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  • Vincent Chen, MS IVGillian Lieberman, MD

    CT of the Left Atrium and CT of the Left Atrium and Pulmonary Veins before RadioPulmonary Veins before Radio--

    Frequency Catheter Ablation for Frequency Catheter Ablation for AtrialAtrial

    FibrillationFibrillation

    Vincent Chen, Harvard Medical School Year IVVincent Chen, Harvard Medical School Year IVGillian Lieberman, MDGillian Lieberman, MD

    Vincent Chen, MS IVGillian Lieberman, MD

    September 2008

  • Vincent Chen, MS IVGillian Lieberman, MD

    2

    AgendaAgenda

    Our patientOur patient

    AtrialAtrial

    fibrillation and the role of the pulmonary fibrillation and the role of the pulmonary

    veinsveins

    PrePre--RFCA imaging with CT RFCA imaging with CT

    epicardialepicardial

    and and

    endocardialendocardial

    reconstructions, measurement of reconstructions, measurement of geometry geometry

    Radiofrequency catheter ablation Radiofrequency catheter ablation

    technique, technique,

    complications, challengescomplications, challenges

  • Vincent Chen, MS IVGillian Lieberman, MD

    3

    Our PatientOur Patient

    75 75 yoyo

    M w/ longstanding M w/ longstanding atrialatrial

    arrhythmiasarrhythmias

    Refractory to medical management Refractory to medical management

    failed failed dofetilidedofetilide, , quinidinequinidine, , amiodaroneamiodarone, , sotalolsotalol

    Chronically Chronically anticoagulatedanticoagulated

    and rate controlled, has and rate controlled, has pacemakerpacemaker

    Recently suffering from increasingly severe shortness of Recently suffering from increasingly severe shortness of breath associated with fatiguebreath associated with fatigue

    Noted to be in Noted to be in atrialatrial

    tachycardia, pacemaker attempted tachycardia, pacemaker attempted to overdrive pace, but failedto overdrive pace, but failed

    Echocardiogram showed reduced ejection fraction, Echocardiogram showed reduced ejection fraction, consistent with worsening symptomsconsistent with worsening symptoms

  • Vincent Chen, MS IVGillian Lieberman, MD

    4

    AtrialAtrial

    FibrillationFibrillation

    Most common sustained cardiac arrhythmiaMost common sustained cardiac arrhythmia

    Most common cardiac arrhythmia requiring Most common cardiac arrhythmia requiring hospitalizationhospitalization

    Occurs when ectopic electrical foci Occurs when ectopic electrical foci firefire independentlyindependently

    Major complications:Major complications:

    Hemodynamic compromise Hemodynamic compromise

    rapid ventricular rate can cause rapid ventricular rate can cause hypotension, chronic poorly controlled tachycardia can cause hypotension, chronic poorly controlled tachycardia can cause ventricular dysfunctionventricular dysfunction

    Thrombi may form and Thrombi may form and embolizeembolize, resulting in significant , resulting in significant morbidity/mortality from strokemorbidity/mortality from stroke

  • Vincent Chen, MS IVGillian Lieberman, MD

    5

    Pulmonary Veins and AFPulmonary Veins and AF

    Thus, we can attempt to interrupt Thus, we can attempt to interrupt conduction pathways that lead to conduction pathways that lead to atrialatrial

    fibrillation, electrically fibrillation, electrically disconnectingdisconnecting

    the pulmonary the pulmonary vein from the atriumvein from the atrium

    Surgical management: modified Surgical management: modified maze procedure maze procedure

    series of series of atrialatrial

    incisionsincisions

    NonNon--surgical management: RFCA surgical management: RFCA of distal pulmonary veinsof distal pulmonary veins

    Ectopic foci are often found in the Ectopic foci are often found in the distal pulmonary veins*distal pulmonary veins*

    * Jais

    P, Haissaguerre

    M, Shah DC, et al. A focal source of atrial

    fibrillation treated by discrete radiofrequency ablation. Circulation 1997;95:572-576

    L atrium

    Pulmonary Veins

  • Vincent Chen, MS IVGillian Lieberman, MD

    6

    RFCA for RFCA for AtrialAtrial

    FibrillationFibrillation

    Under fluoroscopic guidance, Under fluoroscopic guidance, a catheter with an ablation a catheter with an ablation electrode is guided up the electrode is guided up the IVC, across the IVC, across the atrialatrial

    septum, septum,

    then to the pulmonary veinsthen to the pulmonary veins

    The specific ectopic focus or The specific ectopic focus or the entire circumference of the entire circumference of the vein is ablatedthe vein is ablated

    Frequently, to reduce need Frequently, to reduce need for a repeat procedure, all for a repeat procedure, all pulmonary vein pulmonary vein ostiaostia

    are are

    empirically ablatedempirically ablated

  • Vincent Chen, MS IVGillian Lieberman, MD

    7

    Complications of RFCAComplications of RFCA

    Pulmonary vein dissectionPulmonary vein dissection

    AtrialAtrial

    or pulmonary vein perforationor pulmonary vein perforation

    Pulmonary vein Pulmonary vein stenosisstenosis**

    Lengthy fluoroscopic time poses radiation risk Lengthy fluoroscopic time poses radiation risk to patient and physiciansto patient and physicians

    There has been at least one case of radiation There has been at least one case of radiation dermatitis following fluoroscopy for RFCA**dermatitis following fluoroscopy for RFCA**

    * Saad

    EB, Marrouche

    NF, Saad

    CP, et al. Pulmonary vein stenosis

    after catheter ablation of atrial

    fibrillation: emergence of a new clinical syndrome. Ann Intern Med 2003; 138634-638.

    ** Nahass

    GT. Acute radiodermatitis

    after radiofrequency catheter ablation. J Am Acad

    Dermatol

    1997; 36:881-884

  • Vincent Chen, MS IVGillian Lieberman, MD

    8

    Challenges of RFCAChallenges of RFCA

    Pulmonary vein anatomy is quite variablePulmonary vein anatomy is quite variable

    The The normalnormal

    pulmonary vein anatomy is composed of pulmonary vein anatomy is composed of four pulmonary veinsfour pulmonary veins

    However, common However, common ostiaostia

    or extra veins are commonor extra veins are common

    Radiofrequency energy is ideally applied very close to Radiofrequency energy is ideally applied very close to the the venoatrialvenoatrial

    junctionjunction

    Reduce risk of Reduce risk of stenosisstenosis

    the further the ablation is from the the further the ablation is from the ostiumostium, the greater the chance of , the greater the chance of stenosisstenosis

    Reduce risk that portion of pulmonary vein that remains Reduce risk that portion of pulmonary vein that remains electrically attached to atrium may contain ectopic focielectrically attached to atrium may contain ectopic foci

  • Vincent Chen, MS IVGillian Lieberman, MD

    9

    Value of PreValue of Pre--RFCA ImagingRFCA Imaging

    Imaging helps address these challenges, reducing Imaging helps address these challenges, reducing complicationscomplications

    Imaging tells usImaging tells us

    Is the anatomy normal?Is the anatomy normal?

    What is the What is the ostialostial

    diameter of each vein and how far diameter of each vein and how far is it to the first branch?is it to the first branch?

    Are there any extra pulmonary veins?Are there any extra pulmonary veins?

  • Vincent Chen, MS IVGillian Lieberman, MD

    10

    PrePre--RFCA ImagingRFCA Imaging

    In the past, attempts were made to In the past, attempts were made to define the pulmonary vein define the pulmonary vein ostiaostia

    by by injecting contrast into the L atrium injecting contrast into the L atrium and attempting to visualize contrast and attempting to visualize contrast material that refluxed into the material that refluxed into the pulmonary veins (pulmonary pulmonary veins (pulmonary venographyvenography))

    This is difficult, as blood flows the This is difficult, as blood flows the opposite wayopposite way

    Furthermore, the 2D nature of Furthermore, the 2D nature of fluoroscopy doesnfluoroscopy doesnt allow accurate t allow accurate 3D assessment3D assessment

    Thus, we often use CT or MR Thus, we often use CT or MR --

    often CT as patients frequently often CT as patients frequently have pacemakers and thus cannot have pacemakers and thus cannot receive MR imagingreceive MR imaging

  • Vincent Chen, MS IVGillian Lieberman, MD

    11

    MultiMulti--Detector Row CTDetector Row CT

    L atrium

    L ventricle

    R ventricle

    PACS, BIDMC

    C+ axial CT C+ axial CT

    C+ axial CT C+ axial CT

  • Vincent Chen, MS IVGillian Lieberman, MD

    12

    EpicardialEpicardial

    ((ExtraatrialExtraatrial) VR Views) VR Views

    A 3D model of the left atrium and the pulmonary veins is A 3D model of the left atrium and the pulmonary veins is created and can be manipulated to better understand the 3D created and can be manipulated to better understand the 3D structurestructure

    Note this patient has a R middle pulmonary vein!Note this patient has a R middle pulmonary vein!

    PACS, BIDMC

    3D reformation of C+ axial CT 3D reformation of C+ axial CT 3D reformation of C+ axial CT

  • Vincent Chen, MS IVGillian Lieberman, MD

    13

    EndocardialEndocardial

    ((IntraatrialIntraatrial) VR) VR

    EndocardialEndocardial

    reconstructions allow us to open up the reconstructions allow us to open up the atria and look from the insideatria and look from the inside

    L superior pulmonary vein

    L inferior pulmonary vein

    PACS, BIDMC

    R superior pulmonary vein

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