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Cardiac computed tomography for atrial fibrillation ablation – a one-stop shop?
TC cardíaca na ablação da fibrilhação auricular – one-stop-shop?
Ana G. Almeida
Hospital Universitário de Santa Maria, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "885" "paginaFinal" => "887" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ana G. Almeida" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Ana G." "apellidos" => "Almeida" "email" => array:2 [ 0 => "anagalmeida@gmail.com" 1 => "amalmeida@medicina.ulisboa.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Universitário de Santa Maria, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "TC cardíaca na ablação da fibrilhação auricular – <span class="elsevierStyleItalic">one-stop-shop</span>?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac imaging has brought about spectacular innovations in the diagnosis, treatment, monitoring and outcome of cardiovascular disease, and the different imaging modalities constitute a set of tools that are crucial to clinical practice, research and education. The quality and accuracy of the information they provide have improved enormously in the last ten years, in parallel with other impressive technological advances in health care.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiac computed tomography (CCT) has been at the forefront of clinical practice since the introduction in 2004 of 64-slice scanners, which enabled highly accurate and reproducible assessment of coronary lesions. Other clinical applications have also emerged, including in electrophysiology for planning of procedures such as ablation and left atrial appendage closure for the treatment of atrial fibrillation (AF), which are now well-established therapies.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> When planning ablation, CCT provides high-resolution anatomical images of the left atrium and pulmonary veins that can be integrated during the procedure, increasing its accuracy and shortening its duration. Importantly, it can also exclude the presence of thrombi in the left atrium and atrial appendage, an essential step in the ablation procedure and one that has traditionally been performed using transesophageal echocardiography (TEE).</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, CCT has its disadvantages, notably the need for exposure to ionizing radiation and for administration of iodinated contrast. While the latter is relatively easy to manage, by appropriate selection and preparation of patients, radiation exposure is unavoidable and carries potentially serious health risks. The biological effects of ionizing radiation are related to the cumulative effective dose, and its stochastic effects may include the development of cancer, although such effects are assumed to come into play only following acute radiation exposure at high doses (figures of >100 mSv have been suggested).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> The risks associated with low doses, such as those used for diagnostic exams, are less well understood; it has been suggested that there is a threshold dose below which there is no harmful effect, or even that low levels of radiation are protective against the risk of cancer. However, given the lack of convincing evidence from epidemiological studies, it is generally accepted that exposure to any level of radiation carries risks, and that therefore the “as low as reasonably achievable,” or ALARA, principle should be applied, by which the use of imaging studies should be rational and reasonable in order to minimize radiation exposure as far as possible.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Recent technological developments, as well as improved diagnostic ability, have also led to significant changes in clinical attitudes and in diagnostic guidelines, for example in the use of CCT for assessment of stable coronary artery disease.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The technological advances that have resulted in improved image quality and lower radiation doses include current modulation, prospective acquisition and iterative image reconstruction, together with developments in hardware including dual-source scanners with high pitch and acquisition volume, enabling image acquisition in a single cardiac cycle. This is particularly advantageous in patients with arrhythmias, including AF, which is the most frequent arrhythmia in the general population, especially in older individuals.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical validation of new technological developments is the subject of considerable study, since the speed which such developments become available implies the need for equal rapidity in validating them for clinical application.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is against this background that a study by Marques et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> is published in this issue of the <span class="elsevierStyleItalic">Journal</span>, based on a prospective registry, from which 270 patients were selected in whom CCT was performed prior to AF ablation to detect left atrial thrombi, aiming to assess the impact of CCT protocol optimization and technological advances on contrast and radiation doses and on image quality. The study is a good illustration of the difficulties associated with rapid technological advances in CCT with which the authors have had to deal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study population were divided into three chronologically ordered groups representing different stages of technological development. The first two groups underwent exams using a first-generation dual-source 64-slice scanner. A conventional retrospective protocol was used in Group 1, with tube current modulation and peak voltage selected according to body mass index, while in Group 2 the protocol was optimized, using a prospective protocol in patients with regular or arrhythmic heart rate and little R-R variability, and reducing peak voltage and contrast volume. Image quality was similar in these two groups but radiation dose decreased substantially, from 5.6 mSv to 1.3 mSv. Group 3, the most recent, was studied with a third-generation dual-source 192-slice scanner using iterative image reconstruction. As well as enabling images to be acquired in a single heartbeat, which has significant advantages in cases of arrhythmia, this protocol also led to a marked reduction in radiation dose, to a median of 0.6 mSv, as well as to a significantly smaller contrast volume. Image quality in Group 3 was also better than in the previous two groups according to both subjective (visual) and objective (quantitative) assessments.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The choice of quantitative parameters for the objective assessment was interesting: signal-to-noise and contrast-to-noise ratios and density homogeneity, the latter of which was used in this case to distinguish blood flow from thrombus, but can potentially be used for other applications.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The diagnostic accuracy of CCT for the exclusion of thrombi, amply demonstrated in other studies, which report negative predictive values of over 99% validated by TEE,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6–8</span></a> was not tested in this study, in which the prevalence of thrombi (in a low-risk and appropriately anticoagulated population) was extremely low. Even so, the few cases in which there were doubts concerning the presence of thrombus underwent a second scan without additional contrast administration and were confirmed by TEE. The need for a second scan was less frequent in the group assessed using the third-generation scanner.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The optimized protocols were shown to give superior results to those in other published studies in terms of radiation and contrast dose, without sacrificing diagnostic quality.</p><p id="par0060" class="elsevierStylePara elsevierViewall">This study clearly demonstrates the value of innovative advances in technology and increasing expertise in CCT, not only as applied to pre-AF ablation assessment, but with obvious potential for the study of other cardiovascular conditions.</p><p id="par0065" class="elsevierStylePara elsevierViewall">These developments, which will undoubtedly become standard practice in the near future, open up novel possibilities for this imaging modality, due to the quality and reliability of its results, together with marked reductions in radiation doses. Further studies will be needed to establish the actual cost/benefit ratio of CCT, balancing its high and still improving diagnostic quality against patient safety concerns and cost, but we can predict that upcoming technological developments, although they will pose new questions and challenges, are also bound to present both new diagnostic possibilities and reductions in exposure to risk.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Almeida AG. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 3 | 7 |
| 2024 October | 33 | 32 | 65 |
| 2024 September | 51 | 29 | 80 |
| 2024 August | 40 | 31 | 71 |
| 2024 July | 26 | 33 | 59 |
| 2024 June | 24 | 18 | 42 |
| 2024 May | 29 | 16 | 45 |
| 2024 April | 28 | 25 | 53 |
| 2024 March | 32 | 25 | 57 |
| 2024 February | 21 | 20 | 41 |
| 2024 January | 24 | 17 | 41 |
| 2023 December | 17 | 32 | 49 |
| 2023 November | 33 | 27 | 60 |
| 2023 October | 13 | 11 | 24 |
| 2023 September | 23 | 16 | 39 |
| 2023 August | 18 | 21 | 39 |
| 2023 July | 15 | 14 | 29 |
| 2023 June | 16 | 12 | 28 |
| 2023 May | 42 | 25 | 67 |
| 2023 April | 17 | 3 | 20 |
| 2023 March | 29 | 18 | 47 |
| 2023 February | 36 | 17 | 53 |
| 2023 January | 19 | 13 | 32 |
| 2022 December | 31 | 22 | 53 |
| 2022 November | 30 | 24 | 54 |
| 2022 October | 27 | 22 | 49 |
| 2022 September | 19 | 46 | 65 |
| 2022 August | 27 | 20 | 47 |
| 2022 July | 22 | 37 | 59 |
| 2022 June | 27 | 27 | 54 |
| 2022 May | 19 | 27 | 46 |
| 2022 April | 25 | 35 | 60 |
| 2022 March | 22 | 40 | 62 |
| 2022 February | 25 | 40 | 65 |
| 2022 January | 21 | 28 | 49 |
| 2021 December | 19 | 30 | 49 |
| 2021 November | 21 | 26 | 47 |
| 2021 October | 36 | 49 | 85 |
| 2021 September | 18 | 30 | 48 |
| 2021 August | 30 | 27 | 57 |
| 2021 July | 20 | 21 | 41 |
| 2021 June | 25 | 12 | 37 |
| 2021 May | 31 | 38 | 69 |
| 2021 April | 38 | 30 | 68 |
| 2021 March | 28 | 33 | 61 |
| 2021 February | 34 | 22 | 56 |
| 2021 January | 28 | 23 | 51 |
| 2020 December | 22 | 7 | 29 |
| 2020 November | 24 | 15 | 39 |
| 2020 October | 17 | 18 | 35 |
| 2020 September | 25 | 19 | 44 |
| 2020 August | 8 | 10 | 18 |
| 2020 July | 11 | 12 | 23 |
| 2020 June | 29 | 16 | 45 |
| 2020 May | 11 | 11 | 22 |
| 2020 April | 17 | 17 | 34 |
| 2020 March | 21 | 10 | 31 |
| 2020 February | 39 | 17 | 56 |
| 2020 January | 14 | 9 | 23 |
| 2019 December | 11 | 5 | 16 |
| 2019 November | 24 | 15 | 39 |
| 2019 October | 16 | 12 | 28 |
| 2019 September | 10 | 7 | 17 |
| 2019 August | 14 | 10 | 24 |
| 2019 July | 15 | 9 | 24 |
| 2019 June | 17 | 21 | 38 |
| 2019 May | 15 | 7 | 22 |
| 2019 April | 14 | 13 | 27 |
| 2019 March | 7 | 6 | 13 |
| 2019 February | 14 | 25 | 39 |
| 2019 January | 20 | 10 | 30 |
| 2018 December | 21 | 23 | 44 |
| 2018 November | 5 | 4 | 9 |
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