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Role of multidetector computed tomography in the anatomical definition of the left atrium-pulmonary vein complex in patients with atrial fibrillation. Personal experience and pictorial assay

Il ruolo della TCMD nella definizione anatomica del complesso atrio sinistro-vene polmonari nei pazienti affetti da fibrillazione atriale. Esperienza personale e rassegna iconografica

  • Cardiac Radiology/Cardioradiologia
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Abstract

Purpose

This study aimed to illustrate the typical anatomical pattern and anatomical variants of the left atrium-pulmonary vein (LA-PV) complex studied by 16-slice multidetector computed tomography (MDCT) in a population of patients with atrial fibrillation (AF) undergoing percutaneous transcatheter left atrial ablation. Accurate knowledge of this anatomical region is fundamental for increasing the efficiency, efficacy and accuracy of the procedure and for reducing the risk of complications.

Materials and methods

From January 2004 to March 2007, we studied 75 patients (57 men, 18 women) affected by paroxysmal and chronic AF by using MDCT. In 63 patients, the MDCT examination was performed using retrospective cardiac electrocardiographic (ECG) gating and dose modulation, with reconstructions performed at 75% of R-R interval. In the remaining 12 patients, ECG gating was not possible due to high-frequency AF.

Results

We identified 286 PV: 157 right and 129 left. On the right side, eight PV were supernumerary and one was a common trunk, whereas on the left side, we found 22 common trunks and one supernumerary vein. In 61.3% of patients, the anatomical pattern was typical (two right and two left PV). In the remaining 38.7%, it was atypical [two right PV-left common trunk (26.6%); three right PV-two left PV (6.7%); three right PV-left common trunk (2.6%); three right PV-three left PV (1.3%); right common trunk-two left PV (1.3%)]. MDCT identified branching of the right inferior PV in 94.5%, of the right superior PV in 75.6%, of the left superior PV in 7.5% and of the left inferior PV in 7.5%; 3/8 of the right supernumerary veins presented branching. With respect to the left PV ostia, the position of the orifice of the 74 recognised appendages was high in 85.1%, intermediate in 12.1% and low in 2.8%. There was no association between PV anatomical variants and clinical presentation of AF (paroxysmal or chronic).

Conclusions

MDCT represents a fundamental diagnostic imaging tool in the anatomical definition of the LA-PV complex, which is characterised by considerable variability. Radiologists must be familiar with the anatomical variants and help the referring interventional electrophysiologist understand their importance.

Riassunto

Obiettivo

Illustrare quadro tipico e varianti anatomiche del complesso atrio sinistro-vene polmonari (AS-VP) studiato con TC spirale multidetettore a 16 strati (TCMD) in una popolazione di pazienti affetti da fibrillazione atriale (FA) in attesa di essere sottoposti ad intervento di ablazione trans-catetere in atrio sinistro. La precisa conoscenza di questa regione anatomica è indispensabile per realizzare con maggiore efficacia, efficienza ed accuratezza la procedura terapeutica, riducendo le complicanze.

Materiali e metodi

Nel periodo compreso tra gennaio 2004 e marzo 2007 sono stati valutati con TCMD 75 pazienti (57 maschi e 18 femmine) affetti da FA parossistica e cronica. In 63 pazienti l’indagine TCMD è stata effettuata con gating cardiaco retrospettivo e modulazione della dose, ricostruendo la finestra temporale corrispondente al 75% dell’intervallo RR dell’ECG. Nei restanti 12 pazienti non è stato possibile utilizzare il gating cardiaco per la presenza di FA ad alta frequenza.

Risultati

Nei pazienti studiati sono state identificate 286 VP, 157 a destra e 129 a sinistra. A destra sono state riconosciute 8 vene soprannumerarie e 1 tronco comune mentre a sinistra 22 tronchi comuni e 1 vena soprannumeraria. Nel 61,3% dei pazienti il quadro inadeanatomico era tipico (2 VP destre e sinistre) e atipico nel restante 38,7% dei pazienti (26,6% 2 VP destre-tronco comune sinistro; 6,7% 3 VP destre-2 VP sinistre; 2,6% 3 VP destre-tronco comune sinistro; 1,3% 3 VP destre-3 VP sinistre; 1,3% tronco comune destro-2 VP sinistre). Nella definizione dei rami di confluenza pre-ostiali delle VP (branching), la TCMD ha identificato il branching della VP inferiore destra nel 94,5% dei casi, della VP superiore destra nel 75,6%, della VP superiore sinistra nel 7,5% e della VP inferiore sinistra nel 7,5%; 3/8 delle vene soprannumerarie destre presentavano branching. Rispetto all’ostio delle VP sinistre, l’orifizio delle 74 auricole identificate era in posizione alta nel 85,1% dei casi, in posizione intermedia nel 12,1% e bassa nel 2,8%. Non sono state rilevate associazioni tra varianti anatomiche delle VP e presentazione clinica della FA (parossistica o cronica).

Conclusioni

La TCMD è uno strumento diagnostico fondamentale per definire l’anatomia del complesso AS-VP, la cui variabilità anatomica è elevata. Il radiologo deve conoscere le varianti anatomiche e farne capire l’importanza all’elettrofisiologo interventista.

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Authors and Affiliations

  1. Istituto di Radiologia dell’Università degli Studi di Verona, Policlinico G.B. Rossi, P.le L.A. Scuro, 37134, Verona, Italy

    K. Benini

  2. Laboratorio di Elettrofisiologia, Unità Operativa di Cardiologia, Ospedale S. Chiara di Trento, Trento, Italy

    M. Marini & M. Del Greco

  3. Laboratorio di Biofisica e Biosegnali, Dipartimento di Fisica dell’Università di Trento, Trento, Italy

    G. Nollo

  4. Dipartimento di Radiodiagnostica, APSS di Trento, U. O. di Radiologia, Ospedale S. Chiara di Trento, Trento, Italy

    K. Benini, V. Manera & M. Centonze

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  1. K. Benini
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  4. G. Nollo
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  6. M. Centonze
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Correspondence to M. Centonze.

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Benini, K., Marini, M., Del Greco, M. et al. Role of multidetector computed tomography in the anatomical definition of the left atrium-pulmonary vein complex in patients with atrial fibrillation. Personal experience and pictorial assay. Radiol med 113, 779–798 (2008). https://doi.org/10.1007/s11547-008-0299-9

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