Clinical Radiology 69 (2014) 96e102
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Pictorial Review
CT imaging of complications of catheter ablation for atrial fibrillationq G.S. Shroff a, *, M.S. Guirguis a, E.C. Ferguson a, S.A.A. Oldham a, B.K. Kantharia b a
Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, Houston, TX, USA b Division of Cardiovascular Medicine, The University of Texas Medical School at Houston, Houston, TX, USA
article in formation Article history: Received 14 August 2013 Received in revised form 24 August 2013 Accepted 29 August 2013
The complication rate following radiofrequency catheter ablation for atrial fibrillation is low (2 episodes) that terminates spontaneously within 7 days. “Persistent” AF is defined as recurrent AF that is sustained for >7 days. “Longstanding persistent” AF is defined as continuous AF of >12 months’ duration. The term “permanent” AF is not appropriate in the context of patients undergoing catheter or surgical ablation of AF, as it refers to a group of patients for which a decision has been made not to restore or
0009-9260/$ e see front matter Ó 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2013.08.018
G.S. Shroff et al. / Clinical Radiology 69 (2014) 96e102
maintain sinus rhythm by any means, including catheter or surgical ablation. The expert consensus statement also emphasizes gradation of indications for catheter and surgical ablation of AF. Accordingly, a class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed. A class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation. A class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered. A class III recommendation means that AF ablation is of no proven benefit and is not recommended. Although surgical ablation as a standalone or concomitant procedure is considered a class IIa recommendation, because of the technique is percutaneous and non-surgical, catheter ablation is considered a class I recommendation for many patients with AF.1 Surgical ablation, popularly termed the “Maze procedure” was pioneered by Dr Cox. The operation essentially involved creating multiple strategically placed incisions across both the right and left atria designed to interrupt all macro-reentrant circuits that might potentially develop in the atria, thereby precluding the ability of the atrium to flutter or fibrillate. To further simplify the operation, the incisions of the traditional cut-and-sew CoxeMaze procedure have now been replaced with linear lines of ablation created using a variety of energy sources including RF energy, cryoablation, and high-intensity focused ultrasound. The catheter-based ablation was originally described by Haissaguerre and colleagues who also showed that AF is initiated by spontaneous focal discharges originating from the pulmonary veins (PVs) in a majority of patients. Since the original description of RFCA to treat AF, the ablation technique has evolved considerably and involves creation of linear lesions in the atria and ablation of other triggers in addition to the PVs. The basic component of the technique, however, remains fairly uniform. Typically, after obtaining femoral venous access, multipolar catheters are inserted inside different chambers of the heart to record electrical activation from the respective chambers. Access to the left atrium (LA) is obtained via a trans-septal puncture. A circular spiral mapping catheter when placed at the ostia of the PVs records local electrograms from the respective PVs. Another catheter, an ablation catheter, is used to perform ablation lesions at the catheter tipetissue interface contact site by delivering radiofrequency electrical current through the catheter tip. Circumferential ablation of the extra-ostial region of the PVs, and additionally linear lesions at different anatomical locations of the LA, are the most widely used techniques currently. Major centres worldwide have reported that catheter ablation for AF is effective and safe with low (
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Pictorial Review
CT imaging of complications of catheter ablation for atrial fibrillationq G.S. Shroff a, *, M.S. Guirguis a, E.C. Ferguson a, S.A.A. Oldham a, B.K. Kantharia b a
Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, Houston, TX, USA b Division of Cardiovascular Medicine, The University of Texas Medical School at Houston, Houston, TX, USA
article in formation Article history: Received 14 August 2013 Received in revised form 24 August 2013 Accepted 29 August 2013
The complication rate following radiofrequency catheter ablation for atrial fibrillation is low (2 episodes) that terminates spontaneously within 7 days. “Persistent” AF is defined as recurrent AF that is sustained for >7 days. “Longstanding persistent” AF is defined as continuous AF of >12 months’ duration. The term “permanent” AF is not appropriate in the context of patients undergoing catheter or surgical ablation of AF, as it refers to a group of patients for which a decision has been made not to restore or
0009-9260/$ e see front matter Ó 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2013.08.018
G.S. Shroff et al. / Clinical Radiology 69 (2014) 96e102
maintain sinus rhythm by any means, including catheter or surgical ablation. The expert consensus statement also emphasizes gradation of indications for catheter and surgical ablation of AF. Accordingly, a class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed. A class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation. A class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered. A class III recommendation means that AF ablation is of no proven benefit and is not recommended. Although surgical ablation as a standalone or concomitant procedure is considered a class IIa recommendation, because of the technique is percutaneous and non-surgical, catheter ablation is considered a class I recommendation for many patients with AF.1 Surgical ablation, popularly termed the “Maze procedure” was pioneered by Dr Cox. The operation essentially involved creating multiple strategically placed incisions across both the right and left atria designed to interrupt all macro-reentrant circuits that might potentially develop in the atria, thereby precluding the ability of the atrium to flutter or fibrillate. To further simplify the operation, the incisions of the traditional cut-and-sew CoxeMaze procedure have now been replaced with linear lines of ablation created using a variety of energy sources including RF energy, cryoablation, and high-intensity focused ultrasound. The catheter-based ablation was originally described by Haissaguerre and colleagues who also showed that AF is initiated by spontaneous focal discharges originating from the pulmonary veins (PVs) in a majority of patients. Since the original description of RFCA to treat AF, the ablation technique has evolved considerably and involves creation of linear lesions in the atria and ablation of other triggers in addition to the PVs. The basic component of the technique, however, remains fairly uniform. Typically, after obtaining femoral venous access, multipolar catheters are inserted inside different chambers of the heart to record electrical activation from the respective chambers. Access to the left atrium (LA) is obtained via a trans-septal puncture. A circular spiral mapping catheter when placed at the ostia of the PVs records local electrograms from the respective PVs. Another catheter, an ablation catheter, is used to perform ablation lesions at the catheter tipetissue interface contact site by delivering radiofrequency electrical current through the catheter tip. Circumferential ablation of the extra-ostial region of the PVs, and additionally linear lesions at different anatomical locations of the LA, are the most widely used techniques currently. Major centres worldwide have reported that catheter ablation for AF is effective and safe with low (
