3D MRI left atrial scar map guided anatomical pulmonary vein reisolation

We present the case of a 58-year-old woman, suffering from high blood pressure, who presented with documented frequently occurring paroxysmal atrial fibrillation attacks. She underwent two prior pulmonary vein isolations, but her palpitations did not cease. We aimed to achieve a long period free of symptoms, and a 3D MRI late enhancement scar map of the left atrium was obtained before the planned third pulmonary vein isolation procedure to visualize the assumed pulmonary vein reconnection sites. First, the endocardial and epicardial contours of the thin left atrial wall were manually determined on the images, then color-coding was added based on the trasmurality of contrast enhancement in the wall. The reconstructed 3D color-coded left atrial surface revealed the localization of left atrial antral wall scars. These images were integrated into the electroanatomical mapping system and ablation was carried out selectively on the spots showing gaps in the antral scar. Isolation was achieved in all four veins without any complications. The patient has become symptom-free for years now. The reconstructed left atrial 3D MRI images gained in an innovative process visualized the gaps in the previous ablation lines and these images were integrated to guide the first gap-closure redo pulmonary vein isolation procedure in Hungary.