Atrial fibrillation (AF) -the most common arrhythmia -significantly increases the risk of stroke and heart failure. Although catheter ablation can restore normal heart rhythms, patients with persistent AF who develop atrial fibrosis often undergo multiple failed ablations and thus increased procedural risks. Here, we present personalized computational modelling for the reliable predetermination of ablation targets, which are then used to guide the ablation procedure in patients with persistent AF and atrial fibrosis. We first show that a computational model of the atria of patients identifies fibrotic tissue that if ablated will not sustain AF. We then integrated the target-ablation sites in a clinical-mapping system, and tested its feasibility in 10 patients with persistent AF. The computational prediction of ablation targets avoids lengthy electrical mapping Reprints and permissions information is available at www.nature.com/reprints.Users may view, print, copy, and download text and data-mine the content in such documents, for the purposes of academic research, subject always to the full Conditions of use:

Background-Compared with fluoroscopy, the current imaging standard of care for guidance of electrophysiology procedures, magnetic resonance imaging (MRI) provides improved soft-tissue resolution and eliminates radiation exposure. However, because of inherent magnetic forces and electromagnetic interference, the MRI environment poses challenges for electrophysiology procedures. In this study, we sought to test the feasibility of performing electrophysiology studies with real-time MRI guidance. Methods and Results-An MRI-compatible electrophysiology system was developed. Catheters were targeted to the right atrium, His bundle, and right ventricle of 10 mongrel dogs (23 to 32 kg) via a 1.5-T MRI system using rapidly acquired fast gradient-echo images (Ϸ5 frames per second). Catheters were successfully positioned at the right atrial, His bundle, and right ventricular target sites of all animals. Comprehensive electrophysiology studies with recording of intracardiac electrograms and atrial and ventricular pacing were performed. Postprocedural pathological evaluation revealed no evidence of thermal injury to the myocardium. After proof of safety in animal studies, limited real-time MRI-guided catheter mapping studies were performed in 2 patients. Adequate target catheter localization was confirmed via recording of intracardiac electrograms in both patients. Conclusions-To the best of our knowledge, this is the first study to report the feasibility of real-time MRI-guided electrophysiology procedures. This technique may eliminate patient and staff radiation exposure and improve real-time soft tissue resolution for procedural guidance.

Background The safety and clinical utility of magnetic resonance imaging at 1.5T in patients with cardiac implantable devices such as pacemakers (PM) and implantable cardioverter defibrillators (ICD) have been reported. This study aims to evaluate the extent of artifacts on cardiac magnetic resonance (CMR) in patients with PM and ICD (PM/ICD). Methods and Results A total of 71 CMR studies were performed with an established safety protocol in patients with pre-pectoral PM/ICD. The artifact area around the PM/ICD generator was measured in all short axis (SA), horizontal (HLA) and vertical long axis (VLA) SSFP cine planes. The location and extent of artifacts were also assessed in all SA (20 sectors/plane), HLA, and VLA (6 sectors/plane) late gadolinium enhanced CMR (LGE-CMR) planes. The artifact area on cine CMR was significantly larger with ICD versus PM generators in each plane (P<0.001, respectively). In patients with left-sided ICD or biventricular ICD systems, the percentages of sectors with any artifacts on LGE-CMR were 53.7%, 48.0% and 49.2% in SA, HLA and VLA planes, respectively. Meanwhile, patients with left-sided PM or right-sided PM/ICD had fewer artifacts. Anterior and apical regions were severely affected by artifact due to left-sided PM/ICD generators. Conclusions In contrast to patients with right-sided PM/ICD and left-sided PM, the anterior and apical left ventricle can be affected by susceptibility artifacts in patients with left-sided ICD. Artifact reduction methodologies will be necessary to improve the performance of CMR in patients with left sided ICD systems.