Clinical workflow and applicability of electrophysiological cardiovascular magnetic resonance-guided radiofrequency ablation of isthmus-dependent atrial flutter

Paetsch, Ingo; Sommer, Philipp; Jahnke, Cosima; Hilbert, Sebastian; Loebe, Susanne; Schoene, Katharina; Oebel, Sabrina; Krueger, Sascha; Weiß, Steffen; Smink, Jouke; Lloyd, Thomas; Hindricks, Gerhard

doi:10.1093/ehjci/jey143

Cited by 40 publications

(61 citation statements)

References 12 publications

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“…In the conventional EP setting, the proposed non-CE imaging technique for acute identification of necrotic RF ablation lesions may be useful to assess the completeness of treatment before discharging the patient. In future settings where ablation treatment could be carried out in the MR scanner, [58][59][60] non-CE imaging assessment of lesions may be carried out multiple times, to direct additional treatment to areas of incomplete ablation and potentially reduce arrhythmia recurrence.…”

Section: Discussionmentioning

confidence: 99%

Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T₁‐weighted MRI

Tao

Fink

Tunin

et al. 2019

Magnetic Resonance in Med

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To evaluate non-contrast-enhanced MRI of acute radio-frequency ablation (RFA) lesions in the left atrium (LA) and pulmonary vein (PV) ostia. The goal is to provide a method for discrimination between necrotic (permanent) lesions and reversible injury, which is associated with recurrence after treatment of atrial fibrillation. Methods: Fifteen normal swine underwent RFA around the right-superior PV ostia. Electrical pulmonary vein isolation (PVI) was verified by electro-anatomic mapping (EAM) and pacing. MRI was carried out using a 3D respiratory-gated T 1-weighted long inversion time (TWILITE) sequence without contrast agent. Key settings were: inversion time 700 ms, triggering over 2 cardiac cycles, pixel size 1.1 mm 3. Contrastenhanced imaging and T 2-weighted imaging were carried out for comparison. Six animals were sacrificed on ablation day for TTC-stained gross pathology, 9 animals were sacrificed after 2-3 mo after repeat EAM and MRI. Image intensity ratio (IIR) was used to measure lesion enhancement, and gross pathology was used to validate image enhancement patterns and compare lesion widths. Results: RFA lesions exhibited unambiguous enhancement in acute TWILITE imaging (IIR = 2.34 ± 0.49 at 1.5T), and the enhancement patterns corresponded well with gross pathology. Lesion widths in MRI correlated well with gross pathology (R 2 = 0.84), with slight underestimation by 0.9 ± 0.5 mm. Lesion enhancement subsided chronically. Conclusion: TWILITE imaging allowed acute detection of permanent RFA lesions in swine LA and PV ostia, without the need for contrast agent. Lesion enhancement pattern showed good correspondence to gross pathology and was well visualized by volume rendering. This method may provide valuable intra-or post-procedural assessment of RFA treatment.

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Section: Discussionmentioning

confidence: 99%

Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T₁‐weighted MRI

Tao

Fink

Tunin

et al. 2019

Magnetic Resonance in Med

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“…To date, no reports have evaluated the use of iMRI for ablation of AF, but several groups have reported on ablation of atrial flutter using iMRI 19–21. Although earlier works reported significantly longer procedural times than fluoroscopy-guided treatment,20 21 the most recent case series19 shows procedural times that are comparable with fluoroscopy-guided treatment (45.9 min vs 48.4 min for iMRI-guided and conventional treatment, respectively) with similar results with regards to direct procedural success and short-term follow-up. In this publication, a strong learning effect is noted, and procedural times initially decreased sharply and plateaued after 12 procedures.…”

Section: Discussionmentioning

confidence: 99%

“…It seems unlikely that these thresholds can be reached with currently available technologies as essential parts of the required tools for PVI are currently unavailable. Over the past decade, the first applications of interventional MRI are getting close to clinical translation (atrial flutter ablations19) or have already been successfully adopted in select medical centres (diagnostic right sided heart catheterisation) 25. However, these applications are currently limited to relatively low complexity, right-sided procedures.…”

Section: Discussionmentioning

confidence: 99%

“…Instead, this analysis supposes a hospital that has both treatment modalities available and costs of acquisition are accounted for in use cost of both modalities, basing the cost-estimates on local experience. Although an interventional MRI suite is presumably not available in many general hospitals yet, several groups from various countries have published case series from cardiac procedures in interventional MRI suites 19 20 25…”

Section: Discussionmentioning

confidence: 99%

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MRI-guided pulmonary vein isolation for atrial fibrillation: what is good enough? An early health technology assessment

et al. 2019

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Next to anticoagulation, pulmonary vein isolation (PVI) is the most important interventional procedure in the treatment of atrial fibrillation (AF). Despite widespread clinical application of this therapy, patients often require multiple procedures to reach clinical success. In contrast to conventional imaging modalities, MRI allows direct visualisation of the ablation lesion. Therefore, the use of real-time MRI to guide cardiac electrophysiology procedures may increase clinical effectiveness. An essential aspect, from a decision-making point of view, is the effect on costs and the potential cost-effectiveness of new technologies. Generally, health technology assessment (HTA) studies are performed when innovations are close to clinical application. However, early stage HTA can inform users, researchers and funders about the ultimate clinical and economic potential of a future innovation. Ultimately, this can guide funding allocation. In this study, we performed an early HTA evaluate MRI-guided PVIs.MethodsWe performed an economic evaluation using a decision tree with a time-horizon of 1 year. We calculated the clinical effectiveness (defined as the proportion of patients that is long-term free of AF after a single procedure) required for MRI-guided PVI to be cost-effective compared with conventional treatment.ResultsDepending on the cost-effectiveness threshold (willingness to pay for one additional quality-of-life adjusted life year (QALY), interventional MRI (iMRI) guidance for PVI can be cost-effective if clinical effectiveness is 69.8% (at €80 000/QALY) and 77.1% (at €20 000/QALY), compared with 64% for fluoroscopy-guided procedures.ConclusionUsing an early HTA, we established a clinical effectiveness threshold for interventional MRI-guided PVIs that can inform a clinical implementation strategy. If crucial technologies are developed, it seems plausible that iMRI-guided PVIs will be able to reach this threshold.

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“…The requirement of CMR-compatible equipment is being addressed by the development of new devices, such as CMR-compatible lasso catheters [62]. CMR-electrophysiological systems have been tested on animal models and recently 30 patients underwent atrial flutter CMR-guided ablation with satisfactory results [63]. However, peri-procedural CMR ablations have not yet been validated in AF patients.…”

Section: Peri-procedural Cmrmentioning

confidence: 99%

Left Atrial Structural Remodelling in Non-Valvular Atrial Fibrillation: What Have We Learnt from CMR?

et al. 2020

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Left atrial structural, functional and electrical remodelling are linked to atrial fibrillation (AF) pathophysiology and mirror the phrase “AF begets AF”. A structurally remodelled left atrium (LA) is fibrotic, dysfunctional and enlarged. Fibrosis is the hallmark of LA structural remodelling and is associated with increased risk of stroke, heart failure development and/or progression and poorer catheter ablation outcomes with increased recurrence rates. Moreover, increased atrial fibrosis has been associated with higher rates of stroke even in sinus-rhythm individuals. As such, properly assessing the fibrotic atrial cardiomyopathy in AF patients becomes necessary. In this respect, late-gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging is the gold standard in imaging myocardial fibrosis. LA structural remodelling extension offers both diagnostic and prognostic information and influences therapeutic choices. LGE-CMR scans can be used before the procedure to better select candidates and to aid in choosing the ablation technique, during the procedure (full CMR-guided ablations) and after the ablation (to assess the ablation scar). This review focuses on imaging several LA structural remodelling CMR parameters, including size, shape and fibrosis (both extension and architecture) and their impact on procedure outcomes, recurrence risk, as well as their utility in relation to the index procedure timing.

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Clinical workflow and applicability of electrophysiological cardiovascular magnetic resonance-guided radiofrequency ablation of isthmus-dependent atrial flutter

Cited by 40 publications

References 12 publications

Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T₁‐weighted MRI

Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T₁‐weighted MRI

MRI-guided pulmonary vein isolation for atrial fibrillation: what is good enough? An early health technology assessment

Left Atrial Structural Remodelling in Non-Valvular Atrial Fibrillation: What Have We Learnt from CMR?

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Clinical workflow and applicability of electrophysiological cardiovascular magnetic resonance-guided radiofrequency ablation of isthmus-dependent atrial flutter

Cited by 40 publications

References 12 publications

Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T1‐weighted MRI

Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T1‐weighted MRI

MRI-guided pulmonary vein isolation for atrial fibrillation: what is good enough? An early health technology assessment

Left Atrial Structural Remodelling in Non-Valvular Atrial Fibrillation: What Have We Learnt from CMR?

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Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T₁‐weighted MRI

Acute enhancement of necrotic radio‐frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non‐contrast‐enhanced T₁‐weighted MRI