Abstract
Background
Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug refractory atrial fibrillation. However, catheter ablation of atrial fibrillation is still a challenge. This is partially due to the high degree of variability with regard to the individual anatomy. Nevertheless, 3D imaging systems (CT, MRI) provide detailed information about the individual left atrial and pulmonary vein morphology. A 3D CT or MRI reconstruction of the left atrium can be displayed in the Navx-/Ensite-system in a synchronised way during the ablation procedure, thereby facilitating the intervention. This study summarizes our preliminary experience with different strategies of AF ablation using the Navx-/Ensite-system and a CT-/MRI-guided approach.
Methods
In a total of 41 patients, cardiac MRI (n = 7) or multi-detector spiral computed tomography (n = 34) was performed prior to an ablation procedure. Catheter ablation was performed for paroxysmal atrial fibrillation in 31 patients and for persistent atrial fibrillation in 10 patients. A 3D MRI or high resolution spiral CT data acquisition was performed and a surface rendered model of the LA was created. This model was displayed in the Navx-/Ensite-system throughout the ablation procedure.
Results
Catheter ablation was performed using the Navx-system (n = 38) or the Ensite-system (n = 3). Three strategies were used depending on the type of atrial fibrillation: segmental isolation of the pulmonary veins (facilitated by a 3D real-time visualization of the ablation catheter and a circumferential mapping catheter; group A: 20 patients), linear lesions (group C: 3 patients) and a combined approach (group B; 18 patients). The CT-/MRI-models provided an excellent overview over the pulmonary veins and the left atrial appendage. They revealed a high degree of variability with regard to the individual anatomy (e.g. dimensions of the left atrial appendage, pulmonary vein ostia). The CT scans provided a more detailed reconstruction of the left atrial anatomy than the MRI scans (especially in patients who were in atrial fibrillation at the time of the data acquisition). In some patients, the CT-/MRI-models revealed a very small diameter of some pulmonary veins or side branches close to the ostium (e.g. right inferior pulmonary vein). Therefore, no attempt was made to achieve complete pulmonary vein isolation in some patients. In group A, 16/20 (80%) patients had no arrhythmia recurrence [mean follow-up 359 days (SD ± 317 days)]. Twelve out of eighteen (67%) patients in group B [mean follow-up 452 days (SD ± 311 days)] and 2/3 (67%) patients in group C did not experience an arrhythmia recurrence [mean follow-up 1,000 days (SD ± 34 days)]. There were no major complications.
Conclusions
The information derived from 3D CT- or MRI-reconstructions facilitates AF ablations performed with the Navx-/Ensite-mapping system and enhances the safety of these procedures.
Furthermore, the availability of an additional impedance-based 3D real-time visualization of the ablation catheter and the circular mapping catheter placed in the pulmonary veins represents a major advantage of the Navx system.
Similar content being viewed by others
Abbreviations
- AF:
-
Atrial fibrillation
- AP view:
-
Anteroposterior view
- ECG:
-
Electrocardiogram
- LA:
-
Left atrium/left atrial
- LAA:
-
Left atrial appendage
- LSPV:
-
Left superior pulmonary vein
- MDCT:
-
Multi-detector spiral computed tomography
- MRI:
-
Magnetic resonance imaging
- PV(s):
-
Pulmonary vein(s)
- SD:
-
Standard deviation
- 3D reconstructions:
-
Three-dimensional reconstructions
References
Kettering K, Al-Ghobainy R, Wehrmann M, Vonthein R, Mewis C (2006) Atrial linear lesions: feasibility using cryoablation. Pacing Clin Electrophysiol 29:283–289
Oral H, Knight BP, Ozaydin M, Chugh A, Lai SW, Scharf C, Hassan S, Greenstein R, Han JD, Pelosi F, Strickberger SA, Morady F (2002) Segmental ostial ablation to isolate the pulmonary veins during atrial fibrillation: feasibility and mechanistic insights. Circulation 106(10):1256–1262
Haïssaguerre M, Shah DC, Jaïs P, Hocini M, Yamane T, Deisenhofer I, Garrigue S, Clémenty J (2000) Mapping-guided ablation of pulmonary veins to cure atrial fibrillation. Am J Cardiol 86(Suppl):9K–19K
Gerstenfeld EP, Guerra P, Sparks PB, Hattori K, Lesh MD (2001) Clinical outcome after radiofrequency catheter ablation of focal atrial fibrillation triggers. J Cardiovasc Electrophysiol 12(8):900–908
Marrouche NF, Dresing T, Cole C, Bash D, Saad E, Balaban K, Pavia SV, Schweikert R, Saliba W, Abdul-Karim A, Pisano E, Fanelli R, Tchou P, Natale A (2002) Circular mapping and ablation of the pulmonary vein for treatment of atrial fibrillation: impact of different catheter technologies. J Am Coll Cardiol 40(3):464–474
Swartz J, Pellersels G, Silvers J, Patten L, Cervantez D (1994) A catheter-based curative approach to atrial fibrillation in humans. Circulation 90(4.2):I–I335 (abstract)
Haïssaguerre M, Jaïs P, Shah DC, Gencel L, Pradeau V, Garrigues S, Chouairi S, Hocini M, Le-Metayer P, Roudaut R, Clémenty J (1996) Right and left atrial radiofrequency catheter therapy of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 7(12):1132–1144
Ernst S, Schluter M, Ouyang F, Khanedani A, Cappato R, Hebe J, Volkmer M, Antz M, Kuck KH (1999) Modification of the substrate for maintenance of idiopathic human atrial fibrillation: efficacy of radiofrequency ablation using nonfluoroscopic catheter guidance. Circulation 100(20):2085–2092
Jaïs P, Hocini M, Hsu LF, Sanders P, Scavee C, Weerasooriya R, Macle L, Raybaud F, Garrigue S, Shah DC, Le-Metayer, Clémenty J, Haïssaguerre M (2004) Technique and results of linear ablation at the mitral isthmus. Circulation 110(19):2996–3002
Oral H, Chugh A, Lemola K, Cheung P, Hall B, Good E, Han J, Tamirisa K, Bogun F, Pelosi F, Morady F (2004) Noninducibility of atrial fibrillation as an end point of left atrial circumferential ablation for paroxysmal atrial fibrillation: a randomized study. Circulation 110(18):2797–2801
Avitall B, Helms RW, Koblish JB, Sieben W, Kotov AV, Gupta GN (1999) The creation of linear contiguous lesions in the atria with an expandable loop catheter. J Am Coll Cardiol 33(4):972–984
Mitchell MA, McRury ID, Haines DE (1998) Linear atrial ablations in a canine model of chronic atrial fibrillation: morphological and electrophysiological observations. Circulation 97(12):1176–1185
Schwartzman D, Kuck KH (1998) Anatomy-guided linear atrial lesions for radiofrequency catheter ablation of atrial fibrillation. Pacing Clin Electrophysiol 21(10):1959–1978
Ouyang F, Bänsch D, Ernst S, Schaumann A, Hachiya H, Chen M, Chun J, Falk P, Khanedani A, Antz M, Kuck KH (2004) Complete isolation of the left atrium surrounding the pulmonary veins. New insights from the double-Lasso technique in paroxysmal atrial fibrillation. Circulation 110:2090–2096
Ouyang F, Antz M, Ernst S, Hachiya H, Mavrakis H, Deger FT, Schaumann A, Chun J, Falk P, Hennig D, Liu X, Bänsch D, Kuck KH (2005) Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins. Lessons from double Lasso technique. Circulation 111:127–135
Ouyang F, Ernst S, Chun J, Bänsch D, Li Y, Schaumann A, Mavrakis H, Liu X, Deger FT, Schmidt B, Xue Y, Cao J, Hennig D, Huang H, Kuck KH, Antz M (2005) Electrophysiological findings during ablation of persistent atrial fibrillation with electroanatomic mapping and double Lasso catheter technique. Circulation 112:3038–3048
Ernst S, Broemel T, Krumsdorf U, Hachiya H, Ouyang F, Linder C, Falk P, Baensch D, Schaumann A, Kuck KH, Antz M (2003) Three-dimensional reconstruction of pulmonary veins and left atrium. Implications for catheter ablation of atrial fibrillation. Herz 28:559–565
Kettering K, Greil G, Fenchel M, Kramer U, Miller S, Sieverding L, Kuehlkamp V, Mewis C (2005) Initial experience with catheter ablation of complex arrhythmias using the Ensite-/Navx-system and a MRI-/CT-guided approach. Eur Heart J 26(abstract supplement):62
Packer D, Munger T, Peterson L, Monahan K, Barrett R, Friedman P, Asirvatham S (2005) Utility of imported, synchronized CT imaging in electro-anatomic and impedance ranging map-guided wide area circumferential ablation for atrial fibrillation. Heart Rhythm 2(1S; abstract supplement):S193
Estner H, Deisenhofer I, Luik A, Ndrepepa G, von Bary C, Zrenner B, Schmitt C (2006) Electrical isolation of pulmonary veins in patients with atrial fibrillation: reduction of fluoroscopy exposure and procedure duration by the use of a non-fluoroscopic navigation system (NavX). Europace 8:583–587
Kettering K, Greil GF, Busch M, Miller S, Sieverding L, Schreieck J (2006) Catheter ablation of atrial fibrillation: ongoing atrial fibrillation inside a single pulmonary vein after successful electrical disconnection and restoration of sinus rhythm in both atria. Clin Res Cardiol 95:663–667
Marom EM, Herndon JE, Kim YH, McAdams HP (2004) Variations in pulmonary venous drainage to the left atrium: implications for radiofrequency ablation. Radiology 230:824–829
Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T (2004) A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 43:2044–2053
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kettering, K., Greil, G.F., Fenchel, M. et al. Catheter ablation of atrial fibrillation using the Navx-/Ensite-system and a CT-/MRI-guided approach. Clin Res Cardiol 98, 285–296 (2009). https://doi.org/10.1007/s00392-009-0001-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00392-009-0001-9