Efficacy of LGE-MRI-guided fibrosis ablation versus conventional catheter ablation of atrial fibrillation: The DECAAF II trial: Study design.

INTRODUCTION: Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment. We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes. METHODS: The DECAAF II trial (ClinicalTrials. gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first-time ablation procedure were randomized in a 1:1 fashion to receive conventional pulmonary vein isolation (PVI) ablation (Group 1) or PVI + fibrosis-guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3-12 months postablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia postablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90-day postablation blanking period. Patients were followed for a period of 12-18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc.). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint. RESULTS AND CONCLUSION: The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden.

Left atrial fibrosis progression detected by LGE-MRI after ablation of atrial fibrillation.

BACKGROUND: Left atrial (LA) fibrosis is thought to be a substrate for atrial fibrillation (AF) and can be quantified by late gadolinium enhancement magnetic resonance imaging (LGE-MRI). Fibrosis formation in LA is a dynamic process and may either progress or regress following AF ablation. We examined the impact of postablation progression in LA fibrosis on AF recurrence. METHODS: LA enhancement in LGE-MRI was quantified in 127 consecutive patients who underwent first time AF ablation. Serial LGE-MRIs were done prior to AF ablation, 3 months postablation and at least 12 months after second LGE-MRI. Transient postablation lesion (TL) was defined as atrial enhancement caused by ablation lesions that was detected on the first (3 month) but not on the second postablation LGE-MRI. New fibrosis (NF) was defined as atrial enhancement detected on the most recent LGE-MRI, at least 15 months after the ablation procedure. AF recurrence and its correlation with TL and NF was assessed in all patients during the follow-up period. RESULTS: An increase of 1% NF increased the chance of postablation AF recurrence by 3% (hazard ratio [HR] 1.03, 95% CI 1-1.06, P = .05). TL had no significant impact on recurrence (P = .057). After adjusting for cardiovascular risk factors, HR increased as NF became greater. Greater volume of NF (≥21%) corresponded with lower arrhythmia-free survival (37% vs 62%, P = .01). CONCLUSION: NF formation postablation of AF is a novel marker of long-term procedural outcome. Extensive NF is associated with significantly higher risk of atrial arrhythmia recurrence.

Real-time magnetic resonance imaging-guided cryoablation of the pulmonary veins with acute freeze-zone and chronic lesion assessment.

AIMS: The goals of this study were to develop a method that combines cryoablation with real-time magnetic resonance imaging (MRI) guidance for pulmonary vein isolation (PVI) and to further quantify the lesion formation by imaging both acute and chronic cryolesions. METHODS AND RESULTS: Investigational MRI-compatible cryoablation devices were created by modifying cryoballoons and cryocatheters. These devices were used in canines (n = 8) and a complete series of lesions (PVI: n = 5, superior vena cava: n = 4, focal: n = 13) were made under real-time MRI guidance. Late gadolinium enhancement (LGE) magnetic resonance imaging was acquired at acute and chronic time points. Late gadolinium enhancement magnetic resonance imagings show a significant amount of acute tissue injury immediately following cryoablation which subsides over time. In the pulmonary veins, scar covered 100% of the perimeter of the ostium of the veins acutely, which subsided to 95.6 ± 4.3% after 3 months. Focal point lesions showed significantly larger acute enhancement volumes compared to the volumes estimated from gross pathology measurements (0.4392 ± 0.28 cm3 vs. 0.1657 ± 0.08 cm3, P = 0.0043). Additionally, our results with focal point ablations indicate that freeze-zone formation reached a maximum area after 120 s. CONCLUSION: This study reports on the development of an MRI-based cryoablation system and shows that with acute cryolesions there is a large area of reversible injury. Real-time MRI provides the ability to visualize the freeze-zone formation during the freeze cycle and for focal lesions reaches a maximum after 120 s suggesting that for maximizing lesion size 120 s might be the lower limit for dosing duration.

Acute noncontrast T1-weighted magnetic resonance imaging predicts chronic radiofrequency ablation lesions.

BACKGROUND: Magnetic resonance imaging (MRI) has been used to visualize radiofrequency (RF) ablation lesions but the relationship between volumes that enhance in acute MRI and the chronic lesion size is unknown. OBJECTIVES: The main goal was to use noncontrast (native) T1-weighted (T1w) MRI and late gadolinium enhancement (LGE)-MRI to visualize lesions acutely and chronically and correlate the acute area of enhancement with chronic lesion size in histology. MATERIALS AND METHODS: In a canine (n = 9) model RF ablation lesions were created in both ventricles. Native T1w MRI and LGE-MRI were acquired acutely after the ablation procedure. After 8 weeks, another set of RF ablations was performed, and the MRI study was repeated. Volume and depth of enhancement in native T1w MRI and LGE-MRI acquired after the initial ablation procedure were correlated with chronic lesion volume and depth in histology. RESULTS: Thirty-three lesions were analyzed. Native T1w MRI visualized the acute lesions but not the chronic lesions. LGE-MRI showed both acute and chronic lesions. Acute native T1w MRI volume (average of 102.1 ± 48.5 mm3 ) and depth (4.9 ± 1.2 mm) correlated well with chronic histological volume (105.9 ± 51.8 mm3 ) and depth (4.8 ± 1.3 mm) with R2 of 0.881 (P < 0.001) and 0.874 (P < 0.001), respectively. Acute LGE-MRI had a significantly higher volume of enhancement of 499.7 ± 214.4 mm3 (P < 0.001) and depth of 7.5 ± 1.8 mm ( P < 0.001) when compared with chronic histological lesion volume and depth. CONCLUSIONS: Native T1w MRI acquired acutely after RF ablation is a good predictor of chronic lesion size. Acute LGE-MRI significantly overestimates the chronic lesion size.

Durable lesion formation while avoiding esophageal injury during ablation of atrial fibrillation: Lessons learned from late gadolinium MR imaging.

INTRODUCTION: Adequate catheter/atrial tissue contact is critical for lesion formation during radiofrequency (RF) ablation of atrial fibrillation (AF). Late gadolinium enhancement magnetic resonance imaging (LGE-MRI) is a unique tool for the evaluation of lesion formation and detection of acute esophageal injury. METHODS: LGE-MRIs were obtained prior, within 24 hours of, and at 115 ± 62 days after first AF ablation in 36 patients. The Visitag module of CARTO3 was used to collect contact force (CF) and duration from a CF sensing ablation catheter for each registered ablation point. The minimum CF resulting in permanent lesions was determined. Esophageal enhancement detected by acute LGE-MRI was classified as mild, moderate, and severe. The CF resulting in esophageal enhancement was determined. RESULTS: A total of 4,642 registered ablation tags at 50 W power were analyzed. The mean RF duration (5.9 ± 3.7 vs. 5.6 ± 3.2 seconds, P < 0.05), CF (11.5 ± 5.6 vs. 10.9 ± 5.4 g, P < 0.001), and force time integral (FTI) (67.3 ± 54.5 vs. 62.2 ± 52.7 gs, P < 0.01) were significantly higher between ablation tags with and without associated LGE-MRI detected scar. The mean CF (15.7 ± 6.1 vs. 12.6 ± 5.9 g, P < 0.05, n  =  17 patients) in areas of esophageal enhancement was greater than areas without. CONCLUSION: Left atrial short duration ablation lesions with a CF greater than 12 g are more likely to be associated with permanent lesion formation. Ablating on top of the esophagus, CF less than 15 g would help minimize esophageal wall injury.

Age and sex differences in atrial fibrosis among patients with atrial fibrillation.

Aim: Age and female sex are associated with a higher risk of stroke in atrial fibrillation (AF). We sought to determine whether advancing age and female sex are associated with higher atrial fibrosis. Methods and results: We conducted an observational cohort study of patients with AF enrolled in the University of Utah AF Database and a non-AF control group who underwent late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) for atrial fibrosis quantification. Participants with contra-indications for contrast MRI scanning were excluded. Nine hundred and eight consecutive men and women with AF and 15 non-AF controls were included in this study. Left atrial fibrosis increased with age in both men and women with AF. Women with AF (n = 316) were older than men (n = 592): mean age 68.7±11.6 vs. 64.9±11.7 years; P < 0.01, and had higher left atrial fibrosis compared with men 17.5 ± 10.1% vs. 15.3 ± 8.9%; P < 0.001. Women also had a higher prevalence of prior stroke compared with men (15.8% vs. 6.5%; P < 0.001). Age and sex relationships with atrial fibrosis remained significant in multivariate analysis. Compared with the non-AF control group, patients with AF had significantly higher atrial fibrosis: 16.0 ± 9.4 vs. 5.5 ± 5.8%; P < 0.001. Conclusions: Advancing age and female sex are associated with a higher burden of atrial fibrosis in patients with AF. Women with a prior history of stroke also have higher fibrosis compared with both women and men without history of stroke. Advanced fibrosis may explain the female and age association with stroke in AF.

Real-Time MRI-Guided Cardiac Cryo-Ablation: A Feasibility Study.

INTRODUCTION: MRI-based ablation provides an attractive capability of seeing ablation-related tissue changes in real time. Here we describe a real-time MRI-based cardiac cryo-ablation system. METHODS: Studies were performed in canine model (n = 4) using MR-compatible cryo-ablation devices built for animal use: focal cryo-catheter with 8 mm tip and 28 mm diameter cryo-balloon. The main steps of MRI-guided cardiac cryo-ablation procedure (real-time navigation, confirmation of tip-tissue contact, confirmation of vessel occlusion, real-time monitoring of a freeze zone formation, and intra-procedural assessment of lesions) were validated in a 3 Tesla clinical MRI scanner. RESULTS: The MRI compatible cryo-devices were advanced to the right atrium (RA) and right ventricle (RV) and their position was confirmed by real-time MRI. Specifically, contact between catheter tip and myocardium and occlusion of superior vena cava (SVC) by the balloon was visually validated. Focal cryo-lesions were created in the RV septum. Circumferential ablation of SVC-RA junction with no gaps was achieved using the cryo-balloon. Real-time visualization of freeze zone formation was achieved in all studies when lesions were successfully created. The ablations and presence of collateral damage were confirmed by T1-weighted and late gadolinium enhancement MRI and gross pathological examination. CONCLUSION: This study confirms the feasibility of a MRI-based cryo-ablation system in performing cardiac ablation procedures. The system allows real-time catheter navigation, confirmation of catheter tip-tissue contact, validation of vessel occlusion by cryo-balloon, real-time monitoring of a freeze zone formation, and intra-procedural assessment of ablations including collateral damage.

Comparison of centric and reverse-centric trajectories for highly accelerated three-dimensional saturation recovery cardiac perfusion imaging.

PURPOSE: Highly undersampled three-dimensional (3D) saturation-recovery sequences are affected by k-space trajectory since the magnetization does not reach steady state during the acquisition and the slab excitation profile yields different flip angles in different slices. This study compares centric and reverse-centric 3D cardiac perfusion imaging. METHODS: An undersampled (98 phase encodes) 3D ECG-gated saturation-recovery sequence that alternates centric and reverse-centric acquisitions each time frame was used to image phantoms and in vivo subjects. Flip angle variation across the slices was measured, and contrast with each trajectory was analyzed via Bloch simulation. RESULTS: Significant variations in flip angle were observed across slices, leading to larger signal variation across slices for the centric acquisition. In simulation, severe transient artifacts were observed when using the centric trajectory with higher flip angles, placing practical limits on the maximum flip angle used. The reverse-centric trajectory provided less contrast, but was more robust to flip angle variations. CONCLUSION: Both of the k-space trajectories can provide reasonable image quality. The centric trajectory can have higher CNR, but is more sensitive to flip angle variation. The reverse-centric trajectory is more robust to flip angle variation.

Wideband late gadolinium enhanced magnetic resonance imaging for imaging myocardial scar without image artefacts induced by implantable cardioverter-defibrillator: a feasibility study at 3 T.

AIM: Late gadolinium enhanced (LGE) magnetic resonance imaging (MRI) is a useful tool for facilitating ventricular tachycardia (VT) ablation. Unfortunately, most VT ablation candidates often have prophylactic implantable cardioverter-defibrillator (ICD) and do not undergo cardiac MRI largely due to image artefacts generated by ICD. A prior study has reported success of 'wideband' LGE MRI for imaging myocardial scar without image artefacts induced by ICD at 1.5T. The purpose of this study was to widen the availability of wideband LGE MRI to 3T, since it has the potential to achieve higher spatial resolution than 1.5T. METHODS AND RESULTS: We compared the performance of standard and wideband LGE MRI pulse sequences in phantoms and canines with myocardial lesions created by radiofrequency ablation. Standard LGE MRI produced image artefacts induced by ICD and 49% accuracy in detecting 97 myocardial scars examined in this study, whereas wideband LGE MRI produced artefact-free images and 94% accuracy in detecting scars. The mean image quality score (1 = nondiagnostic, 2 = poor, 3 = adequate, 4 = good, 5 = excellent) was significantly (P < 0.001) higher for wideband (3.7 ± 0.8) than for standard LGE MRI (2.1 ± 0.7). The mean artefact level score (1 = minimal, 2 = mild, 3 = moderate, 4 = severe, 5 = nondiagnostic) was significantly (P < 0.001) lower for wideband (2.1 ± 0.8) than for standard LGE MRI (4.0 ± 0.6). Wideband LGE MRI agreed better with gross pathology than standard LGE MRI. CONCLUSION: This study demonstrates the feasibility of wideband LGE MRI for suppression of image artefacts induced by ICD at 3T.

Comparison of left atrial area marked ablated in electroanatomical maps with scar in MRI.

BACKGROUND: Three-dimensional electroanatomic mapping (EAM) is routinely used to mark ablated areas during radiofrequency ablation. We hypothesized that, in atrial fibrillation (AF) ablation, EAM overestimates scar formation in the left atrium (LA) when compared to the scar seen on late-gadolinium enhancement magnetic resonance imaging (LGE-MRI). METHODS AND RESULTS: Of the 235 patients who underwent initial ablation for AF at our institution between August 2011 and December 2012, we retrospectively identified 70 patients who had preprocedural magnetic resonance angiography merged with LA anatomy in EAM software and had a 3-month postablation LGE-MRI for assessment of scar. Ablated area was marked intraprocedurally using EAM software and quantified retrospectively. Scarred area was quantified in 3-month postablation LGE-MRI. The mean ablated area in EAM was 30.5 ± 7.5% of the LA endocardial surface and the mean scarred area in LGE-MRI was 13.9 ± 5.9% (P < 0.001). This significant difference in the ablated area marked in the EAM and scar area in the LGE-MRI was present for each of the 3 independent operators. Complete pulmonary vein (PV) encirclement representing electrical isolation was observed in 87.8% of the PVs in EAM as compared to only 37.4% in LGE-MRI (P < 0.001). CONCLUSIONS: In AF ablation, EAM significantly overestimates the resultant scar as assessed with a follow-up LGE-MRI.

Post-contrast myocardial T(1) and ECV disagree in a longitudinal canine study.

Both post-contrast myocardial T1 and extracellular volume (ECV) measurements have been associated with diffuse interstitial fibrosis. The cardiovascular magnetic resonance (CMR) field is migrating towards ECV, because it is largely insensitive to confounders that affect post-contrast myocardial T1 . Despite the theoretical advantages of myocardial ECV over post-contrast myocardial T1 , systematic experimental studies comparing the two measurements are largely lacking. We sought to measure the temporal changes in post-contrast myocardial T1 and ECV in an established canine model with chronic atrial fibrillation. Seventeen mongrel dogs, implanted with a pacemaker to induce chronic atrial fibrillation via rapid atrial pacing, were scanned multiple times for a total of 46 CMR scans at 3T. These dogs with different disease durations (0-22 months) were part of a separate longitudinal study aimed at studying the relationship between AF and pathophysiology. In each animal, we measured native and post-contrast T1 values and hematocrit. Temporal changes in post-contrast myocardial T1 and ECV, as well as other CMR parameters, were modeled with linear mixed effect models to account for repeated measurements over disease duration. In 17 animals, post-contrast myocardial T1 decreased significantly from 872 to 698 ms (p < 0.001), which corresponds to a 24.9% relative reduction. In contrast, ECV increased from 21.0 to 22.0% (p = 0.38), which corresponds to only a 4.5% relative increase. To partially investigate this discrepancy, we quantified collagen volume fraction (CVF) in post-mortem heart tissues of six canines sacrificed at different disease durations (0-22 months). CVF quantified by histology increased from 0.9 to 1.9% (p = 0.56), which agrees better with ECV than with post-contrast myocardial T1 . This study shows that post-contrast myocardial T1 and ECV may disagree in a longitudinal canine study. A more comprehensive study, including histologic, cardiac, and renal functional analyses, is warranted to test rigorously which CMR parameter (ECV or post-contrast myocardial T1 ) agrees better with CVF.

Evaluation of highly accelerated real-time cardiac cine MRI in tachycardia.

Electrocardiogram (ECG)-gated breath-hold cine MRI is considered to be the gold standard test for the assessment of cardiac function. However, it may fail in patients with arrhythmia, impaired breath-hold capacity and poor ECG gating. Although ungated real-time cine MRI may mitigate these problems, commercially available real-time cine MRI pulse sequences using parallel imaging typically yield relatively poor spatiotemporal resolution because of their low image acquisition efficiency. As an extension of our previous work, the purpose of this study was to evaluate the diagnostic quality and accuracy of eight-fold-accelerated real-time cine MRI with compressed sensing (CS) for the quantification of cardiac function in tachycardia, where it is challenging for real-time cine MRI to provide sufficient spatiotemporal resolution. We evaluated the performances of eight-fold-accelerated cine MRI with CS, three-fold-accelerated real-time cine MRI with temporal generalized autocalibrating partially parallel acquisitions (TGRAPPA) and ECG-gated breath-hold cine MRI in 21 large animals with tachycardia (mean heart rate, 104 beats per minute) at 3T. For each cine MRI method, two expert readers evaluated the diagnostic quality in four categories (image quality, temporal fidelity of wall motion, artifacts and apparent noise) using a Likert scale (1-5, worst to best). One reader evaluated the left ventricular functional parameters. The diagnostic quality scores were significantly different between the three cine pulse sequences, except for the artifact level between CS and TGRAPPA real-time cine MRI. Both ECG-gated breath-hold cine MRI and eight-fold accelerated real-time cine MRI yielded all four scores of ≥ 3.0 (acceptable), whereas three-fold-accelerated real-time cine MRI yielded all scores below 3.0, except for artifact (3.0). The left ventricular ejection fraction (LVEF) measurements agreed better between ECG-gated cine MRI and eight-fold-accelerated real-time cine MRI (mean difference, -1.6%) than between ECG-gated cine MRI and three-fold-accelerated real-time cine MRI (mean difference, -5.7%). Eight-fold-accelerated real-time cine MRI with CS yields acceptable diagnostic quality and relatively accurate LVEF measurements in the challenging setting of tachycardia.

T1 mapping for Head and Neck Cancer Patients undergoing Chemoradiotherapy: Feasibility of 3D Stack of Star Imaging.

BACKGROUND: Measuring tissue oxygen concentration is crucial in understanding the pathophysiological process of hypoxia in head and neck cancer (HNC) and its significant role in cancer biology. This study aimed to determine the feasibility of T1 mapping using a variable flip angle (VFA) technique with stack of stars (SOS) trajectory sampling in HNC patients undergoing chemoradiotherapy (CRT). METHODS: To evaluate the ability of SOS acquisition to detect T1, a phantom study was conducted and compared to conventional Cartesian acquisition (CART). Additionally, four newly diagnosed patients were recruited and underwent two scans each at baseline and inter-treatment. The repeatability of SOS and CART acquisitions was assessed by comparing the T1 measurements of CSF from the baseline and intra-treatment MRI studies. The changes in ∆T1 of the tumors during air and oxygen inhalation between baseline and inter-treatment scans were also evaluated. RESULTS: Our study found that the 3D VFA SOS sequence was effective in reducing motion artifacts compared to the conventional VFA sequence with CART sampling and the same scan time, as demonstrated by the results from the phantom and patient studies. In terms of repeatability, no significant correlation was observed between the variability in ΔT1 measurements of CSF obtained from SOS T1 maps. The SOS ΔT1 measurements showed higher consistency, as evidenced by the ICC values ranging from 0.52 to 0.92. The ∆T1 measurements on the primary tumors increased after the first CRT (p<0.05) for all patients who showed a positive treatment response, except for one patient (0.05

Left atrial volume affects the correlation of voltage map with magnetic resonance imaging.

BACKGROUND: The low-voltage area detected by electroanatomic mapping (EAM) is a surrogate marker of left atrial fibrosis. However, the correlation between the EAM and late gadolinium enhancement magnetic resonance imaging (LGE-MRI) has been inconsistent among studies. This study aimed to investigate how LA size affects the correlation between EAM and LGE-MRI. METHODS: High-density EAMs of the LA during sinus rhythm were collected in 22 patients undergoing AF ablation. The EAMs were co-registered with pre-ablation LGE-MRI models. Voltages in the areas with and without LGE were recorded. Left atrial volume index (LAVI) was calculated from MRI, and LAVI > 62 ml/m2 was defined as significant LA enlargement (LAE). RESULTS: Atrial bipolar voltage negatively correlates with the left atrial volume index. The median voltages in areas without LGE were 1.1 mV vs 2.0 mV in patients with vs without significant LAE (p = 0.002). In areas of LGE, median voltages were 0.4 mV vs 0.8 mV in patients with vs without significant LAE (p = 0.02). A voltage threshold of 1.7 mV predicted atrial LGE in patients with normal or mildly enlarged LA (sensitivity and specificity of 74% and 59%, respectively). In contrast, areas of voltage less than 0.75 mV correlated with LGE in patients with significant LA enlargement (sensitivity 68% and specificity 66%). CONCLUSIONS: LAVI affects left atrial bipolar voltage, and the correlation between low-voltage areas and LGE-MRI. Distinct voltage thresholds according to the LAVI value might be considered to identify atrial scar by EAM.

Optimizing the Distribution of Ablation Lesions to Prevent Postablation Atrial Tachycardia: A Personalized Digital-Twin Study.

BACKGROUND: Although targeting atrial fibrillation (AF) drivers and substrates has been used as an effective adjunctive ablation strategy for patients with persistent AF (PsAF), it can result in iatrogenic scar-related atrial tachycardia (iAT) requiring additional ablation. Personalized atrial digital twins (DTs) have been used preprocedurally to devise ablation targeting that eliminate the fibrotic substrate arrhythmogenic propensity and could potentially be used to predict and prevent postablation iAT. OBJECTIVES: In this study, the authors sought to explore possible alternative configurations of ablation lesions that could prevent iAT occurrence with the use of biatrial DTs of prospectively enrolled PsAF patients. METHODS: Biatrial DTs were generated from late gadolinium enhancement-magnetic resonance images of 37 consecutive PsAF patients, and the fibrotic substrate locations in the DT capable of sustaining reentries were determined. These locations were ablated in DTs by representing a single compound region of ablation with normal power (SSA), and postablation iAT occurrence was determined. At locations of iAT, ablation at the same DT target was repeated, but applying multiple lesions of reduced-strength (MRA) instead of SSA. RESULTS: Eighty-three locations in the fibrotic substrates of 28 personalized biatrial DTs were capable of sustaining reentries and were thus targeted for SSA ablation. Of these ablations, 45 resulted in iAT. Repeating the ablation at these targets with MRA instead of SSA resulted in the prevention of iAT occurrence at 15 locations (18% reduction in the rate of iAT occurrence). CONCLUSIONS: Personalized atrial DTs enable preprocedure prediction of iAT occurrence after ablation in the fibrotic substrate. It also suggests MRA could be a potential strategy for preventing postablation AT.

Cardiac MRI Oversampling in Heart Digital Twins Improves Preprocedure Ventricular Tachycardia Identification in Postinfarction Patients.

BACKGROUND: Ventricular tachycardia (VT), which can lead to sudden cardiac death, occurs frequently in patients after myocardial infarction. Radiofrequency catheter ablation (RFA) is a modestly effective treatment of VT, but it has limitations and risks. Cardiac magnetic resonance (CMR)-based heart digital twins have emerged as a useful tool for identifying VT circuits for RFA treatment planning. However, the CMR resolution used to reconstruct these digital twins may impact VT circuit predictions, leading to incorrect RFA treatment planning. OBJECTIVES: This study sought to predict RFA targets in the arrhythmogenic substrate using heart digital twins reconstructed from both clinical and high-resolution 2-dimensional CMR datasets and compare the predictions. METHODS: High-resolution (1.35 × 1.35 × 3 mm), or oversampled resolution (Ov-Res), short-axis late gadolinium-enhanced CMR was acquired by combining 2 subsequent clinical resolution (Clin-Res) (1.35 × 1.35 × 6 mm) short-axis late gadolinium-enhanced CMR scans from 6 post-myocardial infarction patients undergoing VT ablation and used to reconstruct a total of 3 digital twins (1 Ov-Res, 2 Clin-Res) for each patient. Rapid pacing was used to assess VT circuits and identify the optimal ablation targets in each digital twin. VT circuits predicted by the digital twins were compared with intraprocedural electroanatomic mapping data and used to identify emergent VT. RESULTS: The Ov-Res digital twins reduced partial volume effects and better predicted unique VT circuits compared with the Clin-Res digital twins (66.6% vs 54.5%; P < 0.01). Only the Ov-Res digital twin successfully identified emergent VT after a failed initial ablation. CONCLUSIONS: Digital twin infarct geometry and VT circuit predictions depend on the magnetic resonance resolution. Ov-Res digital twins better predict VT circuits and emergent VT, which may improve RFA outcomes.

Assessing the arrhythmogenic propensity of fibrotic substrate using digital twins to inform a mechanisms-based atrial fibrillation ablation strategy.

Atrial fibrillation (AF), the most common heart rhythm disorder, may cause stroke and heart failure. For patients with persistent AF with fibrosis proliferation, the standard AF treatment-pulmonary vein isolation-has poor outcomes, necessitating redo procedures, owing to insufficient understanding of what constitutes good targets in fibrotic substrates. Here we present a prospective clinical and personalized digital twin study that characterizes the arrhythmogenic properties of persistent AF substrates and uncovers locations possessing rotor-attracting capabilities. Among these, a portion needs to be ablated to render the substrate not inducible for rotors, but the rest (37%) lose rotor-attracting capabilities when another location is ablated. Leveraging digital twin mechanistic insights, we suggest ablation targets that eliminate arrhythmia propensity with minimum lesions while also minimizing the risk of iatrogenic tachycardia and AF recurrence. Our findings provide further evidence regarding the appropriate substrate ablation targets in persistent AF, opening the door for effective strategies to mitigate patients' AF burden.

Unipolar voltage electroanatomical mapping detects structural atrial remodeling identified by LGE-MRI.

BACKGROUND: In atrial fibrillation (AF) management, understanding left atrial (LA) substrate is crucial. While both electroanatomical mapping (EAM) and late gadolinium enhancement MRI (LGE-MRI) are accepted methods for assessing the atrial substrate and are associated with ablation outcome, recent findings have highlighted discrepancies between low voltage areas (LVAs) in EAM and LGE-areas. OBJECTIVE: Explore the relationship between LGE regions and unipolar and bipolar-LVAs utilizing multipolar high-density (HD) mapping. METHODS: 20 patients scheduled for AF ablation underwent pre-ablation LGE-MRI. LA segmentation was conducted using a deep learning approach, which subsequently generated a 3D mesh integrating the LGE data. HD-EAM was performed in sinus rhythm for each patient. The EAM map and LGE-MRI mesh were co-registered. LVAs were defined using voltage cut-offs of 0.5mV for bipolar and 2.5mV for unipolar. Correspondence between LGE-areas and LVAs in the LA was analyzed using confusion matrices and performance metrics. RESULTS: A considerable 87.3% of LGE regions overlapped with unipolar-LVAs, compared to only 16.2% overlap observed with bipolar-LVAs. Across all performance metrics, unipolar-LVAs outperformed bipolar-LVAs in identifying LGE-areas [precision (78.6% vs. 61.1%); sensitivity (87.3% vs. 16.2%); F1 score (81.3% vs. 26.0%); accuracy (74.0% vs. 35.3%)]. CONCLUSION: Our findings demonstrate that unipolar-LVAs highly correlate with LGE regions. These findings support the integration of unipolar mapping alongside bipolar mapping into clinical practice. This would offer a nuanced approach to diagnose and manage atrial fibrillation by revealing critical insights into the complex architecture of the atrial substrate.

Initial feasibility testing of limited field of view magnetic resonance thermometry using a local cardiac radiofrequency coil.

The visualization of lesion formation in real time is one potential benefit of carrying out radiofrequency ablation under magnetic resonance (MR) guidance in the treatment of atrial fibrillation. MR thermometry has the potential to detect such lesions. However, performing MR thermometry during cardiac radiofrequency ablation requires high temporal and spatial resolution and a high signal-to-noise ratio. In this study, a local MR coil (2-cm diameter) was developed to investigate the feasibility of performing limited field of view MR thermometry with high accuracy and speed. The local MR coil allowed high-resolution (1 × 1 × 3 mm(3)) image acquisitions in 76.3 ms with a field of view 64 × 32 mm(2) during an open-chest animal experiment. This represents a 4-fold image acquisition acceleration and an 18-fold field of view reduction compared to that achieved using external MR coils. The signal sensitivity achieved using the local coil was over 20 times greater than that achievable using external coils with the same scan parameters. The local coil configuration provided fewer artifacts and sharper and more stable images. These results demonstrate that MR thermometry can be performed in the heart wall and that lesion formation can be observed during radiofrequency ablation procedures in a canine model.

Arrhythmia insensitive rapid cardiac T1 mapping pulse sequence.

PURPOSE: To develop an arrhythmia-insensitive rapid (AIR) cardiac T1 mapping pulse sequence for quantification of diffuse fibrosis. METHODS: An arrhythmia-insensitive cardiac T1 mapping pulse sequence was developed based on saturation recovery T1 weighting, which is inherently insensitive to heart rate and rhythm, and two single-shot balanced steady-state free precession image acquisitions with centric k-space ordering, where T1 calculation is inherently insensitive to T2 effects. Its performance against conventional cardiac T1 mapping based on inversion recovery (i.e., MOLLI) is compared. Phantom experiments (T1 ranging from 535 to 2123 ms) were performed with heart rate and rhythm simulated at 60 and 120 beats per minute (bpm) and arrhythmia using an external triggering device. Ten human subjects and 17 large animals were scanned precontrast and 5, 10, and 15 min after contrast agent administration. RESULTS: Compared with the reference T1 mapping, AIR yielded lower normalized root-mean-square error than MOLLI (8% vs. 3%, respectively, at 60 bpm, 28% vs. 3%, respectively, at 120 bpm, and 22% vs. 3%, respectively, at arrhythmia). In vivo studies showed that T1 measurements made by MOLLI and AIR were strongly correlated (r = 0.99) but in poor agreement (mean difference = 161.8 ms, upper and lower 95% limits of agreements = 347.5 ms and -24.0 ms). CONCLUSION: Our AIR pulse sequence may be clinically useful for assessment of diffuse myocardial fibrosis in patients.