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Pulmonary vein evaluation

a) SCMR official document standardized acquisition guidelines – relevant extract

1. LV structure and function module
2. Breathhold non-gated contrast-enhanced MRA performed in the coronal projection encompassing the pulmonary veins and left atrium (greater anterior coverage if breathholding permits) (optional – optimize oblique projections,ECG-gated acquisition)
   a. Gadolinium (0.1–0.2 mmol/kg) injected at 2–3 ml/s
   b. Slice thickness 1–2 mm; acquired spatial resolution inplane 1–1.5 mm.
   c. Slices – typically 60–80, as needed to encompass region of interest.
   d. Parallel acquisition used as available
   e. 2–3 volumetric acquisitions – each breathhold typically no longer than 15–18s.
3. Optional – through plane phase contrast flow analysis through each pulmonary vein.

 b) SCMR official document reporting recommendations – relevant extract

Qualitative elements that should be included in CMR-based PV reporting include:
1. Number of pulmonary veins;
2. Atrial side of pulmonary vein return; 
3. Recognition of accessory or anomalous pulmonary veins; and
4. Presence or absence of stenosis in each PV, especially in reporting post-ablation CMR exams.

Quantitative elements that should be included in CMR-based PV reporting are:
1. Maximum ostial diameter of each pulmonary vein;
2. Cardiac phase (e.g. end-atrial diastole) and respiratory phase (e.g. end-expiration) during acquisition of images used for ostial measurements;
3. Minimum ostial diameter of each stenotic pulmonary vein; and
4. Imaging technique used for measurements
The number and position of pulmonary veins is accounted for noting common trunks, accessory veins, and evidence for stenosis or thrombosis cross sectional area of the pulmonary vein may be provided.  A 3D workstation may be used to calculate major and minor axes, and cross sectional area of each pulmonary vein ostium, and compare pre- and post-ablation images side by side. 
 
SCMR recognizes the value of pictorial display of the pulmonary vein orientations, and suggests implementation of diagrams when feasible

c) Standardized web based images

Atrial angiogram
Case from the Heart Hopsital, London.  Indication: Prior to redo atrial ablation. It used 0.1mmol/Kg gadolium at 3mls/s antecubital fossa, parallel imaging.  Departing from protocol, no LV function was assessed on this scan.  Reconstructions are shown for interest - in practice, these are un-necessary as they are made in Carto/Navex.  The right middle pulmonary vein is close to having a separate origin from the right upper and lower PVs.

d) Case of the Week example(s)

Number 08-19 Diagnosing RV dilatation by CMR
History: ** Case of the year winner, 2008

e) Expert opinion – ‘How we do’

None currently.

f) Relevant Online Talks

Free talks
Sorry, no free talks at this time
Members only talks - general

Real-Time EP
By Henry Halperin - Johns Hopkins
Recorded at SCMR 2008: Plenary Session 2 CMR and Electrophysiology

Image Integration of Left Atrial Anatomy in CMR
By Moussa Mansour - Electrophysiology Lab/Arrhythmia Service
Recorded at SCMR 2008: Plenary Session 2 CMR and Electrophysiology

Members only talks - cutting edge

Ablations with X-ray Fused to MR. Kawal Rhode
By Kawal Rhode - King's College, London
Recorded at SCMR 2009 Interventional II - iCMR Applications: Focus on EP and Pediatrics

Ablation Targeting and Assessment
By Dana Peters - Beth Israel Deaconess
Recorded at SCMR 2009 Interventional II - iCMR Applications: Focus on EP and Pediatrics

MRI Guided Cardiac Surgery
By Keith Horvath - National Institutes of Health
Recorded at SCMR 2009 Interventional II - iCMR Applications: Focus on EP and Pediatrics

EP applications with iCMR 2
By Henry Halperin - Johns Hopkins Hospital
Recorded at SCMR 2009 Interventional II - iCMR Applications: Focus on EP and Pediatrics

h) Relevant papers (starting point):

Ferrari VA, Scott CH, Holland GA, Axel L, St. John Sutton M: Ultrafast three-dimensional contrast-enhanced MRA and imaging in the diagnosis of partial anomalous pulmonary venous drainage. JACC 2001;37:1120-8.
Greil GF, Powell AJ, Gildein HP et al. Gadolinium-enhanced threedimensional magnetic resonance angiography of pulmonary and systemic venous anomalies. J Am Coll Cardiol 2002;39:335–41.
Valsangiacomo ER, Levasseur S, McCrindle BW et al. Contrastenhanced MR angiography of pulmonary venous abnormalities in children. Pediatr Radiol 2003;33:92–8.
Kato R, Lickfett L, Meininger G, Dickfeld T, Wu R, Juang G et al. Pulmonary vein anatomy in patients undergoing catheter ablation of atrial fibrillation: lessons learned by use of magnetic resonance imaging. Circulation 2003;107:2004-2010.
Prasad SK, Soukias N, Hornung T, Khan M, Pennell DJ, Gatzoulis MA, Mohiaddin RM. Role of MRA in the Diagnosis of Major Aortopulmonary Collateral Arteries and Partial Anomalous Pulmonary Venous Drainage.Circulation. 2004;109:207-214
Mansour M, Refaat M, Heist EK, Mela T, Cury R, Holmvang G et al. Three-dimensional anatomy of the left atrium by magnetic resonance angiography: implications for catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2006;17:719-723.
Bertaglia E, Brandolino G, Zoppo F, Zerbo F, Pascotto P. Integration of three-dimensional left atrial magnetic resonance images into a real-time electroanatomic mapping system: validation of a registration method. PACE 2008;31:273-282.