Multi-network approach for image segmentation in non-contrast enhanced cardiac 3D MRI of arrhythmic patients.

Left atrial appendage (LAA) is the source of thrombi formation in more than 90% of strokes in patients with nonvalvular atrial fibrillation. Catheter-based LAA occlusion is being increasingly applied as a treatment strategy to prevent stroke. Anatomical complexity of LAA makes percutaneous occlusion commonly performed under transesophageal echocardiography (TEE) and X-ray (XR) guidance especially challenging. Image fusion techniques integrating 3D anatomical models derived from pre-procedural imaging into the live XR fluoroscopy can be applied to guide each step of the LAA closure. Cardiac magnetic resonance (CMR) imaging gains in importance for radiation-free evaluation of cardiac morphology as alternative to gold-standard TEE or computed tomography angiography (CTA). Manual delineation of cardiac structures from non-contrast enhanced CMR is, however, labor-intensive, tedious, and challenging due to the rather low contrast. Additionally, arrhythmia often impairs the image quality in ECG synchronized acquisitions causing blurring and motion artifacts. Thus, for cardiac segmentation in arrhythmic patients, there is a strong need for an automated image segmentation method. Deep learning-based methods have shown great promise in medical image analysis achieving superior performance in various imaging modalities and different clinical applications. Fully-convolutional neural networks (CNNs), especially U-Net, have become the method of choice for cardiac segmentation. In this paper, we propose an approach for automatic segmentation of cardiac structures from non-contrast enhanced CMR images of arrhythmic patients based on CNNs implemented in a multi-stage pipeline. Two-stage implementation allows subdividing the task into localization of the relevant cardiac structures and segmentation of these structures from the cropped sub-regions obtained from previous step leading to efficient and effective way of automated cardiac segmentation.

Pre-procedural determination of device size in left atrial appendage occlusion using three-dimensional cardiac computed tomography.

The complex structure of the left atrial appendage (LAA) brings limitations to the two-dimensional-based LAA occlusion (LAAO) size prediction system using transesophageal echocardiography. The LAA anatomy can be evaluated more precisely using three-dimensional images from cardiac computed tomography (CT); however, there is lack of data regarding which parameter to choose from CT-based images during pre-procedural planning of LAAO. We aimed to assess the accuracy of measurements derived from cardiac CT images for selecting LAAO devices. We retrospectively reviewed 62 patients with Amplatzer Cardiac Plug and Amulet LAAO devices who underwent implantation from 2017 to 2020. The minimal, maximal, average, area-derived, and perimeter-derived diameters of the LAA landing zone were measured using CT-based images. Predicted device sizes using sizing charts were compared with actual successfully implanted device sizes. The mean size of implanted devices was 27.1 ± 3.7 mm. The perimeter-derived diameter predicted device size most accurately (mean error = - 0.8 ± 2.4 mm). All other parameters showed significantly larger error (mean error; minimal diameter = - 4.9 ± 3.3 mm, maximal diameter = 1.0 ± 2.9 mm, average diameter = - 1.6 ± 2.6 mm, area-derived diameter = - 2.0 ± 2.6 mm) than the perimeter-derived diameter (all p for difference < 0.05). The error for other parameters were larger in cases with more eccentrically-shaped landing zones, while the perimeter-derived diameter had minor error regardless of eccentricity. When oversizing was used, all parameters showed significant disagreement. The perimeter-derived diameter on cardiac CT images provided the most accurate estimation of LAAO device size regardless of landing zone eccentricity. Oversizing was unnecessary when using cardiac CT to predict an accurate LAAO size.

Anatomical Characteristics of the Left Atrium and Left Atrial Appendage in Relation to the Risk of Stroke in Patients With Versus Without Atrial Fibrillation.

[Figure: see text].

A new machine learning approach for predicting likelihood of recurrence following ablation for atrial fibrillation from CT.

OBJECTIVE: To investigate left atrial shape differences on CT scans of atrial fibrillation (AF) patients with (AF+) versus without (AF-) post-ablation recurrence and whether these shape differences predict AF recurrence. METHODS: This retrospective study included 68 AF patients who had pre-catheter ablation cardiac CT scans with contrast. AF recurrence was defined at 1 year, excluding a 3-month post-ablation blanking period. After creating atlases of atrial models from segmented AF+ and AF- CT images, an atlas-based implicit shape differentiation method was used to identify surface of interest (SOI). After registering the SOI to each patient model, statistics of the deformation on the SOI were used to create shape descriptors. The performance in predicting AF recurrence using shape features at and outside the SOI and eight clinical factors (age, sex, left atrial volume, left ventricular ejection fraction, body mass index, sinus rhythm, and AF type [persistent vs paroxysmal], catheter-ablation type [Cryoablation vs Irrigated RF]) were compared using 100 runs of fivefold cross validation. RESULTS: Differences in atrial shape were found surrounding the pulmonary vein ostia and the base of the left atrial appendage. In the prediction of AF recurrence, the area under the receiver-operating characteristics curve (AUC) was 0.67 for shape features from the SOI, 0.58 for shape features outside the SOI, 0.71 for the clinical parameters, and 0.78 combining shape and clinical features. CONCLUSION: Differences in left atrial shape were identified between AF recurrent and non-recurrent patients using pre-procedure CT scans. New radiomic features corresponding to the differences in shape were found to predict post-ablation AF recurrence.

Thromboembolism in Atrial Fibrillation: Role of the Left Atrial Appendage.

Atrial fibrillation (AF) is the most common arrhythmia. Patients with AF have a higher risk for thromboembolism than individuals without AF. The left atrial appendage (LAA) is the main source of thromboembolism because of its anatomic, mechanical, and electrophysiologic properties, and accounts for more than 90% of thrombus formation in patients with AF. Advancement in imaging expands knowledge about anatomic and physiologic characteristics of LAA. The risk of thromboembolism events in patients with AF depends on clinical comorbidities and structural and physiologic parameters of atria, especially LAA. This article discusses AF-related thromboembolic events and the role of the LAA.

Anatomic Considerations for Epicardial and Endocardial Left Atrial Appendage Closure.

Left atrial appendage closure is an increasingly used means of achieving thromboprophylaxis in atrial fibrillation, particularly in patients with contraindications to anticoagulation. Left atrial appendage anatomy is highly variable, and preprocedural imaging is critical to choosing the correct device and approach for left atrial appendage closure. This article reviews the common endocardial and epicardial closure systems, including anatomic considerations, advantages and disadvantages, as well as complications to be avoided.

Morphometric study of the left atrial appendage related to closure device deployment: a cadaveric study in Thai population.

BACKGROUND: This study aims to investigate the left atrial appendage (LAA) regarding external morphology, positional relation of the ostium of LAA to the left superior pulmonary vein (LSPV), ostium shape, ostium diameter and functional depth. MATERIALS AND METHODS: Left atrial appendages of 65 cadaveric hearts were examined. RESULTS: The prevalence of Cauliflower, Windsock, Cactus and Chicken wing type of LAA were 27.7%, 27.7%, 26.1%, and 18.5%, respectively. LAA with two lobes was the most common. All specimens showed no accessory LAA. The relation of the ostium to the LSPV was found in two types which were mid-type (LAA ostium was at the same level as LSPV) in 29 (44.6%) cases and inferior type (LAA ostium was below the level of LSPV) in 36 (55.4%) cases. The shapes of LAA ostium were oval and round with a prevalence of 55.4% and 44.6%, respectively. The diameter of round type ranged from 9.53 to 21.51 mm with a mean of 14.56 ± 2.6 mm. While in oval type, the long and short diameters ranged from 11.61 to 31.71 mm with a mean of 14.23 ± 4.2 mm and from 6.70 to 23.90 mm with a mean of 11.66 ± 3.5 mm, respectively. The Surface area of the ostium was calculated from the ostium diameter, range from 71.29 to 594.92 mm2 with a mean of 169.56 ± 84.73 mm2. There was no statistically significant difference of the surface area between LAA types. The mean functional depth of LAA was 11.57 ± 4.43 mm. The functional depth of the Windsock-type appeared to be statistically significant from the others. However, there was no correlation between the functional depth and the ostium surface area. CONCLUSIONS: This morphometric data might be beneficial for deployment of LAA closure device in the Thai population.

Checking the shape and lobation of the right atrial appendage in view of their clinical relevance.

Clinically, anatomy of the appendage of the atrium is associated with atrial fibrillation, with the shape and lobation of the appendage having been used to stratify the risk of thromboembolic events. The aim of this study was to examine the age-dependent change in the shape and lobation of the right atrial appendage. A cross-sectional evaluation of the heart of 172 adults and 61 children, fixed in 4% formalin solution was performed. The morphology of the atrial appendage was assessed based on its shape and number of lobes. The following shapes of the appendage were identified: horse head, parrot beak, anvil, sailboat, and undefined. Using the horse head shape as a reference, the risk for a thromboembolic event was higher for anvil, sailboat and undefined shapes of the appendage (p < 0.001). The number of lobes ranged between 1 and 6 in adults, and 1 and 5 in children. The number of lobes for each shape was equivalent between adults and children (p > 0.05). Our analysis indicated that the number of lobes and the distribution of shapes of the atrial appendage remained unchanged throughout life. The risk for a thromboembolic event increased with the morphological complexity of the appendage (anvil, sailboat, and undefined), with 21% of adult hearts being prone to intra-atrial thrombosis in cases of fibrillation.

Thrombogenic and Arrhythmogenic Roles of the Left Atrial Appendage in Atrial Fibrillation.

Understanding the anatomy, physiology, and arrhythmogenic and thrombogenic roles of the left atrial appendage (LAA) has become very important. The potential deleterious effects of this chamber in patients with atrial fibrillation have led to the development of specific treatments for this structure. It has been established that the LAA is the area where the vast majority of thrombi in nonvalvular atrial fibrillation are formed and that some LAA morphologies may actually facilitate thrombi formation and risk stratification for thromboembolic events in patients with low CHA2DS2-VASc scores. Likewise, clinical data supporting the role of LAA electric isolation to improve freedom from all-atrial arrhythmias are rapidly growing. Acute LAA electric isolation can be achieved in most cases of catheter ablation for atrial fibrillation. However, late LAA reconnections are frequent. Special considerations should be taken when this procedure is performed to avoid myocardial perforation, left phrenic nerve, and left circumflex coronary artery damage. LAA electric isolation is a safe procedure that does not increase the risk of stroke as long as patients remain compliant with lifelong anticoagulation regardless of CHA2DS2-VASc score. Finally, ligation of the LAA has recently been associated with modulation of the renin-angiotensin-aldosterone system with clinical implications in blood pressure control.

Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line.

Electric isolation of the left atrial appendage (LAA) and linear ablations in the area of the LAA base are gaining popularity. However, very little is known about the myocardial architecture and the presence of epicardial blood vessels within this region, which could significantly influence the course of such procedures. We examined 200 autopsied hearts (22.5% females, 46.7 ± 16.8 years old). The LAA isthmus (i.e., the line between the LAA ostium and the mitral annulus) was cut longitudinally. The myocardium was thickest at the LAA end of the isthmus (2.4 ± 0.7 mm) followed by its middle sector (2.1 ± 0.7 mm) inside the LAA, 5 mm from its ostium (1.9 ± 0.7 mm), and the mitral annulus end of the isthmus (1.8 ± 0.6 mm) (P < 0.0001). At least one artery was found in 96.5% of all samples (89.5% were single branched, 7% had two branches). The great cardiac vein was found in 77.0% and the left marginal vein in 2.5%. The artery was interposed between the endocardium and the great cardiac vein in 31.5% of cases. The smallest distance between the endocardium and the artery was 0.5 mm and between the endocardium and the vein was 0.7 mm. In total, we were able to distinguish fifteen different types of vascular arrangements within the LAA isthmus line in this study. The myocardium within the LAA isthmus is thickest at its LAA end. The left circumflex coronary artery branches are the most frequently-occurring vessels within the isthmus and are present in almost all cases, while the great cardiac vein is present in three quarters of hearts. Clin. Anat. 31:1024-1030, 2018. © 2018 Wiley Periodicals, Inc.

Epicardial, Biatrial Ablation With Integrated Uni-bipolar Radiofrequency Technology in Stand-alone Persistent Atrial Fibrillation.

OBJECTIVE: Although minimally invasive approaches for surgical treatment of stand-alone atrial fibrillation have gained popularity for the past decade, ablation technology and extensive lesion sets play a major role in the achievement of a successful procedure, especially in presence of persistent and long-standing persistent atrial fibrillation. We evaluated clinical outcomes after totally endoscopic biatrial epicardial ablation of persistent atrial fibrillation with a novel integrated uni-bipolar radiofrequency device. METHODS: Forty-nine (49) consecutive patients with stand-alone atrial fibrillation underwent right-sided monolateral thoracoscopic surgical ablation with a novel integrated uni-bipolar radiofrequency energy delivery and temperature-controlled technology. Atrial fibrillation was persistent in 13 (26.5%) of 49 and long-standing persistent in 36 (73.5%) of 49 patients. Mean ± SD age was 60.6 ± 10.3 years. Median duration of atrial fibrillation was 74 months. Mean ± SD left atrial diameter was 44.7 ± 4.0 mm. RESULTS: Epicardial en bloc isolation of all pulmonary veins (box lesion) and additional ablation of the right atrial free wall was successfully performed via minimally invasive approach without any intraoperative and postoperative major complications. Intraoperative entrance and exit block was achieved in 77.5% (38/49) and 91.8% (45/49) of patients, respectively. Mean ± SD ablation time was 16.3 ± 4.8 minutes. No intensive care unit stay was required. Postoperative sinus rhythm was achieved in 93.8% (30/32) patients, and no pacemaker implantation was required. At 13 months, 87.7% (43/49) of patients were in sinus rhythm; 71.4% (35/49) were free from antiarrhythmic drugs and 75.5% (37/49) from oral anticoagulation. CONCLUSIONS: Integrated uni-bipolar radiofrequency ablation technology showed to be effective for the surgical treatment of atrial fibrillation with a total endoscopic approach. A versapolar suction device with extensive right-left atrial lesion set may further improve outcomes in patients with nonparoxysmal atrial fibrillation.

Anatomy and Physiologic Roles of the Left Atrial Appendage: Implications for Endocardial and Epicardial Device Closure.

The left atrial appendage has been implicated as a major nidus for thrombus formation, particularly in atrial fibrillation. This discovery has prompted substantial interest in the development of left atrial appendage exclusion devices aimed at decreasing systemic thromboembolism risk. Its deceptively simple appearance belies the remarkable complexity that characterizes its anatomy and physiology. We highlight the key anatomic features and variations of the left atrial appendage as well as its relationships with surrounding structures. We also summarize crucial anatomic factors that should be taken into account by the interventional cardiologist when planning for or performing left atrial appendage exclusion procedures.

Echocardiographic Imaging for Left Atrial Appendage Occlusion: Transesophageal Echocardiography and Intracardiac Echocardiographic Imaging.

Left atrial appendage occlusion (LAAO) is a rapidly evolving technology. Multi-modality imaging and understanding of left atrial appendage anatomy are sure to advance. Two-dimensional and 3-dimensional transesophageal echocardiography with fluoroscopy are the mainstay for LAAO image-guided therapy. Key to successful LAAO is an understanding of the transseptal puncture, LAAO size selection for the device-specific landing zone, and postdeployment evaluation for leak and complications. With advancements in computed tomography, there may be a greater role for intracardiac echocardiographic imaging in specific types of LAAO anatomy and devices.

Impact of left atrial appendage morphology on thrombus formation after successful left atrial appendage occlusion: Assessment with cardiac-computed-tomography.

A standardized imaging algorithm by cardiac computed tomography angiography (cCTA) (LOVE-view) was used in 30 patients to evaluate the influence of different left atrial appendage (LAA) morphologies on development of thrombosis in the LAA 6 months after implantation of an occlusion device (Watchman or Amplatzer-Cardiac-Plug) in patients with non-valvular atrial fibrillation, CHA2DS2-VASc-Score >1 and a contraindication for oral anticoagulation. The distribution of different LAA morphologies was 40% windsock, 17% broccoli and 43% chicken wing type. There was no significant difference in the level of thrombosis regarding LAA morphology or the type of chosen occlusion device. The rates of complete LAA thrombosis was 40% in broccoli type, 33% in windsock and 15% in chicken wing type. Independently of LAA type, 13% had none and 60% incomplete thrombosis. The ratio of density (LA/LAA) was 0.14 in patients with complete thrombosis and 0.67 in those with none or incomplete thrombosis. cCTA and the LOVE-view-imaging-algorithm were shown to be a valuable method for standardized imaging in clinical routine in a greater set of patients. Surprisingly thrombosis of the occluded LAA was still in progress in most cases at 6 months, whereas further studies are needed defining its clinical consequences, especially for the selection of the optimal post-procedural antithrombotic treatment strategy.

The left atrial appendage: from embryology to prevention of thromboembolism.

The left atrial appendage (LAA) is the main source of thromboembolism in patients with non-valvular atrial fibrillation (AF). As such, the LAA can be the target of specific occluding device therapies. Optimal management of patients with AF includes a comprehensive knowledge of the many aspects related to LAA structure and thrombosis. Here we provide baseline notions on the anatomy and function of the LAA, and then focus on current imaging tools for the identification of anatomical varieties. We also describe pathogenetic mechanisms of LAA thrombosis in AF patients, and examine the available evidence on treatment strategies for LAA thrombosis, including the use of non-vitamin K antagonist oral anticoagulants and interventional approaches.

Anatomic characteristics of the mitral isthmus region: The left atrial appendage isthmus as a possible ablation target.

The mitral isthmus is a part of the postero-inferior area of the lateral left atrial wall located between the mitral annulus and the left inferior pulmonary vein ostium. Linear ablation lesions are created within the mitral isthmus for the invasive treatment of left atrial arrhythmias. However, the anatomy of this region is not fully understood. The aim of this study has been to provide a detailed morphometric description of the mitral isthmus region and to propose another possible isthmus within the investigated heart area that may serve as a potential new ablation target. Two hundred autopsied, non-atrial fibrillation hearts (23.5% deriving from females) whose donors were a mean of 47.6±17.6years old were investigated. We macroscopically assessed the anatomy of the postero-inferior area of the lateral left atrial wall. The mean mitral isthmus length was 28.8±7.0mm and was significantly longer than the left atrial appendage (LAA) isthmus (14.2±4.8mm) (p=.00). The distance between the LAA orifice and the left inferior pulmonary vein ostium (18.4±4.8mm) was longer than the LAA isthmus (p=.00) and shorter than the mitral isthmus (p=.00). The LAA isthmus was longer in hearts with a common left pulmonary vein (p=.037). In 65.5% of all cases the area between the right and left mitral isthmus lines was completely smooth. In the remaining hearts, crevices and diverticula (18.0%), intertrabecular recesses (7.0%), trabecular bridges (3.5%), or co-existence of these structures (6%) could be observed. The LAA isthmus line was smooth in 95.5% of all cases, with only small crevices in the remaining 4.5%. In conclusion, regardless of the anatomical variants of the left-sided pulmonary veins, the mitral isthmus area is quite uniform in size. The LAA isthmus is considerably shorter than the mitral isthmus. The mitral isthmus line has many unwanted structures that may entrap the catheter, which is not the case for the LAA isthmus. We proposed the LAA isthmus line for potential clinical use.

Quantitative analysis of the right auricle with 256-slice computed tomography.

PURPOSE: To quantitatively measure the morphology parameters of the right auricle with 256-slice multidetector computed tomography angiography (MDCTA) in healthy people. MATERIALS AND METHODS: A retrospective analysis of 200 patients who had undergone coronary MDCTA with negative findings was performed. The raw imaging data were reconstructed and the right auricular volume, right atrial volume, right auricle height, base long and short axes, base perimeter and area, normal angle, and distance were quantitatively measured. RESULTS: Men had significantly (P < 0.05) greater values than women in the right auricular volume (13.3 ± 4.0 vs. 11.7 ± 3.7 mL) and height (33.0 ± 5.0 vs. 30.5 ± 5.2 mm), the base long axis (34.4 ± 4.1 vs. 33.2 ± 3.9 mm), area (787.6 ± 177.6 vs. 771.0 ± 143.2 mm2) and perimeter (119.2 ± 17.5 vs. 115.0 ± 13.0), and the normal distance (22.4 ± 6.6 vs. 20.2 ± 6.7 mm). The normal 95 % reference range for the right auricular parameters was put forward. The right auricular parameters had a good correlation with the right atrium volume, aortic diameter, the body weight, height, and body surface area but a bad correlation with the vertebral body height. Significantly (P < 0.05) greater values were found in the normal angle and distance in subjects below than over 40 years of age. No other significant (P > 0.05) difference existed in the other right auricular parameters. CONCLUSION: Quantitative measurements of the right auricle can help us get a good understanding of the right auricular morphology and its relationship with surrounding structures and are helpful for cardiac interventions of electrophysiology and radiofrequency ablation.

Morphologic Assessment of the Left Atrial Appendage in Patients with Atrial Fibrillation by Gray Values-Inverted Volume-Rendered Imaging of Three-Dimensional Transesophageal Echocardiography: A Comparative Study with Computed Tomography.

BACKGROUND: Accurate assessment of left atrial appendage (LAA) morphology is crucial in determining an LAA occlusion strategy. The aim of this study was to develop a novel echocardiographic volume-rendered imaging technique to visualize LAA morphology. METHODS: This was a retrospective study. Forty patients with atrial fibrillation who underwent three-dimensional (3D) transesophageal echocardiography (TEE) and cardiac computed tomographic angiography (CCTA) before catheter ablation were enrolled. Full-volume 3D data were acquired and displayed in gray values-inverted (GVI) mode. Threshold segmentation and interactive segmentation were used to create 3D digital replicas of the LAA chambers. The morphologic classification, number of lobes, and dimensions of the LAA were analyzed and compared with the data obtained with CCTA. RESULTS: LAA morphology and measurements were successfully acquired via CCTA and 3D GVI TEE in all 40 cases. In terms of LAA morphologic classifications, 19 cases of chicken wing, eight of windsock, nine of cauliflower, and four of cactus morphology were determined using 3D GVI TEE, and 20 cases of chicken wing, eight of windsock, eight of cauliflower, and four of cactus morphology were determined using CCTA. The κ value between these two methods was 0.963. Measurements of maximal diameter, minimal diameter, and area of the ostia and the depth of the LAAs were larger when based on the 3D GVI transesophageal echocardiographic data than when using cardiac computed tomographic angiographic data (P < .01); however, there was agreement between the results. Formed thrombi were well displayed by both computed tomography and 3DGVI TEE. CONCLUSIONS: Three-dimensional GVI TEE can be used to acquire LAA morphologic volume-rendered images that are similar to computed tomographic volume-rendered images, and it shows promise as a feasible and valuable modality for planning individual LAA occlusion procedures.

Cardiac Computed Tomography Angiography for Left Atrial Appendage Closure.

Atrial fibrillation is prevalent and percutaneous left atrial appendage (LAA) closure is increasingly performed worldwide. This procedure is technically challenging and the success and procedural complexities depend on anatomy of the LAA and surrounding structures. These are readily depicted on cardiac computed tomography angiography (CCTA), which offers unique imaging planes. CCTA allows not only preplanning anatomic LAA assessment, but can also be used to evaluate for pre-existing LAA thrombus, and done postprocedure for surveillance for device-related thrombus, residual leak, and complications. In this article, we review the practical utility of CCTA for LAA closure.