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

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 intra procedural 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.