The impact of respiration on left atrial and pulmonary venous anatomy: Implications for image-guided intervention

Noseworthy, Peter A.; Malchano, Zachary J.; Ahmed, Jameel; Holmvang, Godtfred; Ruskin, Jeremy N.; Reddy, Vivek Y.

doi:10.1016/j.hrthm.2005.08.008

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Volume 2, Issue 11 , Pages 1173-1178, November 2005

The impact of respiration on left atrial and pulmonary venous anatomy: Implications for image-guided intervention

Peter A. Noseworthy, MD
- Cardiac Arrhythmia Service, Radiology Department, Massachusetts General Hospital – Harvard Medical School, Boston, Massachusetts
Zachary J. Malchano, BS
- Cardiac Arrhythmia Service, Radiology Department, Massachusetts General Hospital – Harvard Medical School, Boston, Massachusetts
Jameel Ahmed, MD
- Cardiac Arrhythmia Service, Radiology Department, Massachusetts General Hospital – Harvard Medical School, Boston, Massachusetts
Godtfred Holmvang, MD
- Cardiac MRI Unit, Radiology Department, Massachusetts General Hospital – Harvard Medical School, Boston, Massachusetts
Jeremy N. Ruskin, MD
- Cardiac Arrhythmia Service, Radiology Department, Massachusetts General Hospital – Harvard Medical School, Boston, Massachusetts
Vivek Y. Reddy, MD
- Cardiac Arrhythmia Service, Radiology Department, Massachusetts General Hospital – Harvard Medical School, Boston, Massachusetts
- Address for correspondence: Vivek Y. Reddy, MD, Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Gray Bigelow 109, Boston, Massachusetts 02114, Phone: (617) 726-2928, Fax: (617) 726-1460

published online 12 August 2005.

Background

Image-guided intervention using pre-acquired CT/MR 3-dimensional images is an emerging strategy for atrial fibrillation (AF) ablation but may be limited by its use of static images to depict dynamic physiology. The effect of biologic factors such as respiration on the left atrial-pulmonary venous (LA-PV) anatomy is not well understood but is likely to have important implications. Conventional CT/MR imaging is performed during an inspiratory breath-hold, while electroanatomical mapping (EAM) during “quiet” breathing approximates an expiratory breath-hold. This study examined the effects of respiration on LA-PV anatomy and the error introduced by respiration on the integration of EAM with 3D MR imaging.

Methods

Pre-procedural MRI angiography was performed at both end-expiration (EXP) and end -inspiration (INSP) in 20 patients undergoing AF catheter ablation. 3D INSP and EXP surface reconstructions of the LA-PVs were compared. In selected pts, EAM data acquired during the ablation procedure (n=7) were integrated with the 3D MRI datasets.

Results

Qualitative assessment of the INSP and EXP 3D images revealed splaying of the PVs and reduction in PV caliber of the right-sided PVs during held inspiration. After aligning these two datasets, the average surface-to-surface distance calculated by region ranged from 1.99mm (right middle PV) to 3.79mm (left superior PV). Registration of the EAM to the MRI models was better for the EXP dataset (2.30±0.73mm) than the INSP dataset (3.03±0.57mm; p=0.004).

Conclusion

There are significant changes in LA-PV anatomy with respiration. MR images acquired during standard held inspiration may introduce unnecessary errors in registration during image-guided intervention.

Keywords: Electrophysiology , Registration , Magnetic Resonance Imaging , Electroanatomical Mapping , Left Atrium , Pulmonary Veins , Respiration , Atrial Fibrillation , Ablation