CMR-Guided Approach to Localize and Ablate Gaps in Repeat AF Ablation Procedure

Bisbal, Felipe; Guiu, Esther; Cabanas‐Grandío, Pilar; Berruezo, Antonio; Prat-González, Susana; Vidal, Bárbara; Garrido, César; Andreu, David; Fernández-Armenta, Juan; Tolosana, José Marı́a; Arbelo, Elena; Caralt, Teresa M. de; Perea, Rosario J.; Brugada, Josep; Mont, Lluı́s

doi:10.1016/j.jcmg.2014.01.014

Cited by 129 publications

(157 citation statements)

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“…Some groups have recommended the use of cardiac MRIdetected left atrial delayed gadolinium enhancement [37][38][39] for the identification of patients in whom AF is likely to recur after catheter ablation 38,40,41 , although an external validation of the feasibility of this technique is needed 42 . The CHARGE AF consortium identified a set of clinical parameters and biomarkers that could be used to predict AF incidence during follow-up, but did not provide information on the most appropriate prevention or therapy approach 43 .…”

Section: Guidance Through Af Characterizationmentioning

confidence: 99%

Defining the major health modifiers causing atrial fibrillation: a roadmap to underpin personalized prevention and treatment

et al. 2015

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Despite the important advances that have enabled better stroke prevention in atrial fibrillation (AF) and more effective maintenance of sinus rhythm over the past decades, a large unmet need to improve the prevention and treatment of AF remains. Mortality for AF remains at 3.5% per year, and death is often experienced as sudden death or as a result of heart failure 1,2 . Each year, approximately 20% of patients with AF need to be hospitalized 3,4 , and stroke occurs in 1.5% of patients with AF who are receiving anticoagulant drugs 5 . Furthermore, more than half of the patients with AF are symptomatic despite adequate anticoagulation and rate control 4,6 . In view of the projected increase in the incidence and prevalence of AF 7-9 , as well as the substantial burden of death and dis ability that is still associated with this condition 10 , the status quo is unacceptable.Current management of patients with AF comprises treatment of the accompanying cardiovascular conditions, oral anticoagulation, rate control -with medications that slow atrioventricular nodal recovery or, rarely, with atrioventricular nodal ablation -and rhythm-control therapy with antiarrhythmic drugs, electrical cardioversion, catheter ablation or, at times, AF surgery 11,12 . Unfortunately, most of these current approaches are disconnected from our understanding of the major mechanisms that cause AF 1,13,14 1,2,7,19,20 Abstract | Despite remarkable advances in antiarrhythmic drugs, ablation procedures, and stroke-prevention strategies, atrial fibrillation (AF) remains an important cause of death and disability in middle-aged and elderly individuals. Unstructured management of patients with AF sharply contrasts with our detailed, although incomplete, knowledge of the mechanisms that cause AF and its complications. Altered calcium homeostasis, atrial fibrosis and ageing, ion-channel dysfunction, autonomic imbalance, fat-cell infiltration, and oxidative stress, in addition to a susceptible genetic background, contribute to the promotion, maintenance, and progression of AF. However, clinical management of patients with AF is currently guided by stroke risk parameters, AF pattern, and symptoms. In response to this apparent disconnect between the known pathophysiology of AF and clinical management, we propose a roadmap to develop a set of clinical markers that reflect the major causes of AF in patients. Thereby, the insights into the mechanisms causing AF will be transformed into a format that can underpin future personalized strategies to prevent and treat AF, ultimately informing better patient care.230 | APRIL 2016 | VOLUME 13 www.nature.com/nrcardio CONSENSUS STATEMENT © 2 0 1 6 M a c m i l l a n P u b l i s h e r s L i m i t e d . A l l r i g h t s r e s e r v e d .

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Section: Guidance Through Af Characterizationmentioning

confidence: 99%

Defining the major health modifiers causing atrial fibrillation: a roadmap to underpin personalized prevention and treatment

et al. 2015

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“…2 This necessarily means that DE-CMR can reliably identify the sites of PV reconnection. The sensitivity/specificity and positive/negative predictive values of detecting PV reconnection with DE-CMR were 100%/57% and 94%/100%, respectively.…”

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“…In addition to the aforementioned limitations, this technique has not been externally validated, and thus its superiority over other reported methodologies cannot be demonstrated. 2,4 However, voltage mapping also has not been validated as a reliable tool to predict PV reconnection. Considering that the spatial resolution of a point-bypoint map using a 3.5-mm tip catheter is ≈6 mm in diameter and that the voxel size of DE-CMR can be as small as 1.25×1.25×2.5 mm, 2,4 we consider it inappropriate to use voltage mapping as the gold standard.…”

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confidence: 99%

“…2,4 However, voltage mapping also has not been validated as a reliable tool to predict PV reconnection. Considering that the spatial resolution of a point-bypoint map using a 3.5-mm tip catheter is ≈6 mm in diameter and that the voxel size of DE-CMR can be as small as 1.25×1.25×2.5 mm, 2,4 we consider it inappropriate to use voltage mapping as the gold standard. In light of these facts, we believe that the conclusions of the study by Harrison et al must be interpreted with caution and considered hypothesis-generating rather than as a definitive demonstration.…”

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Letter by Bisbal et al Regarding Article, “Repeat Left Atrial Catheter Ablation: Cardiac Magnetic Resonance Prediction of Endocardial Voltage and Gaps in Ablation Lesion Sets”

Bisbal

Berruezo

Mont

2015

Circ: Arrhythmia and Electrophysiology

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We read with great interest the article of Harrison et al. 1 The authors report that delayed-enhancement cardiac magnetic resonance (DE-CMR) is unable to predict the site of pulmonary vein (PV) reconnection after ablation of atrial fibrillation. They found a weak point-by-point correlation between DE-CMR and peak-to-peak endocardial voltage. The authors are to be commended for their thorough analysis of DE-CMR and voltage data; however, some study limitations should be acknowledged, which we believe preclude the dismissal of DE-CMR evaluation of PV reconnection based on the results of their study.A recently published study by our group demonstrated that ablation at the gaps depicted on the DE-CMR (CMR-gap) led to reisolation of 95.6% of PVs, even when the earliest activation did not match a CMR-gap. 2 This necessarily means that DE-CMR can reliably identify the sites of PV reconnection. The sensitivity/specificity and positive/negative predictive values of detecting PV reconnection with DE-CMR were 100%/57% and 94%/100%, respectively. 3 Several DE-CMR acquisition, image postprocessing, and procedural differences might explain these conflicting results. Compared with our study, Harrison et al collected a significantly lower number of points to create the map, with a mean of 338±210 points per map (range, 51-901), compared with 808±159 points per map in our study (range, 520-1004). Of note, 3 maps (15%) in their study had <100 points. The lower mapping density could have led to insufficient voltage information in the areas of interest to clearly define small breaks in ablation lines. The lack of a contact force mapping catheter, which was used in our study, could potentially result in false low-voltage areas because of poor tip-tissue contact. In addition, DE-CMR was acquired with a greater voxel size (1.25×1.25×4 mm) than has been reported by other groups (1.25×1.25×2.5 mm), 2,4 which would preclude detection of smaller anatomic gaps. Remarkably, 55% of patients in their study had >1 prior ablation. Evidence has been published on the attenuation over time of gadolinium signal-intensity at sites of scar. 5 The use of restrictive signal-intensity thresholds in patients with >1 prior procedures may misclassify, as healthy myocardium, areas of less intense scar created on the first procedure. To overcome this issue, we included only patients undergoing a second procedure.Finally, we disagree with the statement that the DE-CMR acquisition and postprocessing protocol used by Harrison et al is a validated method. In addition to the aforementioned limitations, this technique has not been externally validated, and thus its superiority over other reported methodologies cannot be demonstrated. 2,4 However, voltage mapping also has not been validated as a reliable tool to predict PV reconnection. Considering that the spatial resolution of a point-bypoint map using a 3.5-mm tip catheter is ≈6 mm in diameter and that the voxel size of DE-CMR can be as small as 1.25×1.25×2.5 mm, 2,4 we consider it inappropriate to use voltage m...

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“…6 Identification of such gaps by noninvasive techniques, such as cardiac magnetic resonance imaging (CMR), would have high clinical utility. [7][8][9][10][11] Article see p 270…”

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confidence: 99%

Closing the Knowledge Gaps

Jiménez

Dickfeld

2015

Circ: Arrhythmia and Electrophysiology

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CMR-Guided Approach to Localize and Ablate Gaps in Repeat AF Ablation Procedure

Abstract: DE-CMR can successfully guide repeated PVI procedures by accurately identifying and localizing gaps and may reduce procedural duration and radiofrequency application time.

Cited by 129 publications

References 20 publications

Defining the major health modifiers causing atrial fibrillation: a roadmap to underpin personalized prevention and treatment

Defining the major health modifiers causing atrial fibrillation: a roadmap to underpin personalized prevention and treatment

Letter by Bisbal et al Regarding Article, “Repeat Left Atrial Catheter Ablation: Cardiac Magnetic Resonance Prediction of Endocardial Voltage and Gaps in Ablation Lesion Sets”

Closing the Knowledge Gaps

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