How to perform and interpret rotational angiography in the electrophysiology laboratory

Sophisticated imaging methods have been growing in popularity since the introduction of curative ablation procedures for atrial fibrillation (AF). This trend is predicated on the need for a precise anatomic guidance within the complex left atrial (LA) anatomy and less reliance on electrocardiographic characteristics of the substrate. Traditional two-dimensional imaging methods such as fluoroscopy would not satisfy the needs of a complex catheter navigation inside three-dimensional (3D) anatomic structures that may not be confined to the radiographic cardiac silhouette (e.g., pulmonary veins [PVs]). Consequently, development of imaging methods produced techniques of 3D reconstruction of the LA, PVs, and other surrounding structures. These 3D images provided by different modalities (electroanatomic mapping, computed tomography [CT], MRI, etc.) quickly became the mainstay of anatomically guided AF ablation procedures. An additional push to higher use of 3D imaging guidance was provided by the increased recognition of previously unknown procedural complications such as PV stenosis or esophageal perforation. Avoiding these complications requires a better understanding of anatomic relationships within the ablation field. Distances within the heart frequently are short, which emphasizes the importance of accuracy of exact anatomic replication and registration of cardiac structures. Existing imaging methods (e.g., electroanatomic mapping) frequently lack such accuracy of reconstruction because they are based on indirect assumptions. Merge techniques may provide higher anatomic accuracy, but they become more technologically challenging and present new problems with registration precision. Thus, the search for more accurate and at the same time simple and practical imaging methods continues. Angiography has always been the gold standard of anatomic accuracy, but application of biplane angiography to real-time guidance of ablation procedures is limited. The latest development in electrophysiologic (EP) imaging is 3D rotational angiography or atriography (3DATG), which combines the accuracy of direct angiography with the benefits of computer animation. Its feasibility and clinical utility in the setting of LA imaging and AF ablation were recently described. ^,  This article focuses on hands-on practical application of this exciting new method in the modern EP laboratory.