First experience with rotational angiography of the right ventricle to guide ventricular tachycardia ablation

Rotational angiography with three-dimensional reconstruction (3DRA) is a new imaging tool recently introduced to guide mapping and ablation of the left atrium.

The purpose of this study was to determine the utility of 3DRA for imaging the ventricles and guiding ventricular tachycardia (VT) ablation.

Using the Philips Allura Xper FD10 system, 3DRA was performed in eight patients referred for right ventricular outflow tract (RVOT) VT ablation. The imaging protocol for right ventricular (RV) injection is described. IV contrast was injected at the RA/IVC junction over 4 sec and 3DRA was obtained immediately. Images were segmented manually on the EP Navigator workstation and registered on live fluoroscopy. Intracardiac electrograms were superimposed on 3DRA creating a true electroanatomic map (ElectroNav). CARTO mapping and echocardiograms were performed on all patients, cardiac computed tomography (CT) in 4, and magnetic resonance imaging (MRI) in 1.

Three-dimensional rotational angiography was successful in 7 of 8 patients. Image interpretation was unsuccessful in one patient due to poor isocentering. RV imaging was performed with 82 ± 18 mL of contrast. RV image segmentation required 19 ± 5 minutes. CARTO maps of the RVOT required 43 ± 12 minutes and additional fluoroscopy. Three-dimensional rotational angiography was used to guide VT ablation by providing realistic anatomic images of the pulmonary valve plane, endo-views of the ventricle, and ablation point tagging. Anatomic detail provided by 3DRA was qualitatively superior to CARTO. VT ablation was acutely successful in all patients. Close concordance between echocardiographic, CT/MRI, and 3DRA measurements of the RVOT was observed (r = 0.9, P <.01).

Three-dimensional rotational angiography of the RV and RVOT is a feasible imaging technique that utilizes a protocol of timed angiography, manual segmentation, image registration, and superimposition of intracardiac electrograms to create an angiogram-based electroanatomic model of these structures.