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Preprocedural Planning for Left Atrial Procedures in Atrial Fibrillation
Variant: 1
Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transesophageal | Usually Appropriate | O |
| MRA chest without and with IV contrast | Usually Appropriate | O |
| MRI heart function and morphology without and with IV contrast | Usually Appropriate | O |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CT heart function and morphology with IV contrast | Usually Appropriate | ☢☢☢☢ |
| MRA chest without IV contrast | May Be Appropriate | O |
| MRI heart function and morphology without IV contrast | May Be Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Arteriography coronary | Usually Not Appropriate | ☢☢☢ |
| Catheter venography pulmonary | Usually Not Appropriate | ☢☢☢☢ |
| MRA coronary arteries without and with IV contrast | Usually Not Appropriate | O |
| MRA coronary arteries without IV contrast | Usually Not Appropriate | O |
| CT chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA coronary arteries with IV contrast | Usually Not Appropriate | ☢☢☢ |
| SPECT or SPECT/CT MPI rest and stress | Usually Not Appropriate | ☢☢☢☢ |
Variant: 2
Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transesophageal | Usually Appropriate | O |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CT heart function and morphology with IV contrast | Usually Appropriate | ☢☢☢☢ |
| MRA chest without and with IV contrast | May Be Appropriate | O |
| MRI heart function and morphology without and with IV contrast | May Be Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Arteriography coronary | Usually Not Appropriate | ☢☢☢ |
| Catheter venography pulmonary | Usually Not Appropriate | ☢☢☢☢ |
| MRA chest without IV contrast | Usually Not Appropriate | O |
| MRA coronary arteries without and with IV contrast | Usually Not Appropriate | O |
| MRA coronary arteries without IV contrast | Usually Not Appropriate | O |
| MRI heart function and morphology without IV contrast | Usually Not Appropriate | O |
| CT chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA coronary arteries with IV contrast | Usually Not Appropriate | ☢☢☢ |
| SPECT or SPECT/CT MPI rest and stress | Usually Not Appropriate | ☢☢☢☢ |
Variant: 3
Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transesophageal | Usually Appropriate | O |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CT heart function and morphology with IV contrast | Usually Appropriate | ☢☢☢☢ |
| MRI heart function and morphology without and with IV contrast | May Be Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Arteriography coronary | Usually Not Appropriate | ☢☢☢ |
| Catheter venography pulmonary | Usually Not Appropriate | ☢☢☢☢ |
| MRA chest without and with IV contrast | Usually Not Appropriate | O |
| MRA chest without IV contrast | Usually Not Appropriate | O |
| MRA coronary arteries without and with IV contrast | Usually Not Appropriate | O |
| MRA coronary arteries without IV contrast | Usually Not Appropriate | O |
| MRI heart function and morphology without IV contrast | Usually Not Appropriate | O |
| CT chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA coronary arteries with IV contrast | Usually Not Appropriate | ☢☢☢ |
| SPECT or SPECT/CT MPI rest and stress | Usually Not Appropriate | ☢☢☢☢ |
Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Discussion of Procedures by Variant
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
A. Arteriography Coronary
A. Arteriography Coronary
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
B. Catheter Venography Pulmonary
B. Catheter Venography Pulmonary
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
C. CT Chest With IV Contrast
C. CT Chest With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
D. CT Chest Without and With IV Contrast
D. CT Chest Without and With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
E. CT Chest Without IV Contrast
E. CT Chest Without IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
F. CT Heart Function and Morphology With IV Contrast
F. CT Heart Function and Morphology With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
G. CTA Chest With IV Contrast
G. CTA Chest With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
H. CTA Coronary Arteries With IV Contrast
H. CTA Coronary Arteries With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
I. MRA Chest Without and With IV Contrast
I. MRA Chest Without and With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
J. MRA Chest Without IV Contrast
J. MRA Chest Without IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
K. MRA Coronary Arteries Without and With IV Contrast
K. MRA Coronary Arteries Without and With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
L. MRA Coronary Arteries Without IV Contrast
L. MRA Coronary Arteries Without IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
M. MRI Heart Function and Morphology Without and With IV Contrast
M. MRI Heart Function and Morphology Without and With IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
N. MRI Heart Function and Morphology Without IV Contrast
N. MRI Heart Function and Morphology Without IV Contrast
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
O. SPECT or SPECT/CT MPI Rest and Stress
O. SPECT or SPECT/CT MPI Rest and Stress
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
P. US Echocardiography Transesophageal
P. US Echocardiography Transesophageal
Variant 1: Atrial fibrillation, atrial tachycardia, or atypical atrial flutter. Preprocedural planning prior to left atrial ablation.
Q. US Echocardiography Transthoracic Resting
Q. US Echocardiography Transthoracic Resting
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
A. Arteriography Coronary
A. Arteriography Coronary
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
B. Catheter Venography Pulmonary
B. Catheter Venography Pulmonary
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
C. CT Chest With IV Contrast
C. CT Chest With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
D. CT Chest Without and With IV Contrast
D. CT Chest Without and With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
E. CT Chest Without IV Contrast
E. CT Chest Without IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
F. CT Heart Function and Morphology With IV Contrast
F. CT Heart Function and Morphology With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
G. CTA Chest With IV Contrast
G. CTA Chest With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
H. CTA Coronary Arteries With IV Contrast
H. CTA Coronary Arteries With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
I. MRA Chest Without and With IV Contrast
I. MRA Chest Without and With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
J. MRA Chest Without IV Contrast
J. MRA Chest Without IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
K. MRA Coronary Arteries Without and With IV Contrast
K. MRA Coronary Arteries Without and With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
L. MRA Coronary Arteries Without IV Contrast
L. MRA Coronary Arteries Without IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
M. MRI Heart Function and Morphology Without and With IV Contrast
M. MRI Heart Function and Morphology Without and With IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
N. MRI Heart Function and Morphology Without IV Contrast
N. MRI Heart Function and Morphology Without IV Contrast
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
O. SPECT or SPECT/CT MPI Rest and Stress
O. SPECT or SPECT/CT MPI Rest and Stress
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
P. US Echocardiography Transesophageal
P. US Echocardiography Transesophageal
Variant 2: Atrial fibrillation. Preprocedural planning prior to left atrial appendage endovascular occlusion.
Q. US Echocardiography Transthoracic Resting
Q. US Echocardiography Transthoracic Resting
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
A. Arteriography Coronary
A. Arteriography Coronary
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
B. Catheter Venography Pulmonary
B. Catheter Venography Pulmonary
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
C. CT Chest With IV Contrast
C. CT Chest With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
D. CT Chest Without and With IV Contrast
D. CT Chest Without and With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
E. CT Chest Without IV Contrast
E. CT Chest Without IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
F. CT Heart Function and Morphology With IV Contrast
F. CT Heart Function and Morphology With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
G. CTA Chest With IV Contrast
G. CTA Chest With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
H. CTA Coronary Arteries With IV Contrast
H. CTA Coronary Arteries With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
I. MRA Chest Without and With IV Contrast
I. MRA Chest Without and With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
J. MRA Chest Without IV Contrast
J. MRA Chest Without IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
K. MRA Coronary Arteries Without and With IV Contrast
K. MRA Coronary Arteries Without and With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
L. MRA Coronary Arteries Without IV Contrast
L. MRA Coronary Arteries Without IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
M. MRI Heart Function and Morphology Without and With IV Contrast
M. MRI Heart Function and Morphology Without and With IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
N. MRI Heart Function and Morphology Without IV Contrast
N. MRI Heart Function and Morphology Without IV Contrast
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
O. SPECT or SPECT/CT MPI Rest and Stress
O. SPECT or SPECT/CT MPI Rest and Stress
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
P. US Echocardiography Transesophageal
P. US Echocardiography Transesophageal
Variant 3: Atrial fibrillation. Preprocedural planning prior to electrical or pharmacologic cardioversion.
Q. US Echocardiography Transthoracic Resting
Q. US Echocardiography Transthoracic Resting
Summary of Recommendations
Supporting Documents
The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.
For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.
Appropriateness Category Names and Definitions
|
Appropriateness Category Name |
Appropriateness Rating |
Appropriateness Category Definition |
|
Usually Appropriate |
7, 8, or 9 |
The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients. |
|
May Be Appropriate |
4, 5, or 6 |
The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal. |
|
May Be Appropriate (Disagreement) |
5 |
The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned. |
|
Usually Not Appropriate |
1, 2, or 3 |
The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable. |
Relative Radiation Level Information
Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.
|
Relative Radiation Level Designations |
||
|
Relative Radiation Level* |
Adult Effective Dose Estimate Range |
Pediatric Effective Dose Estimate Range |
|
O |
0 mSv |
0 mSv |
|
☢ |
<0.1 mSv |
<0.03 mSv |
|
☢☢ |
0.1-1 mSv |
0.03-0.3 mSv |
|
☢☢☢ |
1-10 mSv |
0.3-3 mSv |
|
☢☢☢☢ |
10-30 mSv |
3-10 mSv |
|
☢☢☢☢☢ |
30-100 mSv |
10-30 mSv |
|
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.” |
||
References
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.