Extra-Cavity Image Registration via the Aortic Root During Left Ventricular Mapping and Ablation

Figures

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  Figure 1.. Well-aligned PM anatomies between CT images and ICE maps after extra-cavity registration. The anterior and posterior PM were indirectly visualized as the cavern or dentation-like structures (yellow asterisks) on CT image. The ICE reconstructed PMs were indicated as green or purple color structures. After extra-cavity registration, the CT images were found to be well-aligned with ICE maps. APM, anterior papillary muscle; LV, left ventricle; PPM, posterior papillary muscle.

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  Figure 2.. Imaging registration and verification. A. The paired landmarks (shown as flags) were respectively tagged on the aortic root in the FAM map (left, gray) and CT map (right, orange). B. The aortic CT map was superimposed on the FAM map after landmark and surface registration. C. After registration, the LV CT image (purple) was moved into real space without positions within LV and compared with the LV chamber reconstructed by ICE (gray), and the 2 anatomies were well accommodated. AO, aortic root; CT, computed tomography; FAM; fast anatomical mapping; ICE, intracardiac echocardiography; LV left ventricle.

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  Figure 3.. Ablation of fascicular ventricular tachycardia after extra-cavity registration only. This was a case of idiopathic left ventricular tachycardia arising from the left-sided His. After extra-cavity registration via the aortic root, the LV anatomy segmented from CT image was activated and moved into real space. All subsequent mapping and ablation were carried out guided by this CT image only, the left anterior and posterior fascicles were mapped out and found well aligned with the LV septum. The tachycardia was successfully treated by ablation at the origin (indicated by red point). AO, aortic root; CT, computed tomography; FAM; fast anatomical mapping; LAO, left anterior oblique; LV, left ventricle; RAO, right anterior oblique.

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  Figure 4.. Ablation of papillary muscle ventricular arrhythmia after extra-cavity registration only. This was a case of premature ventricular contraction originating from lateral head of anterior PM. After extra-cavity registration via the aortic root, the LV anatomy of CT image was activated and moved into real space, and the PMs were exhibited as cavern structure in Figure 4A (asterisk, anterior PM; pound, posterior PM). Further mapping was performed on the medial and lateral bundles of anterior PM. The origin of premature ventricular contraction was localized at the middle part of lateral head (Figure 4B and 4C). AO, aortic root; LAO, left anterior oblique; LL, left lateral; LV, left ventricle; RAO, right anterior oblique.

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  Figure 5.. Ablation of pathological ventricular tachycardia after extra-cavity registration only. This was a case of arrhythmogenic cardiomyopathy. After extra-cavity registration via the aortic root, the LV anatomy of CT image was activated and moved into real space. The voltage point-by-point mapping was initially performed at the LV endocardial side (left panel). No significant low voltage area was observed. Epicardial voltage mapping showed there was a large low-voltage area (right panel). Substrate modification ablation was targeted to the border zone. Of note, the 2 epicardial and endocardial LV CT map were derived from CT imaging separately, and both were well aligned with manually created maps. Endo, endocardial; Epi, epicardial; LL, left lateral; RAO, right anterior oblique.