The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Background— The global burden of atrial fibrillation (AF) is unknown. Methods and Results— We systematically reviewed population-based studies of AF published from 1980 to 2010 from the 21 Global Burden of Disease regions to estimate global/regional prevalence, incidence, and morbidity and mortality related to AF (DisModMR software). Of 377 potential studies identified, 184 met prespecified eligibility criteria. The estimated number of individuals with AF globally in 2010 was 33.5 million (20.9 million men [95% uncertainty interval (UI), 19.5–22.2 million] and 12.6 million women [95% UI, 12.0–13.7 million]). Burden associated with AF, measured as disability-adjusted life-years, increased by 18.8% (95% UI, 15.8–19.3) in men and 18.9% (95% UI, 15.8–23.5) in women from 1990 to 2010. In 1990, the estimated age-adjusted prevalence rates of AF (per 100 000 population) were 569.5 in men (95% UI, 532.8–612.7) and 359.9 in women (95% UI, 334.7–392.6); the estimated age-adjusted incidence rates were 60.7 per 100 000 person-years in men (95% UI, 49.2–78.5) and 43.8 in women (95% UI, 35.9–55.0). In 2010, the prevalence rates increased to 596.2 (95% UI, 558.4–636.7) in men and 373.1 (95% UI, 347.9–402.2) in women; the incidence rates increased to 77.5 (95% UI, 65.2–95.4) in men and 59.5 (95% UI, 49.9–74.9) in women. Mortality associated with AF was higher in women and increased by 2-fold (95% UI, 2.0–2.2) and 1.9-fold (95% UI, 1.8–2.0) in men and women, respectively, from 1990 to 2010. There was evidence of significant regional heterogeneity in AF estimations and availability of population-based data. Conclusions— These findings provide evidence of progressive increases in overall burden, incidence, prevalence, and AF-associated mortality between 1990 and 2010, with significant public health implications. Systematic, regional surveillance of AF is required to better direct prevention and treatment strategies.

Worldwide Epidemiology of Atrial Fibrillation: A Global Burden of Disease 2010 Study

During the past decade, catheter ablation of atrial fibrillation (AF) has evolved rapidly from an investigational procedure to its current status as a commonly performed ablation procedure in many major hospitals throughout the world. Surgical ablation of AF, using either standard or minimally invasive techniques, is also performed in many major hospitals throughout the world.

In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society.1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons and the American College of Cardiology. Since the publication of the 2007 document, there has been much learned about AF ablation, and the indications for these procedures have changed. Therefore the purpose of this 2012 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a Task Force, convened by the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society and charged with defining the indications, techniques, and outcomes of this procedure. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation, including definitions relevant to this topic.

This statement summarizes the opinion of the Task Force members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF. This statement is not intended to recommend or promote catheter ablation of AF. Rather the ultimate judgment regarding care of a particular patient …

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: Recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA).

An imaging system for use in medical intervention procedure planning includes a medical scanner system for generating a volume of cardiac image data, a data acquisition system for acquiring the volume of cardiac image data, an image generation system for generating a viewable image from the volume of cardiac image data, a database for storing information from the data acquisition and image generation systems, an operator interface system for managing the medical scanner system, the data acquisition system, the image generation system, and the database, and a post-processing system for analyzing the volume of cardiac image data, displaying the viewable image and being responsive to the operator interface system. The operator interface system includes instructions for using the volume of cardiac image data and the viewable image for bi-ventricular pacing planning, atrial fibrillation procedure planning, or atrial flutter procedure planning.

Method and apparatus for medical intervention procedure planning

A method of creating 3D models to be used for cardiac interventional procedure planning. Acquisition data is obtained from a medical imaging system and cardiac image data is created in response to the acquisition data. A 3D model is created in response to the cardiac image data and three anatomical landmarks are identified on the 3D model. The 3D model is sent to an interventional system where the 3D model is in a format that can be imported and registered with the interventional system.

Method, system and computer product for cardiac interventional procedure planning

Introduction: This study examines the feasibility of atrial fibrillation (AF) ablation using registered three-dimensional computed tomography (CT) images of the left atrium with fluoroscopy.



Methods and Results: A total of 50 consecutive patients with symptomatic AF refractory to medical therapy (32 paroxysmal, 18 persistent, age 55 ± 10 years) were randomized to undergo a catheter-based AF ablation procedure with or without the CT-fluoroscopy guidance system. All patients underwent preprocedural contrast-enhanced CT imaging and segmentation of the left atrium. For the CT-fluoroscopy group, circumferential lesions encompassing the pulmonary vein (PV) antrum and linear lesions along the roof of the left atrium between the superior PVs and the mitral isthmus were created on the CT image, which was registered with real-time fluoroscopy. The registered images were then used to navigate the ablation catheters to the sites of planned ablation. After the ablation sites were completed, any remaining PV potentials were isolated with electrophysiological guidance. In the control patients, the same technique was performed without using the CT-fluoro guidance system. CT scans were accurately registered to fluoroscopic images with minimal manual correction. Operators could navigate catheters on the registered images to preplanned, extraostial sites for ablation. CT-fluoroscopy guidance decreased procedure duration and fluoro times (P < 0.05). At a mean follow-up of 9 ± 2 months, 21 patients (84%) in the CT-fluoro guidance group and 16 patients (64%) in the control group have had no recurrence of AF.



Conclusion: CT-fluoroscopic-guided left atrial ablation is feasible and allows appropriate catheter manipulation in the left atrium.

Computed tomography-fluoroscopy image integration-guided catheter ablation of atrial fibrillation.

Background— Anatomic structures such as the left atrium and the pulmonary veins (PVs) are not delineated by fluoroscopy because there is no contrast differentiation between them and the surrounding anatomy. Representation of an anatomic structure via a 3D model obtained from computed tomography (CT) imaging and subsequent projection of these images over the fluoroscopy system may help in navigation of the mapping and ablation catheter to the appropriate sites during electrophysiology procedures.

Methods and Results— In this feasibility study, in vitro experiments were performed with a plastic heart model (phantom) with 2 catheters or radiopaque platinum beads placed in the phantom at the time of CT imaging and fluoroscopy. Subsequently, 20 consecutive patients underwent contrast-enhanced, ECG-gated CT scanning. Left atrial volumes were generated from the reconstructed data at &75% of the R-R interval during the cardiac cycle. Similarly, the superior vena cava and the coronary sinus were also reconstructed from these images. During the electrophysiology procedure, digital records (cine sequences) were obtained. Using predetermined algorithms, both the phantom model and the patients’ 3D left atrial models derived from the CT were registered with projection images of fluoroscopy. Registration was performed with a transformation that linked the superior vena cava and the coronary sinus from the CT model with a catheter placed inside the coronary sinus via the superior vena cava. Registration was successfully accomplished with the plastic phantom and in all 20 patients. Registration accuracy was assessed in the phantom by assessing the overlapping beads seen both in the CT and the fluoroscopy images. The mean registration error was 1.4 mm (range 0.9 to 2.3 mm). Accuracy of the registered images was assessed in patients with recordings from a basket catheter placed sequentially in the superior PVs and by injecting contrast into the PVs to assess overlapping of contrast-filled PVs with the corresponding vessels on the registered images. The images could be calibrated quite accurately. Any rotational error, which was usually minor, could be corrected by rotating the images as needed.

Conclusions— Registration of 3D models of the left atrium and PVs with fluoroscopic images of the same is feasible and could enable appropriate navigation and localization of the mapping and ablation catheter during procedures such as atrial fibrillation ablation.

Received May 27, 2005; revision received July 20, 2005; accepted August 22, 2005.

Registration of Three-Dimensional Left Atrial Computed Tomographic Images With Projection Images Obtained Using Fluoroscopy

An imaging system for use in a medical intervention procedure is disclosed. A first image acquisition system of a first modality employing a catheter at an anatomical region of a patient is configured to produce a first image of the anatomical region using fluoroscopy, the first image comprising a set of fluoroscopy projection images. A second image acquisition system of a second different modality is configured to generate a 3D model of the anatomical region. An anatomical reference system is common to both the first and second image acquisition systems. A processing circuit is configured to process executable instructions for registering the 3D model with the fluoroscopy image in response to the common reference system and discernible parameters associated with the catheter in both the first and second image acquisition systems.

Jasbir Sra

Papers

Method and apparatus for medical intervention procedure planning

Method, system and computer product for cardiac interventional procedure planning

Computed tomography-fluoroscopy image integration-guided catheter ablation of atrial fibrillation.

Registration of Three-Dimensional Left Atrial Computed Tomographic Images With Projection Images Obtained Using Fluoroscopy

Method and system for registering 3D models of anatomical regions with projection images of the same