Advertisement

Submit Manuscripts
Author Information
Subscribe/Renew
Order Reprints
Email Alerts
Feedback
RSS Feed
CME

About the Journal
Editorial Board & Staff

About JACC CME
Hardware/Software Requirements
Contact Us
Policy on Privacy and Confidentiality
Copyright Information

JACC Imaging Homepage JACC Interventions Homepage
Still not a subscriber to JACC Imaging or JACC Interventions?
Click here
to sign up now!

ACC.org
Cardiosmart
Cardiosource
CVN
Imaging Library
JACC Imaging
JACC Interventions

Click here for more guidelines.
2009 Focused Updates: ACC/AHA Guidelines for STEMI and ACC/AHA/SCAI Guidelines for PCI
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
ACC 2009 Advocacy Position Statement: Principles for Comparative Effectiveness Research
CME Topic Collections Past Issues Search Current Issue Home
     

J Am Coll Cardiol, 2008; 52:1272-1273, doi:10.1016/j.jacc.2008.07.015
© 2008 by the American College of Cardiology Foundation
This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in Web of Science
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Halperin, H. R.
Right arrow Articles by Nazarian, S.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Halperin, H. R.
Right arrow Articles by Nazarian, S.
Related Collections
Right arrowRelated Articles

EDITORIAL COMMENT

Damage Assessment After Ablation

Role of Cardiovascular Magnetic Resonance*

Henry R. Halperin, MD, MAP, FACC* and Saman Nazarian, MD

Departments of Medicine, Radiology, and Biomedical Engineering, Johns Hopkins Hospital, Baltimore, Maryland

* Reprint requests and correspondence: Dr. Henry R. Halperin, Department of Medicine, Radiology, and Biomedical Engineering, Johns Hopkins Hospital, Blalock 524A, 600 North Wolfe Street, Baltimore, Maryland 21287 (Email: hhalper{at}jhmi.edu).

Key Words: magnetic resonance imaging • MRI • atrial fibrillation • ablation

As the most common sustained cardiac arrhythmia, atrial fibrillation (AF) is the primary cause of many hospital admissions (1), and is associated with significant secondary morbidity by increasing the risk of stroke (2), heart failure (3), and all-cause mortality (4). The incidence of AF is on the rise, and it is projected that by the year 2050 more than 10 million patients will be affected by AF in the U.S. alone (5). Antiarrhythmic medications have limited success in maintaining sinus rhythm, are associated with side effects, and seem to be ineffective at reducing mortality compared with a strategy of rate control and anticoagulation (6). Given the significant morbidity associated with this common arrhythmia, surgical (7) and catheter ablation (8–10) techniques have been developed to treat AF. However, despite the incorporation of various strategies for ablation (9,11–14), long-term recurrence rates of atrial fibrillation remain at nearly 25% after ablation (15,16). The potential for recovery of acute pulmonary vein isolation (17) and subjective end points for denervation and complex fractionated electrogram ablation obscure the contribution of each strategy to long-term procedural success. Noninvasive techniques to assess objective anatomic changes after AF ablation have the potential to improve our understanding of the contribution of anatomical end points to eventual success rates. Peters et al. (18) previously reported the capability of 3-dimensional navigator-gated delayed enhancement magnetic resonance imaging (MRI) for detection of left atrial scar after AF ablation. In this issue of the Journal, McGann et al. (19) expand the MRI experience in quantification of the extent and distribution of myocardial injury after AF ablation.

Targeted ablation versus generalized debulking.   It is well known that a critical amount of excitable myocardial mass is necessary for maintenance of fibrillation. It has also been reported that nonencircling left atrial lesions are as effective at eliminating AF as pulmonary vein isolation (11,20). More recently it has been shown that the duration of radiofrequency energy delivery is an independent predictor of clinical outcome after AF ablation (21). These findings suggest that some of the beneficial effects of myocardial ablation toward maintenance of sinus rhythm may be caused by the reduction of atrial tissue capable of supporting fibrillation. The finding by McGann et al. (19) that the degree of atrial scar after AF ablation correlates directly with freedom from AF lends further support to the hypothesis that generalized rather than targeted atrial debulking by catheter ablation may have an important role in AF suppression.

Understanding the relative importance of lesions targeted for pulmonary vein isolation, parasympathetic denervation, and suppression of complex fractionated atrial electrograms versus the importance of debulking lesions toward maintenance of sinus rhythm has the potential to significantly change catheter ablation strategies for AF. Future studies designed and powered to distinguish the relative importance of targeted versus debulking lesions in patients with paroxysmal versus permanent AF will expand on the interesting results reported by McGann et al. (19).

Future role of MRI.   Electroanatomical systems with image integration have revolutionized anatomically-based electrophysiology procedures by providing information from pre-acquired MRI and computed tomography images to guide catheter localization. Delayed-enhancement MRI seems to be a promising tool for identification of the scar substrate for arrhythmia (22–25) and for identification of radiofrequency lesions after ablation (18,19,26). The ability to import delayed-enhancement scar images into electroanatomical systems has the potential to reduce mapping time and to improve the efficacy of initial and follow-up ablation procedures. Ultimately, techniques may become available for real-time MRI guidance of electrophysiology procedures, enabling real-time visualization of myocardial scar for guidance of mapping and real-time feedback for titration of radiofrequency lesion application.


   Footnotes
 
* Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. Back


   References
Top
 References
 
1. McDonald AJ, Pelletier AJ, Ellinor PT, Camargo Jr CA. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004 Ann Emerg Med 2008;51:58-65.[CrossRef][Web of Science][Medline]

2. Flegel KM, Shipley MJ, Rose G. Risk of stroke in non-rheumatic atrial fibrillation Lancet 1987;1:526-529.[CrossRef][Web of Science][Medline]

3. Cha YM, Redfield MM, Shen WK, Gersh BJ. Atrial fibrillation and ventricular dysfunction: a vicious electromechanical cycle Circulation 2004;109:2839-2843.[Free Full Text]

4. Kannel WB, Abbott RD, Savage DD, McNamara PM. Coronary heart disease and atrial fibrillation: the Framingham Study Am Heart J 1983;106:389-396.[CrossRef][Web of Science][Medline]

5. Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence Circulation 2006;114:119-125.[Abstract/Free Full Text]

6. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation N Engl J Med 2002;347:1825-1833.[Abstract/Free Full Text]

7. Prasad SM, Maniar HS, Camillo CJ, et al. The Cox Maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures J Thorac Cardiovasc Surg 2003;126:1822-1828.[Abstract/Free Full Text]

8. Haissaguerre M, Gencel L, Fischer B, et al. Successful catheter ablation of atrial fibrillation J Cardiovasc Electrophysiol 1994;5:1045-1052.[Web of Science][Medline]

9. Pappone C, Rosanio S, Oreto G, et al. Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation Circulation 2000;102:2619-2628.[Abstract/Free Full Text]

10. Calkins H, Brugada J, Packer DL, et al. HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007;4:816-861.[CrossRef][Web of Science][Medline]

11. Nademanee K, McKenzie J, Kosar E, et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate J Am Coll Cardiol 2004;43:2044-2053.[Abstract/Free Full Text]

12. Pappone C, Santinelli V, Manguso F, et al. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation Circulation 2004;109:327-334.[Abstract/Free Full Text]

13. Kumagai K, Muraoka S, Mitsutake C, Takashima H, Nakashima H. A new approach for complete isolation of the posterior left atrium including pulmonary veins for atrial fibrillation J Cardiovasc Electrophysiol 2007;18:1047-1052.[CrossRef][Web of Science][Medline]

14. Wang XH, Liu X, Sun YM, Shi HF, Zhou L, Gu JN. Pulmonary vein isolation combined with superior vena cava isolation for atrial fibrillation ablation: a prospective randomized study Europace 2008;10:600-605.[Abstract/Free Full Text]

15. Oral H, Pappone C, Chugh A, et al. Circumferential pulmonary-vein ablation for chronic atrial fibrillation N Engl J Med 2006;354:934-941.[Abstract/Free Full Text]

16. Noheria A, Kumar A, Wylie Jr. JV, Josephson ME. Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation: a systematic review Arch Intern Med 2008;168:581-586.[Abstract/Free Full Text]

17. Cheema A, Dong J, Dalal D, et al. Incidence and time course of early recovery of pulmonary vein conduction after catheter ablation of atrial fibrillation J Cardiovasc Electrophysiol 2007;18:387-391.[CrossRef][Web of Science][Medline]

18. Peters DC, Wylie JV, Hauser TH, et al. Detection of pulmonary vein and left atrial scar after catheter ablation with three-dimensional navigator-gated delayed enhancement MR imaging: initial experience Radiology 2007;243:690-695.[Abstract/Free Full Text]

19. McGann CJ, Kholmovski EG, Oakes RS, et al. New magnetic resonance imaging-based method for defining extent of left atrial wall injury after the ablation of atrial fibrillation J Am Coll Cardiol 2008;52:1263-1271.[Abstract/Free Full Text]

20. Oral H, Chugh A, Good E, et al. Randomized comparison of encircling and nonencircling left atrial ablation for chronic atrial fibrillation Heart Rhythm 2005;2:1165-1172.[CrossRef][Web of Science][Medline]

21. Katritsis D, Ellenbogen KA, Giazitzoglou E, et al. Clinical outcome of left atrial ablation for paroxysmal atrial fibrillation is related to the extent of radiofrequency ablation J Interv Card Electrophysiol 2008;22:31-37.[CrossRef][Web of Science][Medline]

22. Bello D, Fieno DS, Kim RJ, et al. Infarct morphology identifies patients with substrate for sustained ventricular tachycardia J Am Coll Cardiol 2005;45:1104-1108.[Abstract/Free Full Text]

23. Nazarian S, Bluemke DA, Lardo AC, et al. Magnetic resonance assessment of the substrate for inducible ventricular tachycardia in nonischemic cardiomyopathy Circulation 2005;112:2821-2825.[Abstract/Free Full Text]

24. Yan AT, Shayne AJ, Brown KA, et al. Characterization of the peri-infarct zone by contrast-enhanced cardiac magnetic resonance imaging is a powerful predictor of post-myocardial infarction mortality Circulation 2006;114:32-39.[Abstract/Free Full Text]

25. Assomull RG, Prasad SK, Lyne J, et al. Cardiovascular magnetic resonance, fibrosis, and prognosis in dilated cardiomyopathy J Am Coll Cardiol 2006;48:1977-1985.[Abstract/Free Full Text]

26. Lardo AC, McVeigh ER, Jumrussirikul P, et al. Visualization and temporal/spatial characterization of cardiac radiofrequency ablation lesions using magnetic resonance imaging Circulation 2000;102:698-705.[Abstract/Free Full Text]


Related Articles

New Magnetic Resonance Imaging-Based Method for Defining the Extent of Left Atrial Wall Injury After the Ablation of Atrial Fibrillation
Christopher J. McGann, Eugene G. Kholmovski, Robert S. Oakes, Joshua J.E. Blauer, Marcos Daccarett, Nathan Segerson, Kelly J. Airey, Nazem Akoum, Eric Fish, Troy J. Badger, Edward V.R. DiBella, Dennis Parker, Rob S. MacLeod, and Nassir F. Marrouche
J. Am. Coll. Cardiol. 2008 52: 1263-1271. [Abstract] [Full Text] [PDF]

Inside This Issue of JACC
J. Am. Coll. Cardiol. 2008 52: A32. [Full Text] [PDF]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in Web of Science
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Halperin, H. R.
Right arrow Articles by Nazarian, S.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Halperin, H. R.
Right arrow Articles by Nazarian, S.
Related Collections
Right arrowRelated Articles
 
  CME Topic Collections Past Issues Search Current Issue Home

Advertisement