Sabrina Reiml, Daniel Toth, Maria Panayiotou, Bernhard Fahn, Rashed Karim, Jonathan Behar, Christopher Rinaldi, Reza Razavi, Kawal Rhode, Alexander Brost, Peter Mountney
KEYWORDS: Visualization, Heart, Lead, 3D modeling, Cardiology, Electrophysiology, Electrical breakdown, Image segmentation, Visual process modeling, 3D acquisition, 3D visualizations, Tissues, Magnetic resonance imaging
Heart failure is a serious disease affecting about 23 million people worldwide. Cardiac resynchronization therapy is used to treat patients suffering from symptomatic heart failure. However, 30% to 50% of patients have limited clinical benefit. One of the main causes is suboptimal placement of the left ventricular lead. Pacing in areas of myocardial scar correlates with poor clinical outcomes. Therefore precise knowledge of the individual patient’s scar characteristics is critical for delivering tailored treatments capable of improving response rates. Current research methods for scar assessment either map information to an alternative non-anatomical coordinate system or they use the image coordinate system but lose critical information about scar extent and scar distribution. This paper proposes two interactive methods for visualizing relevant scar information. A 2-D slice based approach with a scar mask overlaid on a 16 segment heart model and a 3-D layered mesh visualization which allows physicians to scroll through layers of scar from endocardium to epicardium. These complementary methods enable physicians to evaluate scar location and transmurality during planning and guidance. Six physicians evaluated the proposed system by identifying target regions for lead placement. With the proposed method more target regions could be identified.
KEYWORDS: Photovoltaics, 3D modeling, Process modeling, Atrial fibrillation, Image registration, 3D acquisition, Data modeling, 3D image processing, Visualization, Veins
Catheter ablation is a common treatment option for drug-refractory atrial fibrillation. In many cases, pulmonary vein isolation is the treatment of choice. With current fluoro overlay methods or electroanatomic mapping systems, it is possible to visualize three-dimensional (3-D) anatomy as well as target ablation lines to provide additional context information. Today, however, these lines need to be set manually before the procedure by the physician, which may interrupt the clinical workflow. As a solution, we present an automatic approach for the planning of ablation target lines. Our method works on surface models extracted from 3-D images. To propose suitable ablation lines, a reference model annotated with reference ablation lines is nonrigidly registered to the model segmented from a new patient’s 3-D data. After registration, the reference plan is transferred from the reference anatomy to the individual patient anatomy. Due to the high anatomical variations observed in clinical practice, additional landmark constraints are employed in the registration process to increase the robustness of our approach. We evaluated our method on 43 clinical datasets by benchmarking it against professionally planned ablation lines and achieved an average error over all datasets of 2.7±2.0 mm. A qualitative evaluation of the ablation planning lines matched clinical expectations.
Minimally invasive interventions often involve tools of curvilinear shape like catheters and guide-wires. If the camera parameters of a fluoroscopic system or a stereoscopic endoscope are known, a 3-D reconstruction of corresponding points can be computed by triangulation. Manual identification of point correspondences is time consuming, but there exist methods that automatically select corresponding points along curvilinear structures. The focus here is on the evaluation of a recent published method for catheter reconstruction from two views. A previous evaluation of this method using clinical data yielded promising results. For that evaluation, however, no 3-D ground truth data was available such that the error could only be estimated using the forward-projection of the reconstruction. In this paper, we present a more extensive evaluation of this method based on both clinical and phantom data. For the evaluation using clinical images, 36 data sets and two different catheters were available. The mean error found when reconstructing both catheters was 0.1mm ± 0.1mm. To evaluate the error in 3-D, images of a phantom were acquired from 13 different angulations. For the phantom, A 3D C-arm CT voxel data set of the phantom was also available. A reconstruction error was calculated by comparing the triangulated 3D reconstruction result to the 3D voxel data set. The evaluation yielded an average error of 1.2mm ± 1.2mm for the circumferential mapping catheter and 1.3mm ± 1.0mm for the ablation catheter.
Minimally invasive catheter ablation has become the preferred treatment option for atrial fibrillation. Although the standard ablation procedure involves ablation points set by radio-frequency catheters, cryo-balloon catheters have even been reported to be more advantageous in certain cases. As electro-anatomical mapping systems do not support cryo-balloon ablation procedures, X-ray guidance is needed. However, current methods to provide support for cryo-balloon catheters in fluoroscopically guided ablation procedures rely heavily on manual user interaction. To improve this, we propose a first method for automatic cryo-balloon catheter localization in fluoroscopic images based on a blob detection algorithm. Our method is evaluated on 24 clinical images from 17 patients. The method successfully detected the cryoballoon in 22 out of 24 images, yielding a success rate of 91.6 %. The successful localization achieved an accuracy of 1.00 mm ± 0.44 mm. Even though our methods currently fails in 8.4 % of the images available, it still offers a significant improvement over manual methods. Furthermore, detecting a landmark point along the cryo-balloon catheter can be a very important step for additional post-processing operations.
Minimally invasive catheter ablation is a common treatment option for atrial fibrillation. A common treatment strategy is pulmonary vein isolation. In this case, individual ablation points need to be placed around the ostia of the pulmonary veins attached to the left atrium to generate transmural lesions and thereby block electric signals. To achieve a durable transmural lesion, the tip of the catheter has to be stable with a sufficient tissue contact during radio-frequency ablation. Besides the steerable interface operated by the physician, the movement of the catheter is also influenced by the heart and breathing motion - particularly during ablation. In this paper we investigate the influence of breathing motion on different areas of the endocardium during radio frequency ablation. To this end, we analyze the frequency spectrum of the continuous catheter contact force to identify areas with increased breathing motion using a classification method. This approach has been applied to clinical patient data acquired during three pulmonary vein isolation procedures. Initial findings show that motion due to respiration is more pronounced at the roof and around the right pulmonary veins.
Abdominal aortic aneurysms are a common disease of the aorta which are treated minimally invasive in about 33 % of the cases. Treatment is done by placing a stent graft in the aorta to prevent the aneurysm from growing. Guidance during the procedure is facilitated by fluoroscopic imaging. Unfortunately, due to low soft tissue contrast in X-ray images, the aorta itself is not visible without the application of contrast agent. To overcome this issue, advanced techniques allow to segment the aorta from pre-operative data, such as CT or MRI. Overlay images are then subsequently rendered from a mesh representation of the segmentation and fused to the live fluoroscopic images with the aim of improving the visibility of the aorta during the procedure. The current overlay images typically use forward projections of the mesh representation. This fusion technique shows deficiencies in both the 3-D information of the overlay and the visibility of the fluoroscopic image underneath. We present a novel approach to improve the visualization of the overlay images using non-photorealistic rendering techniques. Our method preserves the visibility of the devices in the fluoroscopic images while, at the same time, providing 3-D information of the fused volume. The evaluation by clinical experts shows that our method is preferred over current state-of-the-art overlay techniques. We compared three visualization techniques to the standard visualization. Our silhouette approach was chosen by clinical experts with 67 %, clearly showing the superiority of our new approach.
Minimally invasive catheter ablation of electric foci, performed in electrophysiology labs, is an attractive treatment
option for atrial fibrillation (AF) - in particular if drug therapy is no longer effective or tolerated. There
are different strategies to eliminate the electric foci inducing the arrhythmia. Independent of the particular
strategy, it is essential to place transmural lesions. The impact of catheter contact force on the generated lesion
quality has been investigated recently, and first results are promising. There are different approaches to measure
catheter-tissue contact. Besides traditional haptic feedback, there are new technologies either relying on catheter
tip-to-tissue contact force or on local impedance measurements at the tip of the catheter.
In this paper, we present a novel tool for post-procedural ablation point evaluation and visualization of contact
force characteristics. Our method is based on localizing ablation points set during AF ablation procedures. The
3-D point positions are stored together with lesion specific catheter contact force (CF) values recorded during
the ablation. The force records are mapped to the spatial 3-D positions, where the energy has been applied.
The tracked positions of the ablation points can be further used to generate a 3-D mesh model of the left atrium
(LA). Since our approach facilitates visualization of different force characteristics for post-procedural evaluation
and verification, it has the potential to improve outcome by highlighting areas where lesion quality may be less
than desired.
Atrial fibrillation (AFib) has been identified as a major cause of stroke. Radiofrequency
catheter ablation has become an increasingly important treatment option, especially
when drug therapy fails. Navigation under X-ray can be enhanced by using augmented fluoroscopy.
It renders overlay images from pre-operative 3-D data sets which are then fused with
X-ray images to provide more details about the underlying soft-tissue anatomy. Unfortunately,
these fluoroscopic overlay images are compromised by respiratory and cardiac motion. Various
methods to deal with motion have been proposed. To meet clinical demands, they have to be
fast. Methods providing a processing frame rate of 3 frames-per-second (fps) are considered
suitable for interventional electrophysiology catheter procedures if an acquisition frame rate of
2 fps is used. Unfortunately, when working at a processing rate of 3 fps, the delay until the actual
motion compensated image can be displayed is about 300 ms. More recent algorithms can
achieve frame rates of up to 20 fps, which reduces the lag to 50 ms. By using a novel approach
involving a 3-D catheter model, catheter segmentation and a distance transform, we can speed
up motion compensation to 25 fps which results in a display delay of only 40 ms on a standard
workstation for medical applications. Our method uses a constrained 2-D/3-D registration to
perform catheter tracking, and it obtained a 2-D tracking error of 0.61 mm.
Electrophysiology (EP) procedures are conducted by cardiac specialists to help diagnose and treat abnormal heart
rhythms. Such procedures are conducted under mono-plane and bi-plane x-ray fluoroscopy guidance to allow the
specialist to target ablation points within the heart. Ablations lesions are usually set by applying radio-frequency energy
to endocardial tissue using catheters placed inside a patient's heart. Recently we have developed a system capable of
overlaying information involving the heart and targeted ablation locations from pre-operational image data for additional
assistance. Although useful, such information offers only approximate guidance due to heart beat and breathing motion.
As a solution to this problem, we propose to make use of a 2D lasso catheter tracking method. We apply it to bi-plane
fluoroscopy images to dynamically update fluoro overlays. The dynamic overlays are computed at 3.5 frames per second
to offer real-time updates matching the heart motion. During the course of our experiments, we found an average 3-D
error of 1.6 mm on average. We present the workflow and features of the motion-adjusted, augmented fluoroscopy
system and demonstrate the dramatic improvement in the overlay quality provided by this approach.
Felix Bourier, Alexander Brost, Andreas Kleinoeder, Tanja Kurzendorfer, Martin Koch, Attila Kiraly, Hans-Juergen Schneider, Joachim Hornegger, Norbert Strobel, Klaus Kurzidim
Atrial fibrillation (AFib), the most common arrhythmia, has been identified as a major
cause of stroke. The current standard in interventional treatment of AFib is the pulmonary
vein isolation (PVI). PVI is guided by fluoroscopy or non-fluoroscopic electro-anatomic mapping
systems (EAMS). Either classic point-to-point radio-frequency (RF)- catheter ablation or
so-called single-shot-devices like cryo-balloons are used to achieve electrically isolation of the
pulmonary veins and the left atrium (LA). Fluoroscopy-based systems render overlay images
from pre-operative 3-D data sets which are then merged with fluoroscopic imaging, thereby
adding detailed 3-D information to conventional fluoroscopy. EAMS provide tracking and
visualization of RF catheters by means of electro-magnetic tracking. Unfortunately, current
navigation systems, fluoroscopy-based or EAMS, do not provide tools to localize and visualize
single shot devices like cryo-balloon catheters in 3-D. We present a prototype software
for fluoroscopy-guided ablation procedures that is capable of superimposing 3-D datasets as
well as reconstructing cyro-balloon catheters in 3-D. The 3-D cyro-balloon reconstruction was
evaluated on 9 clinical data sets, yielded a reprojected 2-D error of 1.72 mm ± 1.02 mm.
Atrial fibrillation (AFib) is the most common heart arrhythmia. In certain situations,
it can result in life-threatening complications such as stroke and heart failure. For paroxsysmal
AFib, pulmonary vein isolation (PVI) by catheter ablation is the recommended choice of
treatment if drug therapy fails. During minimally invasive procedures, electrically active tissue
around the pulmonary veins is destroyed by either applying heat or cryothermal energy to the
tissue. The procedure is usually performed in electrophysiology labs under fluoroscopic guidance.
Besides radio-frequency catheter ablation devices, so-called single-shot devices, e.g., the
cryothermal balloon catheters, are receiving more and more interest in the electrophysiology
(EP) community. Single-shot devices may be advantageous for certain cases, since they can
simplify the creation of contiguous (gapless) lesion sets around the pulmonary vein which is
needed to achieve PVI. In many cases, a 3-D (CT, MRI, or C-arm CT) image of a patient's left
atrium is available. This data can then be used for planning purposes and for supporting catheter
navigation during the procedure. Cryo-thermal balloon catheters are commercially available in
two different sizes. We propose the Atrial Fibrillation Planning Tool (AFiT), which visualizes
the segmented left atrium as well as multiple cryo-balloon catheters within a virtual reality, to
find out how well cryo-balloons fit to the anatomy of a patient's left atrium. First evaluations
have shown that AFiT helps physicians in two ways. First, they can better assess whether cryoballoon
ablation or RF ablation is the treatment of choice at all. Second, they can select the
proper-size cryo-balloon catheter with more confidence.
Atrial fibrillation is the most common heart arrhythmia and a leading cause of stroke.
The treatment option of choice is radio-frequency catheter ablation, which is performed in electrophysiology
labs using C-Arm X-ray systems for navigation and guidance. The goal is to
electrically isolate the pulmonary vein-left atrial junction thereby rendering myocardial fibers
responsible for induction and maintenance of AF inactive. The use of overlay images for fluoroscopic
guidance may improve the quality of the ablation procedure, and can reduce procedure
time. Overlay images, acquired using CT, MRI, or C-arm CT, can add soft-tissue information,
otherwise not visible under X-ray. MRI can be used to image a wide variety of anatomical
details without ionizing radiation. In this paper, we present a method to register a 3-D MRI
volume to 2-D biplane X-ray images using the coronary sinus. Current approaches require registration
of the overlay images to the fluoroscopic images to be performed after the trans-septal
puncture, when contast agent can be administered. We present a new approach for registration
to align overlay images before the trans-septal puncture. To this end, we manually extract the
coronary sinus from pre-operative MRI and register it to a multi-electorde catheter placed in the
coronary sinus.
The treatment of atrial fibrillation has gained increasing importance in the field of
computer-aided interventions. State-of-the-art treatment involves the electrical isolation of the
pulmonary veins attached to the left atrium under fluoroscopic X-ray image guidance. Due to
the rather low soft-tissue contrast of X-ray fluoroscopy, the heart is difficult to see. To overcome
this problem, overlay images from pre-operative 3-D volumetric data can be used to add
anatomical detail. Unfortunately, these overlay images are static at the moment, i.e., they do not
move with respiratory and cardiac motion. The lack of motion compensation may impair X-ray
based catheter navigation, because the physician could potentially position catheters incorrectly.
To improve overlay-based catheter navigation, we present a novel two stage approach for respiratory
and cardiac motion compensation. First, a cascade of boosted classifiers is employed to
segment a commonly used circumferential mapping catheter which is firmly fixed at the ostium
of the pulmonary vein during ablation. Then, a 2-D/2-D model-based registration is applied to
track the segmented mapping catheter. Our novel hybrid approach was evaluated on 10 clinical
data sets consisting of 498 fluoroscopic monoplane frames. We obtained an average 2-D tracking
error of 0.61 mm, with a minimum error of 0.26 mm and a maximum error of 1.62 mm.
These results demonstrate that motion compensation using registration-based catheter tracking
is both feasible and accurate. Using this approach, we can only estimate in-plane motion. Fortunately,
compensating for this is often sufficient for EP procedures where the motion is governed
by breathing.
Atrial fibrillation is the most common sustained heart arrhythmia and a leading cause
of stroke. Its treatment by radio-frequency catheter ablation, performed using fluoroscopic image
guidance, is gaining increasingly more importance. Two-dimensional fluoroscopic navigation
can take advantage of overlay images derived from pre-operative 3-D data to add anatomical
details otherwise not visible under X-ray. Unfortunately, respiratory motion may impair
the utility of these static overlay images for catheter navigation. We developed an approach for
image-based 3-D motion compensation as a solution to this problem. A bi-plane C-arm system
is used to take X-ray images of a special circumferential mapping catheter from two directions.
In the first step of the method, a 3-D model of the device is reconstructed. Three-dimensional
respiratory motion at the site of ablation is then estimated by tracking the reconstructed catheter
model in 3-D. This step involves bi-plane fluoroscopy and 2-D/3-D registration. Phantom data
and clinical data were used to assess our model-based catheter tracking method. Experiments
involving a moving heart phantom yielded an average 2-D tracking error of 1.4 mm and an average
3-D tracking error of 1.1 mm. Our evaluation of clinical data sets comprised 469 bi-plane
fluoroscopy frames (938 monoplane fluoroscopy frames). We observed an average 2-D tracking
error of 1.0 mm ± 0.4 mm and an average 3-D tracking error of 0.8 mm ± 0.5 mm. These results
demonstrate that model-based motion-compensation based on 2-D/3-D registration is both
feasible and accurate.
arm X-ray imaging devices are commonly used for minimally invasive cardiovascular or other interventional
procedures. Calibrated state-of-the-art systems can, however, not only be used for 2D imaging but also for
three-dimensional reconstruction either using tomographic techniques or even stereotactic approaches.
To evaluate the accuracy of X-ray object localization from two views, a simulation study assuming an ideal
imaging geometry was carried out first. This was backed up with a phantom experiment involving a real C-arm
angiography system. Both studies were based on a phantom comprising five point objects. These point objects
were projected onto a flat-panel detector under different C-arm view positions. The resulting 2D positions were
perturbed by adding Gaussian noise to simulate 2D point localization errors. In the next step, 3D point positions
were triangulated from two views. A 3D error was computed by taking differences between the reconstructed 3D
positions using the perturbed 2D positions and the initial 3D positions of the five points. This experiment was
repeated for various C-arm angulations involving angular differences ranging from 15° to 165°. The smallest 3D
reconstruction error was achieved, as expected, by views that were 90° degrees apart. In this case, the simulation
study yielded a 3D error of 0.82 mm ± 0.24 mm (mean ± standard deviation) for 2D noise with a standard
deviation of 1.232 mm (4 detector pixels). The experimental result for this view configuration obtained on an
AXIOM Artis C-arm (Siemens AG, Healthcare Sector, Forchheim, Germany) system was 0.98 mm ± 0.29 mm,
respectively.
These results show that state-of-the-art C-arm systems can localize instruments with millimeter accuracy,
and that they can accomplish this almost as well as an idealized theoretical counterpart. High stereotactic
localization accuracy, good patient access, and CT-like 3D imaging capabilities render state-of-the-art C-arm
systems ideal devices for X-ray based minimally invasive procedures.
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