Tailored management of atrial fibrillation using a LGE-MRI based model: from the clinic to the electrophysiology laboratory.

Ablation provides a good therapeutic alternative for atrial fibrillation (AF) management; however, its effectiveness relies in adequate patient selection. Late gadolinium enhancement-magnetic resonance imaging (LGE-MRI) allows for atrial arrhythmic substrate, as well as postablation scarring visualization. In this article, we describe a new staging system for AF based on the amount of left atrial enhancement on LGE-MRI (Utah I ≤ 5%, Utah II >5-20%, Utah III > 20-35%, and Utah IV > 35%). On the basis of patient stage, a more tailored approach to AF management can be taken. This includes triaging appropriate candidates for ablation (Utah stages I-III), as well as anticoagulation management based on an increase on the predictive statistics of the CHADS(2). LGE-MRI also allows for ablation lesion characterization. Acute edema, defined as enhancement on T2-weighted MRI images immediately post-AF ablation correlates with low voltage areas but not with LGE-MRI-defined scar. Post-AF ablation LGE-MRI scans show significant heterogeneity in the atrial wall on portions subject to radiofrequency (RF). We have postulated that some of these areas correspond to no-reflow type phenomenon. Postablation LGE-MRI can also help identify breaks in lesion sets and its correlation with conduction recovery has been used successfully to guide redo procedures. Real-time MRI-based ablation system has the potential advantage of tissue lesion visualization during RF delivery. To that end, we have developed a 3-Tesla-based real-time MRI ablation system. We demonstrated the feasibility to safely navigate, pace, and record intracardiac EGMs in the atrial chambers, as well as applying RF energy while directly visualizing lesion formation in real time.