Intraprocedural Volume Imaging of the Left Atrium and Pulmonary Veins with Rotational X‐Ray Angiography: Implications for Catheter Ablation of Atrial Fibrillation

INTRODUCTION: The use of preprocedural CT or MR imaging to generate patient-specific cardiac anatomy greatly facilitates catheter ablation of the left atrium and pulmonary veins (LA-PVs) to treat atrial fibrillation (AF). This report details the accuracy and utility of an intraprocedural means to generate 3-D volumetric renderings of the LA-PV anatomy: contrast-enhanced rotational X-ray angiography (3DRA). METHODS AND RESULTS: Preprocedural CT or MR imaging and intraprocedural rotational angiography was performed in 42 patients undergoing AF ablation procedures. Initially, pulmonary artery (PA) bolus-chase contrast injections were performed (20 mL, 20 mL/s) to establish pulmonary transit time and cardiac isocentering. Depending on cardiac size, either a single PA injection (80-100 mL, 20 mL/s) or two separate dedicated left/right PA branch injections were performed (60 mL each, 20 mL/s). For the latter, the two volumes of the left/right portions of the LA-PVs were registered and fused. LA-PV 3DRA images were assessed qualitatively and quantitatively in comparison with CT/MR images. The majority of the 3DRA acquisitions (71%) were deemed at least "useful" in delineating the LA-PV anatomy. The LA appendage was delineated in 57% of the cases. A blinded quantitative comparison of PV ostial diameters resulted in an absolute difference of only 2.7 +/- 2.3 mm, 2.2 +/- 1.8 mm, 2.4 +/- 2.2 mm, and 2.2 +/- 2.3 mm for the left-superior, left-inferior, right-superior, and right-inferior PVs, respectively. The feasibility for registering the 3DRA image with real-time electroanatomical mapping was also demonstrated. CONCLUSION: Intraprocedural contrast-enhanced rotational angiography provides volumetric 3-D images of the LA-PVs of comparable diagnostic value to dedicated preprocedural CT/MR imaging.