CT angiography-derived three-dimensional pulmonary vein topography is related to the outcome after cryoballoon ablation

Figures

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  Figure 1. Study flowchart. Cryo PVI, pulmonary vein isolation (PVI) using cryoballoon (Cryo); CTA, computed tomography angiography; PV, pulmonary vein; AF, atrial fibrillation.

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  Figure 2. CTA-derived workflow to assess pulmonary vein (PV) anatomy and topography. (A) Definition of the ostial pulmonary vein (PV) diameter in two perpendicular planes. The red and green lines mark the planes, and the dotted lines delineate the particular PV diameter in each orientation (upper left, upper right). Automatic border detection of the PV orifice in a 2D planar orientation; the purple line encircles the orifice (lower left). 3D reconstruction of the left atrium from a posterior view; the purple line corresponds to the encircled PV orifice in 3D orientation (lower right. (B) Angiographic view (left anterior oblique 50°) illustrating the relative position of the PV ostium, site of transseptal puncture, catheter sheath, and cryoballoon (upper left). 2D planar view of the left atrium and proximal course of the left inferior PV; the red dots mark the orifice area, and the green dots mark the PV area in the further course (upper right). Simulated angiographic view (frontal) of the orifice and proximal course of the left inferior PV computed from the CT angiography (lower left). 3D reconstruction of the upper right two-dimensional view (lower right). Blue oval, puncture site of the…

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  Figure 3. Number of occlusions and freedom from AF recurrence following PVI. (A) Left side: x-ray (LAO 50°) of occlusion grade 1 with significant reflow of contrast agent due to poor balloon occlusion of the left inferior pulmonary vein. Right side: x-ray (RAO 30°) of occlusion grade 3 with no reflow of contrast agent due to optimal balloon occlusion of the right superior pulmonary vein. Blue circle: inflated cryoballoon, the red outlines mark the outer borders of the particular pulmonary vein, and the white double arrow marks the extent of poor occlusion. OTP, esophageal temperature probe; CS, coronary sinus catheter; RVA, right ventricular apex catheter. (B) Mean amount of occlusion attempts for each pulmonary vein to reach optimal occlusion grading, distinguished between successful pulmonary vein isolation (PVI success, blue bars) and AF recurrence (PVI failure, red bars) 1 year following index procedure; the black lines mark standard error of the mean. LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein. *p < 0.05.

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  Figure 4. One-year freedom of AF is associated with PVI topography. (A) Mean septum angle (angle α), measured between the intra-atrial septum (two different positions: red and brown) and the PV orifice (PV marked blue). PVI success: no recurrent AF 1 year after PVI using the cryoballoon (blue bars). PVI failure: recurrent AF within the first year after ablation (red bars). (B) Mean orifice angle (angle β), measured between the PV orifice and the course of the pulmonary vein. Blue: transseptal puncture site. Red and brown: two different PV orientations indicating the topographical variation of orifice angle β. (C) Mean intra-atrial angle (angle γ) measured between the distance of the interatrial septum (brown) to the PV ostium and the distance of the PV ostium to the PV course. Blue: PV. PVI success (freedom from AF within 1 year, blue bars) and PVI failure (recurrent AF within the first year after PVI, red bars). LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein. Mean and SEM. *p < 0.05.

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  Figure 5. ROC analysis of septum, orifice, and intra-atrial angulation predicting 1-year freedom from AF after PVI using the cryoballoon. ROC analysis of septum angle α (A), orifice angle β (B), and intra-atrial angle γ (C) for prediction of 1-year freedom from AF. Red box: optimal threshold (Youden index). AUC, area under the curve; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein.