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Multi–Detector Row CT of the Left Atrium and Pulmonary Veins before Radio-frequency Catheter Ablation for Atrial Fibrillation¹

¹ From the Division of Thoracic Imaging of the Department of Radiology and the Atrial Arrhythmia Center, University of Pittsburgh, Rm 4660 CHP-MT, 200 Lothrop St, Pittsburgh, PA 15213. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received February 12, 2003; revision requested April 28 and received May 19; accepted May 29. Supported in part by a grant from General Electric Medical Systems. Address correspondence to J.M.L. (e-mail: lacomisjm@msx.upmc.edu).

View larger version (96K): [in a new window]   Figure 1. Left atrium and myocardial sleeves of the distal pulmonary veins. Schematic illustrates how the myocardium (white outline) of the left atrium (LA) extends into the distal pulmonary veins. Note that the sleeves of the left-sided veins are longer than those of the right-sided veins and that the left superior pulmonary vein (LSPV) has the longest myocardial sleeve. LIPV = left inferior pulmonary vein, RIPV = right inferior pulmonary vein, RSPV = right superior pulmonary vein.

View larger version (174K): [in a new window]   Figure 2. RFCA targets. Gated multi-detector row CT scans (endocardial view) obtained in a patient with paroxysmal atrial fibrillation in normal sinus rhythm during the study show the left side of the left atrium. One or more of the distal pulmonary veins (a) was the original target for RFCA. As the procedure has evolved, newer targets include the pulmonary vein ostia (b) and (as in this patient) the pulmonary vein inflow vestibule (c). LAA = orifice of the left atrial appendage, LI = left inferior pulmonary vein, LS = left superior pulmonary vein.

View larger version (168K): [in a new window]   Figure 2. RFCA targets. Gated multi-detector row CT scans (endocardial view) obtained in a patient with paroxysmal atrial fibrillation in normal sinus rhythm during the study show the left side of the left atrium. One or more of the distal pulmonary veins (a) was the original target for RFCA. As the procedure has evolved, newer targets include the pulmonary vein ostia (b) and (as in this patient) the pulmonary vein inflow vestibule (c). LAA = orifice of the left atrial appendage, LI = left inferior pulmonary vein, LS = left superior pulmonary vein.

View larger version (160K): [in a new window]   Figure 2. RFCA targets. Gated multi-detector row CT scans (endocardial view) obtained in a patient with paroxysmal atrial fibrillation in normal sinus rhythm during the study show the left side of the left atrium. One or more of the distal pulmonary veins (a) was the original target for RFCA. As the procedure has evolved, newer targets include the pulmonary vein ostia (b) and (as in this patient) the pulmonary vein inflow vestibule (c). LAA = orifice of the left atrial appendage, LI = left inferior pulmonary vein, LS = left superior pulmonary vein.

View larger version (147K): [in a new window]   Figure 3a. RFCA technique. (a) Fluoroscopic image depicts the ablation electrode (arrowheads) and the intracardiac echocardiography catheter (arrow) within the left superior pulmonary vein ostium. (b) As thermal energy is applied, an electroanatomic virtual map (CARTO-Biosense/Webster, Diamond Bar, Calif) shows the aggregate of ablated regions. Each red sphere represents a few millimeters of ablated tissue.

View larger version (200K): [in a new window]   Figure 3b. RFCA technique. (a) Fluoroscopic image depicts the ablation electrode (arrowheads) and the intracardiac echocardiography catheter (arrow) within the left superior pulmonary vein ostium. (b) As thermal energy is applied, an electroanatomic virtual map (CARTO-Biosense/Webster, Diamond Bar, Calif) shows the aggregate of ablated regions. Each red sphere represents a few millimeters of ablated tissue.

View larger version (127K): [in a new window]   Figure 4. Normal pulmonary vein ostium. Volume-rendered (VR) image (left posterior oblique epicardial view) from nongated multi-detector row CT shows the right inferior pulmonary vein ostium.

View larger version (145K): [in a new window]   Figure 5. Segments of the distal pulmonary veins. Slab reformatted image shows the V1 through V3 segments of an accessory right middle lobe pulmonary vein. The V1 segment is the most important segment to include on epicardial views.

View larger version (116K): [in a new window]   Figure 6. Normal ostial branches. VR image (posteroanterior epicardial view) from nongated multi-detector row CT shows ostial branches (arrows) of the left superior (LS), right inferior (RI), and right superior (RS) pulmonary veins. The V1 segment of each of these veins is less than 5 mm in length.

View larger version (136K): [in a new window]   Figure 7a. Intervenous saddle in a patient with normal pulmonary venous anatomy and accessory drainage of the right middle lobe. Bilateral VR images (endocardial view) from nongated multi-detector row CT show the intervenous saddles (solid white lines) between the right superior (RS) and right middle lobe (RM) pulmonary veins and the right superior and right inferior (RI) pulmonary veins (a), and between the left superior (LS) and left inferior (LI) pulmonary veins (b). The left inferior pulmonary vein intravenous saddle is also seen (dotted white line in b). Note the artifact from a pacer lead (arrows in a).

View larger version (154K): [in a new window]   Figure 7b. Intervenous saddle in a patient with normal pulmonary venous anatomy and accessory drainage of the right middle lobe. Bilateral VR images (endocardial view) from nongated multi-detector row CT show the intervenous saddles (solid white lines) between the right superior (RS) and right middle lobe (RM) pulmonary veins and the right superior and right inferior (RI) pulmonary veins (a), and between the left superior (LS) and left inferior (LI) pulmonary veins (b). The left inferior pulmonary vein intravenous saddle is also seen (dotted white line in b). Note the artifact from a pacer lead (arrows in a).

View larger version (116K): [in a new window]   Figure 8. Normal pulmonary venous anatomy. On a nongated multi-detector row CT scan (right posterior oblique epicardial view), single right and left superior and inferior pulmonary veins drain into the left atrium without accessory veins. LI = left inferior, LS = left superior, RI = right inferior, RS = right superior.

View larger version (119K): [in a new window]   Figure 9a. Common (conjoined) veins. (a) VR image (posteroanterior epicardial view) from nongated multi-detector row CT shows a right common vein (RCV). LI = left inferior pulmonary vein, LS = left superior pulmonary vein. (b) VR image (right posterior oblique epicardial view) from nongated multi-detector row CT performed in a different patient shows a left common vein (LCV). RI = right inferior pulmonary vein, RS = right superior pulmonary vein. Both right and left common veins are normal variants of the pulmonary venous anatomy, but the latter occurs much more frequently than the former.

View larger version (106K): [in a new window]   Figure 9b. Common (conjoined) veins. (a) VR image (posteroanterior epicardial view) from nongated multi-detector row CT shows a right common vein (RCV). LI = left inferior pulmonary vein, LS = left superior pulmonary vein. (b) VR image (right posterior oblique epicardial view) from nongated multi-detector row CT performed in a different patient shows a left common vein (LCV). RI = right inferior pulmonary vein, RS = right superior pulmonary vein. Both right and left common veins are normal variants of the pulmonary venous anatomy, but the latter occurs much more frequently than the former.

View larger version (145K): [in a new window]   Figure 10a. Supernumerary (accessory) pulmonary veins. VR images (epicardial view) from gated (a, c) and nongated (b) multi-detector row CT performed in three different patients show an accessory right middle lobe pulmonary vein (RM in a), a superior segment right lower lobe (ssRLL) pulmonary vein (b), and a lingula pulmonary vein (c). Accessory veins contribute to the complexity of normal pulmonary venous anatomy and may drain a pulmonary lobe or lobe segment.

View larger version (110K): [in a new window]   Figure 10b. Supernumerary (accessory) pulmonary veins. VR images (epicardial view) from gated (a, c) and nongated (b) multi-detector row CT performed in three different patients show an accessory right middle lobe pulmonary vein (RM in a), a superior segment right lower lobe (ssRLL) pulmonary vein (b), and a lingula pulmonary vein (c). Accessory veins contribute to the complexity of normal pulmonary venous anatomy and may drain a pulmonary lobe or lobe segment.

View larger version (112K): [in a new window]   Figure 10c. Supernumerary (accessory) pulmonary veins. VR images (epicardial view) from gated (a, c) and nongated (b) multi-detector row CT performed in three different patients show an accessory right middle lobe pulmonary vein (RM in a), a superior segment right lower lobe (ssRLL) pulmonary vein (b), and a lingula pulmonary vein (c). Accessory veins contribute to the complexity of normal pulmonary venous anatomy and may drain a pulmonary lobe or lobe segment.

View larger version (159K): [in a new window]   Figure 11. Anomalous pulmonary venous anatomy. Chest CT was performed to evaluate for pulmonary embolism in a patient without atrial fibrillation but with partial anomalous pulmonary venous drainage of the left upper lobe into the left brachiocephalic vein. This CT scan shows a vessel (arrow) to the left of the aortic arch that courses toward the mediastinum.

View larger version (150K): [in a new window]   Figure 12a. Potential pitfall of the paintbrush technique. (a, b) Posteroanterior epicardial VR image (b) shows a truncated ssRLL pulmonary vein because the vein was incompletely included in the "painting" of the axial multi-detector row CT source image (a). Arrow indicates vein. (c, d) Lateral reformatted image (c) with the ssRLL vein correctly "painted" (arrowheads) results in the posteroanterior epicardial VR image seen in d, which shows the vein draining into the top of the left atrium. These four images illustrate the need for careful review of the source images prior to VR.

View larger version (146K): [in a new window]   Figure 12b. Potential pitfall of the paintbrush technique. (a, b) Posteroanterior epicardial VR image (b) shows a truncated ssRLL pulmonary vein because the vein was incompletely included in the "painting" of the axial multi-detector row CT source image (a). Arrow indicates vein. (c, d) Lateral reformatted image (c) with the ssRLL vein correctly "painted" (arrowheads) results in the posteroanterior epicardial VR image seen in d, which shows the vein draining into the top of the left atrium. These four images illustrate the need for careful review of the source images prior to VR.

View larger version (147K): [in a new window]   Figure 12c. Potential pitfall of the paintbrush technique. (a, b) Posteroanterior epicardial VR image (b) shows a truncated ssRLL pulmonary vein because the vein was incompletely included in the "painting" of the axial multi-detector row CT source image (a). Arrow indicates vein. (c, d) Lateral reformatted image (c) with the ssRLL vein correctly "painted" (arrowheads) results in the posteroanterior epicardial VR image seen in d, which shows the vein draining into the top of the left atrium. These four images illustrate the need for careful review of the source images prior to VR.

View larger version (157K): [in a new window]   Figure 12d. Potential pitfall of the paintbrush technique. (a, b) Posteroanterior epicardial VR image (b) shows a truncated ssRLL pulmonary vein because the vein was incompletely included in the "painting" of the axial multi-detector row CT source image (a). Arrow indicates vein. (c, d) Lateral reformatted image (c) with the ssRLL vein correctly "painted" (arrowheads) results in the posteroanterior epicardial VR image seen in d, which shows the vein draining into the top of the left atrium. These four images illustrate the need for careful review of the source images prior to VR.

View larger version (62K): [in a new window]   Figure 13a. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (63K): [in a new window]   Figure 13b. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (59K): [in a new window]   Figure 13c. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (69K): [in a new window]   Figure 13d. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (61K): [in a new window]   Figure 13e. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (50K): [in a new window]   Figure 13f. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (51K): [in a new window]   Figure 13g. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (61K): [in a new window]   Figure 13h. Standard epicardial views: posteroanterior view, 30°-45° cranial tilt (a), anteroposterior view, 45° cranial tilt (b), anteroposterior view, 45° caudal tilt (c), 45° right posterior oblique view, 30°-45° cranial tilt (d), 45° left posterior oblique view, 30°-45° cranial tilt (e), right lateral view, 30°-45° cranial tilt (f), left lateral view, 30°-45° cranial tilt (g), and inferior view (h). Multiple extraatrial projections, either filmed or displayed as a cine loop, are needed to display the left atrium and pulmonary veins in three dimensions without overlap. Together, these projections provide an accurate 3D model to help the electrophysiologist gain an understanding of the complexity of the relevant anatomy and anatomic relationships prior to RFCA.

View larger version (121K): [in a new window]   Figure 14a. Usefulness of epicardial views. (a) VR image from CT performed in a patient with a nondilated left atrium (left atrial volume = 52 mL) demonstrates normal pulmonary venous anatomy, with right superior and right inferior ostial branches (arrows). (b) VR image (epicardial view) from multi-detector row CT performed in a patient with a dilated left atrium (left atrial volume = 181 mL) depicts a left common vein (LCV).

View larger version (129K): [in a new window]   Figure 14b. Usefulness of epicardial views. (a) VR image from CT performed in a patient with a nondilated left atrium (left atrial volume = 52 mL) demonstrates normal pulmonary venous anatomy, with right superior and right inferior ostial branches (arrows). (b) VR image (epicardial view) from multi-detector row CT performed in a patient with a dilated left atrium (left atrial volume = 181 mL) depicts a left common vein (LCV).

View larger version (45K): [in a new window]   Figure 15. Usefulness of an SSD view of the left atrium. SSD images from multi-detector row CT performed in a patient with a nondilated left atrium (left atrial volume = 56 mL) show the measurements of atrial dimensions in three planes (X, Y, Z) similar to those obtained with echocardiography.

View larger version (140K): [in a new window]   Figure 16a. Usefulness of endocardial VR images. Right (a) and left (b) VR images (endocardial view) from multi-detector row CT demonstrate normal right inferior (RI) and right superior (RS) veins and a normal left common pulmonary vein (LCV), with the ostial diameters and circumferences measured. Note the typical prominent endocardial ridge (arrowheads), which separates the left pulmonary venous vestibule from the orifice of the left atrial appendage.

View larger version (164K): [in a new window]   Figure 16b. Usefulness of endocardial VR images. Right (a) and left (b) VR images (endocardial view) from multi-detector row CT demonstrate normal right inferior (RI) and right superior (RS) veins and a normal left common pulmonary vein (LCV), with the ostial diameters and circumferences measured. Note the typical prominent endocardial ridge (arrowheads), which separates the left pulmonary venous vestibule from the orifice of the left atrial appendage.