Evaluation of quantification methods for left arial late gadolinium enhancement based on different references in patients with atrial fibrillation

  • Sung Ho Hwang
  • Yu-Whan Oh
  • Dae In Lee
  • Jaemin Shim
  • Sang-Weon Park
  • Young-Hoon Kim
Original Paper


By using late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging, we compared left atrial late gadolinium enhancement (LA-LGE) quantification methods based on different references to characterize the left atrial wall in patients with atrial fibrillation (AF). Thirty-eight patients who underwent three-dimensional LGE-CMR imaging before catheter ablation for AF were classified into three groups depending on their clinical AF type: (1) paroxysmal AF (PAF; n = 12); (2) persistent AF (PeAF; n = 16); and (3) recurrent AF after catheter ablation (RAF; n = 10). To quantify LA-LGE on LGE-CMR imaging, we used the thresholds of 2 standard deviations (2-SD), 3-SD, 4-SD, 5-SD, or 6-SD above the mean signal from the unenhanced left ventricular myocardium, and we used the full width at half maximum (FWHM) technique, which was based on the maximum signal from the mitral valve with high signal intensity. The 6-SD threshold and FWHM techniques were statistically reproducible with an intraclass correlation coefficient >0.7. On applying the FWHM technique, the normalized LA-LGE volume by LA wall area showed a significant difference between the RAF, PeAF, and PAF groups (0.22 ± 0.04, 0.16 ± 0.06, and 0.09 ± 0.03 mL/cm2, respectively) (P < 0.05). Furthermore, most of the fibrotic scarring and low-voltage tissue on the electroanatomic map corresponded well with the extent of LA-LGE. The FWHM technique based on the mitral valve can provide a reproducible quantification of LA-LGE related to AF in the thin LA wall.


Atrial fibrillation Catheter ablation Magnetic resonance imaging Reproducibility of results Human 


Conflict of interest



  1. 1.
    Estes NA III, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJ, Waldo AL, Wyse DG, American College of Cardiology/American Heart Association Task Force on Performance M, Physician Consortium for Performance I, Heart Rhythm S (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117(8):1101–1120CrossRefGoogle Scholar
  2. 2.
    Kopecky SL, Gersh BJ, McGoon MD, Whisnant JP, Holmes DR Jr, Ilstrup DM, Frye RL (1987) The natural history of lone atrial fibrillation: a population-based study over three decades. N Engl J Med 317(11):669–674PubMedCrossRefGoogle Scholar
  3. 3.
    Verma A, Wazni OM, Marrouche NF, Martin DO, Kilicaslan F, Minor S, Schweikert RA, Saliba W, Cummings J, Burkhardt JD, Bhargava M, Belden WA, Abdul-Karim A, Natale A (2005) Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure. J Am Coll Cardiol 45(2):285–292PubMedCrossRefGoogle Scholar
  4. 4.
    Boldt A, Wetzel U, Lauschke J, Weigl J, Gummert J, Hindricks G, Kottkamp H, Dhein S (2004) Fibrosis in left atrial tissue of patients with atrial fibrillation with and without underlying mitral valve disease. Heart 90(4):400–405PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Lima JA, Judd RM, Bazille A, Schulman SP, Atalar E, Zerhouni EA (1995) Regional heterogeneity of human myocardial infarcts demonstrated by contrast-enhanced MRI potential mechanisms. Circulation 92(5):1117–1125PubMedCrossRefGoogle Scholar
  6. 6.
    Arheden H, Saeed M, Higgins CB, Gao DW, Bremerich J, Wyttenbach R, Dae MW, Wendland MF (1999) Measurement of the distribution volume of gadopentetate dimeglumine at echo-planar MR imaging to quantify myocardial infarction: comparison with 99mTc-DTPA autoradiography in rats. Radiology 211(3):698–708PubMedCrossRefGoogle Scholar
  7. 7.
    Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O, Klocke FJ, Bonow RO, Judd RM (2000) The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 343(20):1445–1453PubMedCrossRefGoogle Scholar
  8. 8.
    Simonetti OP, Kim RJ, Fieno DS, Hillenbrand HB, Wu E, Bundy JM, Finn JP, Judd RM (2001) An improved MR imaging technique for the visualization of myocardial infarction. Radiology 218(1):215–223PubMedCrossRefGoogle Scholar
  9. 9.
    Misfeld M, Sievers HH (2007) Heart valve macro- and microstructure. Philos Trans R Soc Lond B Biol Sci 362(1484):1421–1436PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    European Heart Rhythm Association; Heart Rhythm Society, Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Zamorano JL; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; European Society of Cardiology Committee for Practice Guidelines; Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation (2006) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). J Am Coll Cardiol 48(4):854–906CrossRefGoogle Scholar
  11. 11.
    Shah AN, Mittal S, Sichrovsky TC, Cotiga D, Arshad A, Maleki K, Pierce WJ, Steinberg JS (2008) Long-term outcome following successful pulmonary vein isolation: pattern and prediction of very late recurrence. J Cardiovasc Electrophysiol 19(7):661–667PubMedCrossRefGoogle Scholar
  12. 12.
    Flett AS, Hasleton J, Cook C, Hausenloy D, Quarta G, Ariti C, Muthurangu V, Moon JC (2011) Evaluation of techniques for the quantification of myocardial scar of differing etiology using cardiac magnetic resonance. JACC Cardiovasc Imaging 4(2):150–156PubMedCrossRefGoogle Scholar
  13. 13.
    Pappone C, Rosanio S, Oreto G, Tocchi M, Gugliotta F, Vicedomini G, Salvati A, Dicandia C, Mazzone P, Santinelli V, Gulletta S, Chierchia S (2000) Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation. Circulation 102(21):2619–2628PubMedCrossRefGoogle Scholar
  14. 14.
    Oakes RS, Badger TJ, Kholmovski EG, Akoum N, Burgon NS, Fish EN, Blauer JJ, Rao SN, DiBella EV, Segerson NM, Daccarett M, Windfelder J, McGann CJ, Parker D, MacLeod RS, Marrouche NF (2009) Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation 119(13):1758–1767PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86(2):420–428PubMedCrossRefGoogle Scholar
  16. 16.
    Akcakaya M, Rayatzadeh H, Basha TA, Hong SN, Chan RH, Kissinger KV, Hauser TH, Josephson ME, Manning WJ, Nezafat R (2012) Accelerated late gadolinium enhancement cardiac MR imaging with isotropic spatial resolution using compressed sensing: initial experience. Radiology 264(3):691–699PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Tatli S, Zou KH, Fruitman M, Reynolds HG, Foo T, Kwong R, Yucel EK (2004) Three-dimensional magnetic resonance imaging technique for myocardial-delayed hyperenhancement: a comparison with the two-dimensional technique. J Magn Reson Imaging 20(3):378–382PubMedCrossRefGoogle Scholar
  18. 18.
    Huber AM, Schoenberg SO, Hayes C, Spannagl B, Engelmann MG, Franz WM, Reiser MF (2005) Phase-sensitive inversion-recovery MR imaging in the detection of myocardial infarction. Radiology 237(3):854–860PubMedCrossRefGoogle Scholar
  19. 19.
    Malcolme-Lawes LC, Juli C, Karim R, Bai W, Quest R, Lim PB, Jamil-Copley S, Kojodjojo P, Ariff B, Davies DW, Rueckert D, Francis DP, Hunter R, Jones D, Boubertakh R, Petersen SE, Schilling R, Kanagaratnam P, Peters NS (2013) Automated analysis of atrial late gadolinium enhancement imaging that correlates with endocardial voltage and clinical outcomes: a 2-center study. Heart Rhythm 10(8):1184–1191PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Kim HW, Farzaneh-Far A, Kim RJ (2009) Cardiovascular magnetic resonance in patients with myocardial infarction: current and emerging applications. J Am Coll Cardiol 55(1):1–16PubMedCrossRefGoogle Scholar
  21. 21.
    Bondarenko O, Beek AM, Hofman MB, Kuhl HP, Twisk JW, van Dockum WG, Visser CA, van Rossum AC (2005) Standardizing the definition of hyperenhancement in the quantitative assessment of infarct size and myocardial viability using delayed contrast-enhanced CMR. J Cardiovasc Magn Reson 7(2):481–485PubMedCrossRefGoogle Scholar
  22. 22.
    Nattel S, Burstein B, Dobrev D (2008) Atrial remodeling and atrial fibrillation: mechanisms and implications. Circ Arrhythm Electrophysiol 1(1):62–73PubMedCrossRefGoogle Scholar
  23. 23.
    Akkaya M, Higuchi K, Koopmann M, Damal K, Burgon NS, Kholmovski E, McGann C, Marrouche N (2013) Higher degree of left atrial structural remodeling in patients with atrial fibrillation and left ventricular systolic dysfunction. J Cardiovasc Electrophysiol 24(5):485–491PubMedCrossRefGoogle Scholar
  24. 24.
    Beukema WP, Elvan A, Sie HT, Misier AR, Wellens HJ (2005) Successful radiofrequency ablation in patients with previous atrial fibrillation results in a significant decrease in left atrial size. Circulation 112(14):2089–2095PubMedCrossRefGoogle Scholar
  25. 25.
    Tops LF, Bax JJ, Zeppenfeld K, Jongbloed MR, van der Wall EE, Schalij MJ (2006) Effect of radiofrequency catheter ablation for atrial fibrillation on left atrial cavity size. Am J Cardiol 97(8):1220–1222PubMedCrossRefGoogle Scholar
  26. 26.
    Reant P, Lafitte S, Jais P, Serri K, Weerasooriya R, Hocini M, Pillois X, Clementy J, Haissaguerre M, Roudaut R (2005) Reverse remodeling of the left cardiac chambers after catheter ablation after 1 year in a series of patients with isolated atrial fibrillation. Circulation 112(19):2896–2903PubMedGoogle Scholar
  27. 27.
    Taclas JE, Nezafat R, Wylie JV, Josephson ME, Hsing J, Manning WJ, Peters DC (2010) Relationship between intended sites of RF ablation and post-procedural scar in AF patients, using late gadolinium enhancement cardiovascular magnetic resonance. Heart Rhythm 7(4):489–496PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  • Sung Ho Hwang
    • 1
  • Yu-Whan Oh
    • 1
  • Dae In Lee
    • 2
  • Jaemin Shim
    • 2
  • Sang-Weon Park
    • 2
  • Young-Hoon Kim
    • 2
    • 3
  1. 1.Department of RadiologyKorea University Medical CenterSeoulRepublic of Korea
  2. 2.Division of Cardiology, Department of Internal MedicineKorea University Medical CenterSeoulRepublic of Korea
  3. 3.Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea UniversitySeoulSouth Korea

Personalised recommendations