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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EThis session addressed innovative imaging methods used for the evaluation and treatment of atrial fibrillation, with a focus on various echocardiography techniques and cardiac magnetic resonance imaging. Improvements in imaging methods have resulted in higher quality atrial imaging, lower radiation exposure, and improved prognosis of outcomes following AF therapy.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eechocardiography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eatrial fibrosis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eleft atrial strain\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eangiography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eelectroanatomical mapping\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDECAAF\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003ELeft atrial (LA) pressure and volume overload lead to LA remodeling, with changes in size, structure, and function. These changes are associated with adverse cardiovascular (CV) outcomes. Assessment of LA size provides important prognostic information regarding the risk of atrial fibrillation (AF), heart failure, stroke, and death, and outcomes of AF cardioversion and ablation. An enlarged left atrium impacts the success of rhythm control and predisposes the patient to recurrence of AF [Camm AJ et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2010]. Monica Rosca, MD, Prof Dr CC Iliescu Cardiovascular Diseases Institute, Bucharest, Romania, discussed imaging evaluation of the left atrium in patients with AF.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ELA enlargement occurs in the superior-inferior or medial-lateral axis. Therefore, M-mode linear dimensions (anteroposterior LA diameter) are not recommended for quantification of LA size (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Evangelista A et al. \u003Cem\u003EEur J Echocardiogr\u003C\/em\u003E. 2008; Lester SJ et al. \u003Cem\u003EAm J Cardiol.\u003C\/em\u003E 1999].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/54\/32\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022M-Mode Linear Dimensions Are Inaccurate for Left Atrial Size AssessmentLester SJ et al. Best method in clinical practice and in research studies to determine left atrial size. Am J Cardiol. 1999;84:829\u0026#x2013;832. Copyright (1999), with permission from Excerpta Medica Inc.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1536197989\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;M-Mode Linear Dimensions Are Inaccurate for Left Atrial Size AssessmentLester SJ et al. Best method in clinical practice and in research studies to determine left atrial size. \u0026amp;lt;em\u0026amp;gt;Am J Cardiol\u0026amp;lt;\/em\u0026amp;gt;. 1999;84:829\u0026#x2013;832. Copyright (1999), with permission from Excerpta Medica Inc.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/54\/32\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/54\/32\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/54\/32\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11618\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EM-Mode Linear Dimensions Are Inaccurate for Left Atrial Size Assessment\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003ELester SJ et al. Best method in clinical practice and in research studies to determine left atrial size. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E. 1999;84:829\u2013832. Copyright (1999), with permission from Excerpta Medica Inc.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003ELA volume is a more accurate description of the size and is more strongly associated with the risk of CV events compared to LA area or diameter [Tsang TS et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2006]. The recommended method for assessment of LA size by echocardiography is the biplane area-length formula, which has been used in most studies [Lang RM et al. \u003Cem\u003EJ Am Soc Echocardiogr.\u003C\/em\u003E 2005]. However, the assumptions used may be inaccurate and LA volume is underestimated with this method compared with computed tomography (CT) and magnetic resonance imaging (MRI).\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe use of 3D echocardiography (3DE) avoids geometric assumptions and atrial cavity foreshortening, providing higher volumes than 2D echocardiography (2DE). 3DE has been validated against MRI [Rodevan O et al. \u003Cem\u003EInt J Card Imaging.\u003C\/em\u003E 1999] and has been shown to be accurate, with low test-retest variation and lower intraobserver and interobserver variability compared with 2DE [Jenkins C et al. \u003Cem\u003EJ Am Soc Echocardiogr\u003C\/em\u003E. 2005]. However, 3DE is limited by a dependence on 2D image quality and lack of cutoffs. The former also provides high-quality images of LA anatomy. Furthermore, 3D transesophageal echocardiography improves left atrial appendage morphology and size assessment, which is important for guiding percutaneous closure [Nucifora G et al. \u003Cem\u003ECirc Cardiovasc Imaging\u003C\/em\u003E. 2011].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EAnalysis of transmitral or pulmonary venous flow patterns with pulse wave Doppler echocardiography is a simple method for assessing LA function. Pulse wave Doppler echocardiography can be used to identify changes in flow patterns consistent with atrial stunning as well as recovery of atrial mechanical function after restoration of sinus rhythm.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003ELongitudinal myocardial velocities can be quantified with tissue Doppler imaging, providing a relatively load-independent measure of left ventricular (LV) systolic and diastolic function [Yamamoto T et al. \u003Cem\u003EJ Am Soc Echocardiogr.\u003C\/em\u003E 2003]. Tissue Doppler imaging is also useful for measuring atrial segment velocities and atrial strain rate for assessment of atrial function. Speckle tracking echocardiography is an angle independent tool for thorough assessment of LA performance but has not been validated for this use.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EEchocardiography is considered an accurate modality for measuring LA size and function. 3DE is useful for guiding and monitoring interventions involving the atrial septum and LA appendage, while tissue Doppler imaging and speckle tracking echocardiography provide valuable information about atrial mechanics. Thorough evaluation of atrial size and function can improve the management of AF, refine risk stratification, and guide therapy.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EPercentage of MRI-Detected Atrial Fibrosis Predicts AF Recurrence After Ablation\u003C\/h2\u003E\u003Cp id=\u0022p-11\u0022\u003EAtrial wall fibrosis and structural remodeling provide a substrate for the progression of AF and are associated with AF presence and persistence [Platonov PG et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2011]. Nassir F. Marrouche, MD, University of Utah Health Sciences Center, Salt Lake City, Utah, discussed the use of cardiac MRI for the detection of atrial fibrosis. According to Dr Marrouche, the MRI sequence used is key to the accurate evaluation of atrial fibrosis. His laboratory has developed protocols and pulse fibrosis sequences to optimize the images.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EChallenges in MRI imaging of atrial fibrosis include acquisition errors and patient-related challenges. According to Dr Marrouche, acquisition errors include the wrong T1, wrong phase-encoding direction, partial coverage of the left atrium, errors in navigator prescription, and the wrong main frequency at 3T, as demonstrated in the Delayed-Enhancement MRI (DE-MRI) Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation (DECAAF) study [Marrouche NF et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2014]. Patient-related challenges may include a high degree of heart rhythm irregularity, a high degree of nonregular respiration, rapid heart rate (\u0026gt;\u2009120 bpm), and high body mass index (\u0026gt;\u2009135 kg\/m\u003Csup\u003E2\u003C\/sup\u003E).\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EA study of DE-MRI of the relatively load-independent measure categorized AF patients undergoing ablation according to structural remodeling stage based on the percentage of LA wall enhancement [McGann C et al. \u003Cem\u003ECirc Arrhythm Electrophysiol.\u003C\/em\u003E 2014]. The DE-MRI result was validated with surgical biopsy. The study found that extensive LA wall enhancement predicted a poor response to catheter ablation for AF.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EThe Utah Staging System was developed to categorize patients according to the percentage of fibrosis quantified with DE-MRI, relative to the LA wall volume. It has been found that the percentage of patients with persistent AF increases with the degree of fibrosis found on DE-MRI, Dr Marrouche said. The risk of stroke has also been shown to increase with the degree of atrial fibrosis [Daccarett M et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EAtrial fibrosis detected by DE-MRI in patients with AF was associated with recurrent arrhythmia after catheter ablation in the DECAAF trial [Marrouche NF et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EDE-MRI also detected ablation scarring 3 months postablation. The main predictor of recurrent AF after ablation was the percent of residual fibrosis, calculated as the amount of postablation scar plus fibrosis minus the scar. Dr Marrouche summarized his presentation with an algorithm for MRI-based (fibrosis-guided) patient selection and treatment strategy.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\u003Ch2 class=\u0022\u0022\u003ELA Strain Assessment in Management of AF\u003C\/h2\u003E\u003Cp id=\u0022p-17\u0022\u003EErwan Donal, MD, Pontchaillou Hospital, Rennes, France, discussed the use of LA strain for assessing LA function in patients with AF. LA strain and strain rate are measures of local myocardial deformation that can be measured with tissue Doppler velocities or speckle tracking echocardiography. LA function consists of the reservoir function (filling pressure and LA compliance), conduit function (LV relaxation), and active contraction function (LV compliance, LV end-diastolic pressure, and LA intrinsic contractility).\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003ELA volume can be assessed with 3D transthoracic echocardiography but measuring LA strain is more sensitive for assessing LA function. Speckle tracking improves the robustness of LA strain measurement. LA function assessment with speckle tracking takes 3.8 minutes, with 8% intraobserver variability and 9.5% interobserver variability [Paraskevaidis IA et al. \u003Cem\u003EHeart.\u003C\/em\u003E 2009]. Global atrial systolic and diastolic strain rates are highly sensitive, are load dependent, and are related to LV longitudinal function as well as age [Boyd AC et al. \u003Cem\u003EHeart.\u003C\/em\u003E 2011]. \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E describes results of studies of LA function assessed by atrial strain.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11620\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11620\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11620\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-19\u0022 class=\u0022first-child\u0022\u003EStudies of Left Atrial Function Assessed by Atrial Strain\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-23\u0022\u003EProf Donal concluded that atrial function can be evaluated by assessing the extent of LA remodeling with the speckle tracking approach in many clinical conditions. Expectations are high for the assessment of the atrial reservoir function with this approach as well. Further research and validation of speckle tracking are needed.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EEAM Integrated With Other Modalities Produces Good-Quality Images and Reduces Radiation Exposure\u003C\/h2\u003E\u003Cp id=\u0022p-24\u0022\u003EOle-Alexander Breithardt, MD, Heart Center, University Hospital, Leipzig, Germany, discussed the use of rotational LA angiography and 3D image-integrated fluoroscopy for AF ablation guidance. The LA anatomy varies from patient to patient. For that reason, the standard workflow includes anatomic imaging before the ablation procedure. This process involves using CT to create a 3D anatomic model, which is integrated with electroanatomical mapping (EAM) to improve the accuracy of the anatomical map. The workflow is complicated and time-consuming and often does not provide a completely accurate map.\u003C\/p\u003E\u003Cp id=\u0022p-25\u0022\u003ERotational 3D angiography (3DRA) is an alternative technique that can produce a 3D image of the LA during the ablation procedure. 3DRA is performed using cardiac C-arm CT with image integration into fluoroscopic views. Several studies of 3DRA have demonstrated quality images and lower radiation exposure with this technique.\u003C\/p\u003E\u003Cp id=\u0022p-26\u0022\u003EA study evaluating 3DRA in different settings on ablation procedural aspects found that accuracy and radiation reduction were greatest with 3DRA and EAM integration [De Potter T et al. \u003Cem\u003EArrhythmia \u0026amp; Electrophysiology Review.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-27\u0022\u003EA pilot study of a novel technique involving the real-time integration of fluoroscopy and real-time 3DE confirmed the technical feasibility of accurate real-time echo-fluoroscopic image overlay in clinical practice in patients undergoing AF ablation or transcatheter aortic valve implantation [Arujuna AV et al. \u003Cem\u003EIEEE J Translat Eng Health Med.\u003C\/em\u003E 2014]. MRI-guided electrophysiology ablation is another novel technique currently under development.\u003C\/p\u003E\u003Cp id=\u0022p-28\u0022\u003EPrecise imaging of LA anatomy in patients with AF is a key factor for patient safety and successful ablation. 3D EAM is the basis for the ablation procedure, but is often insufficient for visualizing the complete and true anatomy. Registration of EAM with other modalities helps overcome these limitations and improves procedural outcomes, while reducing radiation exposure to patients and staff.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/54\/32.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzoc2p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzoc2p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzoc2p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}