Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology

Abstract

Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.

Keywords: Active cardiac devices; Atrial fibrillation; Cardiac computed tomography; Cardiac magnetic resonance imaging; Catheter ablation; Complications • Oesophago-atrial fistula; Imaging-aided ablation; Imaging-guided ablation; Ventricular tachycardia.

Figure 1

Standardized CMR protocol for patients with PM or ICD undergoing a 1.5 T CMR at timepoint before, during, and after CMR. CMR, cardiac magnetic resonance imaging; ECG, electrocardiogram; ICD, implantable cardioverter–defibrillator (modified from); PM, pacemaker.

Figure 2

Wideband sequences (B and D) suppressing device-related artefacts (arrows): two patients with implanted ICDs [A, C Patient 1 imaged without wideband sequences showing relevant device-related artefacts (red arrows) and B, D Patient 2 imaged with wideband sequences]. A, B Cine sequence and B, D LGE imaging. circle: RV device lead. ICDs, implantable cardioverter–defibrillators; LGE, late gadolinium enhancement; RV, right ventricular.

Figure 3

Left atrial appendage thrombus (circle) in early arterial (A) and early venous (later) phase (B) CCT imaging. CCT, cardiac computed tomography.

Figure 4

Example of 3D LA reconstruction with contrast-enhanced CMR angiography (A, B) and 3D LA fibrosis reconstruction (C, D) (using Merisight technology) (green: dense fibrosis; blue: normal atrial myocardium). CMR, cardiac magnetic resonance; LA, left atrial.

Figure 5

Cardiac magnetic resonance of a patient with history of anterior MI prior to VT ablation in cine (A, B) and LGE (C, D) (circle: thrombus in the LV apex). LGE, late gadolinium enhancement; MI, myocardial infarction; VT, ventricular tachycardia.

Figure 6

Three-dimensional reconstruction of cardiac chambers with colour-coded information on regional wall thickness using the InHeart technology. Critical anatomical structures (coronary arteries and veins) are visualized to guide the ablation procedure. Colour coding of LV depicting myocardial thickness: dark red: 1 mm thickness, orange: 3 mm thickness, and yellow: 4 mm thickness; coronary arteries in red, coronary venous system in blue, and left phrenic nerve in green. LV, left atrial.

Figure 7

Different locations of LGE in non-ischaemic (A–C) and ischaemic (D) cardiomyopathy. Circles and arrows indicate the location of LGE:A subepicardially (in a patient after myocarditis), B intramural septal (in a patient with documented cardiac sarcoid), C intramural non-septal, D transmural/subendocardial in a patient with history of anterior transmural MI. Access route and ablation options could include epicardial access (A), bipolar septal ablation (B), bipolar endocardial–epicardial ablation (C), and primary endocardial access (D). LGE, late gadolinium enhancement; MI, myocardial infarction.

Figure 8

Characteristic CT (A–E, G) and endoscopy (F) findings in patients with A + B) oesophageal perforation, C + D) atrio-oesophageal fistula, E) oesophago-pericardial fistula, and F + G) perforating oesophageal ulcer. A) Air in mediastinum (red circle) with exit of water-soluble oral contrast into the mediastinum, B) i.v. contrast and documentation of air in mediastinum (red circle), C and D) air in mediastinum (red circle) and air and thrombus in the left atrium (arrow), E) i.v. contrast and identification of air in mediastinum (red circle) and pericardium (green circle), F) endoscopic finding 5 days after PV isolation with perforated oesophageal ulcer (yellow square), and G) corresponding CT with air in mediastinum (red circle). CT, computed tomography; PV, pulmonary vein.

Figure 9

A patient with history of a prior PV isolation procedure and history of recurrent pneumonia in the right superior lobe following the procedure. A) CT showing high-degree stenosis of the right superior PV (circle), B) 3D reconstruction of the left atrium demonstrating a high-degree ostial stenosis of the right superior PV (circle), C) angiography of the right superior PV after transseptal access through a coronary diagnostic catheter (x) showing high-degree stenosis (arrow) (A indicates diameter of PV after stenosis, B site of stenosis), D) contrast injection into right superior PV after wiring (w) of stenosis (red circle) with transseptal sheath close to PV ostium. CT, computed tomography; PV, pulmonary vein.

Figure 10

A and B) CT images of a patient with complete occlusion of the left inferior PV after prior PV isolation, C and D) post-stenting CT with stent open in left inferior PV, E) perfusion CT prior to stenting of the left inferior PV demonstrating a large perfusion defect in the left lung (blue colour). CT, computed tomography; PV, pulmonary vein

Figure 11

Pre-interventional CMR (cardiovascular magnetic resonance) pulmonary perfusion imaging and angiography for detection and characterization of pulmonary vein stenosis. A, B, C) CMR pulmonary perfusion imaging (anterior–posterior view) depicted a perfusion deficit of the left lower lung lobe (A still frame of original dynamic pulmonary perfusion; B still frame of dynamic pulmonary perfusion after background stationary tissue subtraction; C corresponding pseudo-coloured parametric map of quantitative CMR pulmonary perfusion analysis with SI maximum enhancement as the quantitative measure. D) Three-dimensional contrast-enhanced CMR angiography (posterior–anterior projectional view) revealed total ostial occlusion of the left lower pulmonary vein (arrow). CMR, cardiac magnetic resonance; SI, signal intensity.

Figure 12

Silent cerebral events documented in a Patient 1 day after AF ablation on cerebral MR imaging: A) FLAIR sequence (no lesions), B) DWI with hyperintense lesions, and C) ADC map with corresponding hypointensity [differentiation between SCEs (FLAIR negative) and SCLs (FLAIR positive)]. ADC, apparent diffusion coefficient; DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; MR, magnetic resonance; SCL, silent cerebral lesion; SCE, silent cerebral events.

Figure 13

Left: CT scan with contrast showing active bleeding (arrow) and a large retroperitoneal haematoma (X) following vascular access for pulmonary vein isolation in an obese patient (BMI 32 kg/m²). Bleeding source was the right obturator artery which has a variant originated from the external iliac artery. Right: digital subtraction angiography post-embolization (coil). Courtesy of Dr. N. Thieme, Charité Universitätsmedizin, Berlin. BMI, body mass index; CT, computed tomography.

Figure 14

Interventional CMR-guided ablation procedure. Two catheters (green and red tip) are actively tracked and displayed on MR images and 3D reconstructed cardiac surfaces (green: right atrium, dark blue: left atrium, and light blue: superior and inferior vena cava). Courtesy of Leipzig Heart Center. CMR, cardiac magnetic resonance; MR, magnetic resonance.