Abstract
Catheter ablation is a first-line treatment for many cardiac arrhythmias and is generally performed under X-ray fluoroscopy guidance. However, current techniques for ablating complex arrhythmias such as atrial fibrillation and ventricular tachycardia are associated with sub-optimal success rates and prolonged radiation exposure. Pre-procedure 3-D magnetic resonance imaging (MRI) has improved understanding of the anatomic basis of complex arrhythmias and is being used for planning and guidance of ablation procedures. A particular strength of MRI compared to other imaging modalities is the ability to visualize ablation lesions. Post-procedure MRI is now being applied to assess ablation lesion location and permanence with the goal of identifying factors leading to procedure success and failure. In the future, intra-procedure real-time MRI, together with the ability to image complex 3-D arrhythmogenic anatomy and target additional ablation to regions of incomplete lesion formation, may allow for more successful treatment of even complex arrhythmias without exposure to ionizing radiation. Development of clinical grade MRI-compatible electrophysiology devices is required to transition intra-procedure MRI from preclinical studies to more routine use in patients.
Highlights
Radiofrequency (RF) catheter ablation has advanced over the last 25 years from an experimental procedure to the first-line treatment for a number of cardiac arrhythmias including atrioventricular re-entrant tachycardia, accessory pathway-associated tachycardias, and typical atrial flutter.[1]
Electrospatial mapping technology led to the development of purely anatomic circumferential ablation strategies in which circular lesions are created further from the pulmonary vein (PV) ostia to block the exit of PV triggers[4] (Figure 1A)
Ciaccio et al complemented these findings by computationally predicting suitable locations for monomorphic ventricular tachycardia (MVT) ablation with the use of high-resolution Delayed enhancement CMR (DECMR) scar imaging.[22]
Summary
Radiofrequency (RF) catheter ablation has advanced over the last 25 years from an experimental procedure to the first-line treatment for a number of cardiac arrhythmias including atrioventricular re-entrant tachycardia, accessory pathway-associated tachycardias, and typical atrial flutter.[1]. While the feasibility of X-ray fluoroscopy guidance has been demonstrated for these complex arrhythmias, precise targeting of ablation lesions is limited by fluoroscopy’s inherently poor ability to visualize cardiovascular soft tissue anatomy. The persistence of sub-optimal cure rates, prolonged procedure and radiation exposure times, and the risk of serious complications have motivated new approaches to facilitate anatomy-based catheter ablation for complex arrhythmias. Modern imaging techniques such as magnetic resonance imaging (MRI), intracardiac ultrasound, and X-ray computed tomography (CT) are increasingly used to approach the shortcomings of current mapping and ablation systems. Procedures and on-going advances toward full CMR guidance of electrophysiology procedures
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