2017 Keywordsdeath, sudden, cardiaccardiac imaging techniquescardiac electrophysiologyedemaEditorialsPDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiologyMagnetic Resonance Imaging (MRI)