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The Role of Multimodality Cardiac Imaging in the Management Of CVIA The Role of Multimodality Cardiac REVIEW ARTICLE pISSN 2508-707X / eISSN 2508-7088 Imaging in the Management https://doi.org/10.22468/cvia.2017.00038 CVIA 2017;1(3):177-192 of Patients with Atrial Fibrillation Jung Im Jung Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Received: March 6, 2017 Atrial fibrillation (AF) is the most common arrhythmia and is an independent risk factor for Revised: June 22, 2017 stroke, heart failure, and death. The prevalence of AF is expected to increase in the future Accepted: June 28, 2017 due to increasing life expectancy. In this review, we describe and evaluate the utility of ad- Corresponding author vanced cardiovascular imaging modalities, including echocardiography, cardiac computed Jung Im Jung, MD, PhD tomography, and cardiac magnetic resonance imaging, to provide novel insights into the Department of Radiology, pathogenesis, prediction, and natural history of AF. Moreover, cardiovascular imaging has Seoul St. Mary’s Hospital, become an integral part of the pre-procedural assessment, procedural management, and College of Medicine, follow-up of patients undergoing catheter-based ablation. We believe that knowledge and The Catholic University of Korea, proper use of these cardiovascular imaging modalities will enhance the successful treatment 222 Banpo-daero, Seocho-gu, and management of patients with AF. Seoul 06591, Korea Tel: 82-2-2258-1435 Key words Atrial fibrillation · Catheter ablation · Echocardiography · Fax: 82-2-599-6771 Multidetector computed tomography · Magnetic resonance Imaging. E-mail: [email protected] INTRODUCTION treat AF. Cardiovascular imaging has become an integral part of the pre-procedural assessment, procedural management, and Atrial fibrillation (AF) is the most common arrhythmia man- follow-up of patients undergoing catheter-based left atrium (LA) aged in clinical practice. Its incidence remains relatively low ablation [14,15]. until around the seventh decade of life, but thereafter, the inci- Herein, we review current evidence pertaining to the utility of dence increases exponentially. The overall prevalence of AF rang- advanced imaging modalities in AF. es between 1–2% in the general population. However, its prev- alence is expected to double in the next 50 years because of the PATHOGENESIS AND CLINICAL prolongation of life [1-3]. AF has been shown to be an indepen- OVERVIEW OF ATRIAL FIBRILLATION dent predictor of cardiovascular and all-cause mortalities that primarily occur as a result of two complications: stroke and heart AF is classified into paroxysmal (converting spontaneously to failure [4-10]. sinus rhythm within 7 days), persistent (>7 days), longstanding Aging, hypertension, body mass index, structural heart dis- persistent (>6 months), and permanent forms, in which no fur- ease, heart failure, and pulmonary disease are recognized clini- ther attempts are made to restore sinus rhythm [16]. AF is ini- cal risk factors for the development of AF [11]. Advances in tially paroxysmal and progresses to the persistent and perma- cardiovascular imaging, including echocardiography, cardiac nent types. Annually, 5–15% of paroxysmal AF cases are thought computed tomography (CT), and cardiac magnetic resonance to progress to persistent AF [17,18]. imaging (MRI), have provided novel insights into the pathogen- The pathogenesis of AF is not fully understood. The funda- esis, prediction, and natural history of AF [12,13]. Pulmonary mental arrhythmogenic mechanisms underlying AF are trigger vein (PV) cardiomyocyte sleeve is the most common trigger ini- initiation and maintenance [18-20]. Haïssaguerre et al. [21] found tiation point of AF, and its ablation is one effective method to that the PV cardiomyocyte sleeves play an important role in trig- cc This is an Open Access article distributed under the terms of the Creative Commons gering AF. AF-initiating triggers also exist within and outside the Attribution Non-Commercial License (http://creativecommons.org/licenses/by- PV, and substrates in the form of fiber angles and ganglionated nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduc- tion in any medium, provided the original work is properly cited. plexi enable the formation of localized sources as rotors. Two Copyright © 2017 Asian Society of Cardiovascular Imaging 177 CVIA Multimodality Cardiac Imaging in Patients with Atrial Fibrillation main theories have been suggested regarding maintenance of form of spiral wave reentry (rotors) or focal sources causes AF. The first is multiwavelet reentry, which states that nonhier- secondary disorganization either inside or outside the PVs. PV archical wavelets give rise to fibrillatory conduction. The second isolation with catheter-based ablation is applied to block the trig- is the localized source model, in which macroorganization in the ger as the AF initiator as well as the AF-maintaining driver, while A B Fig. 1. Atrial fibrillation likely results from trigger initiation and maintenance. (A) Triggers [red asterisk for pulmonary vein (PV) origin, and green stars for non-PV origin] are PV and non-PV in origin, with substrates in the form of fiber angles and ganglionated plexi enabling the forma- tion of localized sources in the form of rotors. (B) The proposed mechanism for the maintenance of atrial fibrillation. Multiple wavelet reentry, with nonhierarchical wavelets giving rise to fibrillatory conduction of the atrium as widely distributed substrates. Focal drivers either inside or outside of the PVs, and rotor sources, or spiral wave reentry giving rise to localized sources, stable gradients of activation, and fibrillatory conduction in the rest of the atrium. A D C B Fig. 2. Integration of an electroanatomic map and CT image. (A) Before left atrial (LA) ablation, CT images of the LA are obtained. (B) During the LA ablation procedure, the electroanatomic map is obtained using a mapping catheter. (C) Subsequently, the two images are merged with landmark registration and aligned. (D) After accurate registration of the two images, the catheter ablation procedure is performed under the guidance of the integrated images. 178 CVIA 2017;1(3):177-192 Jung Im Jung CVIA the MAZE operation is carried out to block multiwavelet reentry to the 2014 ACC/AHA/HRS guidelines [23]. (Fig. 1) [22]. The energy sources used for catheter-based ablation are radio- AF treatment first involves the evaluation of associated dis- frequency, cryoenergy, and microwaves. Radiofrequency is the eases; thereafter, anticoagulant therapy is started after the diag- most popular type, and cryoenergy is the most recently intro- nosis of AF. Consequently, rate and rhythm control are also eval- duced. The efficacy and safety of radiofrequency and cryoenergy uated. Catheter-based ablation is considered if medical rhythm are similar [24], with an equivalent one-year freedom from AF control fails. In case of refractory or medication-intolerant AF, but shorter fluoroscopy times [25] and greater reproducibility catheter-based ablation is recommended as class IA according with cryoballoon ablation [26]. A B C Fig. 3. Anatomic variants of the pulmonary veins. (A) The right middle pulmonary vein (supernumerary right pulmonary vein) directly drains into the left atrium (arrows). The endoscopic view clearly visualizes the three orifices of the right superior pulmonary vein (RS), the right middle pulmonary vein (RM), and the right inferior pulmonary vein (RI). (B) The common ostium of the left pulmonary vein. The left superior (LS) and inferior (LI) pulmonary veins join to form a common trunk that drains into the left atrium. The endoscopic view shows the common trunk. (C) Right top pulmonary vein (arrows). An anomalous pulmonary vein arising from the roof of the left atrium and draining a superior part of the right upper lobe. www.e-cvia.org 179 CVIA Multimodality Cardiac Imaging in Patients with Atrial Fibrillation IMAGING ASSISTANCE FOR ATRIAL regarding the anatomy of the PV and LA, as well as the presence FIBRILLATION of contraindications for LA ablation, such as a thrombus or ex- treme LA dilatation [13,15]. Advanced cardiovascular imaging modalities have become an integral part of the preprocedural assessment, procedural Anatomy of the pulmonary vein management, and follow-up of patients undergoing catheter- Before LA ablation, the anatomic variants, ostial diameter, and based ablation and cardiac device implantation. branching pattern of the PV are evaluated to prevent post-proce- dural complications, such as PV stenosis, and also to predict out- What assistance should we provide before left atrial comes [15,28-30]. This is because PV diameter increases accord- ablation? ing to the progression of AF, with the largest diameters being PVs are the most frequent foci of ectopic beats, and they initi- seen in persistent AF [28]. ate paroxysmal AF. Therefore, PV isolation, by removing the PVs normally contain four branches that drain into the LA; the connection between the PV and the LA, is known to terminate right superior PV, the right inferior PV, the left superior PV, and AF [21]. To aid with PV isolation, the integration of electroana- the left inferior PV. Anatomic variants of the PV are common and tomic mapping and anatomical imaging has been introduced. vary in frequency according to report. The most common vari- Among the several image integration systems, electroanatomic ant is a right middle PV (supernumerary right PV), which has mapping
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