Europace Advance Access originally published online on July 28, 2008
Europace 2008 10(10):1226-1227; doi:10.1093/europace/eun198
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CASE REPORTS
Delineation of anatomical relation of important adjacent structures to the left atrium in electroanatomical mapping using fluoroscopy images
Department of Electrophysiology, University of Leipzig, Heart Center, Strümpellstrasse 39, 04289 Leipzig, Germany
Manuscript submitted 9 May 2008. Accepted after revision 8 July 2008.
* Corresponding author. Tel: +49 341 865 1413; fax: +49 341 865 1460. E-mail address: dr.arasharya{at}gmail.com
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Catheter ablation is being used increasingly for the treatment of atrial fibrillation (AF), and more extensive ablations that include linear lesions on the posterior wall of the left atrium (LA) are performed today. A better understanding of the anatomic relationship between the posterior LA wall and the oesophagus is required to identify potentially high-risk areas for the application of radiofrequency energy. We hereby describe a simple method to delineate the anatomical relationship between important adjacent structures and the LA in electroanatomical mapping using plain fluoroscopy images.
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Case report |
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Catheter ablation is being used increasingly for the treatment of paroxysmal and persistent atrial fibrillation (AF), and more extensive ablation procedures that include linear lesions on the posterior wall of the left atrium (LA) are performed today.1
A fistula between the oesophagus and the LA has been reported as an unusual but lethal complication of radiofrequency ablation of AF.2 A better understanding of the anatomic relationship between the posterior LA wall and the oesophagus is required to identify potentially high-risk areas for the application of radiofrequency energy. Sánchez-Quintana et al.1 in an in vitro study showed that the distance between the LA and the oesophagus is <5 mm in 40% of their specimens. It is conceivable that enlargement and thinning of the atrial wall in patients with AF will make this distance even shorter. Therefore, with respect to safety, delineation of the anatomic relationship between oesophagus and LA is of paramount importance.
Isolation and disconnection of the coronary sinus beginning by the ablation on the endocardial surface of the LA adjacent to the coronary sinus followed by ablation inside the coronary sinus if necessary are important steps in the ablation of persistent and chronic AF.3,4 However, the definition of the exact region of the LA, which lies adjacent to the coronary sinus based solely on the fluoroscopy, is difficult. Therefore, defining the exact anatomical relationship between coronary sinus and the LA would simplify this step in the ablation of persistent and chronic AF.
Currently, different methods are used for the visualization of oesophagus and delineation of its anatomic relation to LA. We hereby illustrate a simple method to define the anatomical locations of the oesophagus and the coronary sinus and their relation to the LA using a remote magnetic navigation system (NIOBE II®, Stereotaxis Inc., St Louis, MO, USA) integrated with an electroanatomical mapping system (CARTO-RMT®, Biosense Webster, Inc., Diamond Bar, CA, USA). After registration and integration of these two systems, anatomical location data can be transferred between them (Figure 1). Although the location of the oesophagus and its relation to LA in CARTO-RMT can be defined by using another catheter for its reconstruction, this would dramatically increase the cost of the ablation procedure.
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As shown in Figure 1, the NIOBE II workstation has the capability to define the three-dimensional location of a catheter or an anatomical structure based on its projection in two fluoroscopic views with a 40° difference in the projection. After demarcation of the interested structure in both views, the workstation defines the three-dimensional location of the structures and sends it to the CARTO-RMT system. In the case of ablation of persistent AF, the locations of the oesophagus and coronary sinus were determined easily and transferred to CARTO-RMT to increase the safety and the efficacy of ablation, especially the dissociation of the coronary sinus by endocardial ablation; however, the accuracy of this technique needs to be tested in a series of patients.
Conflict of interest: none declared.
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[1] Sánchez-Quintana D, Cabrera JA, Climent V, Farré J, Mendonça MC, Ho SY. Anatomic relations between the oesophagus and left atrium and relevance for ablation of atrial fibrillation. Circulation (2005) 112:1400–5.
[2] Pappone C, Oral H, Santinelli V, Vicedomini G, Lang CC, Manguso F, et al. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation (2004) 109:2724–6.
[3] Haïssaguerre M, Hocini M, Sanders P, Sacher F, Rotter M, Takahashi Y, et al. Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol (2005) 16:1138–47.[CrossRef][Web of Science][Medline]
[4] Haïssaguerre M, Sanders P, Hocini M, Takahashi Y, Rotter M, Sacher F, et al. Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination. J Cardiovasc Electrophysiol (2005) 16:1125–37.[CrossRef][Web of Science][Medline]
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