Volume 9, Issue 12, Pages (December 2012)

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Volume 9, Issue 12, Pages 2003-2009 (December 2012) Initial experience with magnetic resonance imaging of atrial scar and co-registration with electroanatomic voltage mapping during atrial fibrillation: Success and limitations David D. Spragg, MD, FHRS, Irfan Khurram, MD, Stefan L. Zimmerman, MD, Hirad Yarmohammadi, MD, MPH, Bernie Barcelon, RT, Matthew Needleman, MD, David Edwards, MD, Joseph E. Marine, MD, FHRS, Hugh Calkins, MD, FHRS, Saman Nazarian, MD, FHRS Heart Rhythm Volume 9, Issue 12, Pages 2003-2009 (December 2012) DOI: 10.1016/j.hrthm.2012.08.039 Copyright © 2012 The Heart Rhythm Society Terms and Conditions

Figure 1 A: Electroanatomic voltage map in the posteroanterior projection of a patient undergoing redo pulmonary vein isolation. Low voltage (<0.6 mV) is shown in red; healthy tissues is shown in purple. B: Delayed enhancement magnetic resonance imaging–derived scar map of the same patient showing the same projection of the left atrium. Scar is shown in purple; healthy tissue is shown in red. A white border has been manually traced around the dominant region of scar on the posterior wall of the left atrium. C: Combined projection of scar and voltage data, in the same posteroanterior orientation. The scar border (white tracing) has been superimposed on the image to show full extent of the scar (rather than showing multiple projections of the same image with different voltage and scar transparencies). The site of the left inferior pulmonary vein reconnection is shown (yellow dot; see Figure 4). Heart Rhythm 2012 9, 2003-2009DOI: (10.1016/j.hrthm.2012.08.039) Copyright © 2012 The Heart Rhythm Society Terms and Conditions

Figure 2 Box-plots of voltage amplitude in regions of normal and scar myocardium identified by delayed enhancement magnetic resonance imaging (MRI). A: Data by patient. B: Pooled data across all patients. Box-plots display the median and the 25th to 75th percentile range (center line and solid box), the lower and upper adjacent values (whiskers), and outlier data points (dots). Heart Rhythm 2012 9, 2003-2009DOI: (10.1016/j.hrthm.2012.08.039) Copyright © 2012 The Heart Rhythm Society Terms and Conditions

Figure 3 Data from contingency table analysis of scar/normal tissue by delayed enhancement magnetic resonance imaging (MRI) vs low/normal voltage by electroanatomic mapping demonstrating significant association between scar presence or absence with low or normal voltages, respectively. Heart Rhythm 2012 9, 2003-2009DOI: (10.1016/j.hrthm.2012.08.039) Copyright © 2012 The Heart Rhythm Society Terms and Conditions

Figure 4 A: Catheter-projection view of the Lasso in the ostium of the left inferior pulmonary vein, with superimposition of subsequently applied repeat ablation lesions. Site of pulmonary vein reconnection is shown (yellow dot) and is located in the center of the scar region (see Figures 1B and 1C). B: Lasso electrograms showing earliest activation at Ls19,20 and Ls5,6 (adjacent poles in this particular deployment of the Lasso). Heart Rhythm 2012 9, 2003-2009DOI: (10.1016/j.hrthm.2012.08.039) Copyright © 2012 The Heart Rhythm Society Terms and Conditions