Three-dimensional rotational angiography of the left atrium and esophagus—A virtual computed tomography scan in the electrophysiology lab?

Abstract

Three-dimensional (3D) reconstruction of the heart and surrounding structures has been supplementing traditional two-dimensional imaging to guide diagnostic and therapeutic electrophysiologic procedures. Current methods using computed tomography (CT)/magnetic resonance imaging (MRI) reconstruction have certain limitations. We investigated the feasibility of rotational angiography (RA) combined with simultaneous esophagogram to create an intraprocedural 3D reconstruction of the left atrium (LA) and the esophagus. Rotational angiography was performed. Contrast was injected via a pigtail catheter positioned in the left or right pulmonary artery to achieve a levophase venous cycle opacification of the ipsilateral pulmonary veins and adjacent LA. Simultaneous administration of oral contrast allowed a 3D reconstruction of the esophagus in the same image. Qualitative and quantitative comparison between the intraprocedural 3D RA and a remote CT scan was performed in 11 consecutive patients undergoing ablation for atrial fibrillation. Adequate visualization of the pulmonary veins, adjacent posterior LA, and esophagus was achieved in 10 patients. Determination of pulmonary transit time to guide the initiation of RA resulted in better-quality imaging. A close correlation between 3D RA and CT was found. Based on close proximity between the LA and esophagus, the ablation procedure was modified in three patients. Three-dimensional RA of the LA and esophagus is a promising new method allowing intraprocedural 3D reconstruction of these structures comparable in quality to a CT scan. Further studies refining the method are justified because it could eliminate the need for CT/MRI scans before ablation.