Rationale and Objectives
To evaluate the interobserver agreement of readers in evaluating pulmonary venous anatomy and in measuring pulmonary vein ostial diameters and distance to first bifurcation.
Materials and Methods
This study was approved by our institutional review board. Thin-section contrast material–enhanced multidetector computed tomography examinations of the thorax were retrospectively reviewed in 200 consecutive patients (38 females and 162 males), age 24–79 years (mean, 52.8) referred for imaging before radiofrequency ablation therapy for atrial fibrillation. For each patient, pulmonary venous anatomy and drainage patterns including the number of venous ostia was assessed independently by experienced cardiothoracic radiologists. Pulmonary vein ostial diameter and distance to the first bifurcation of the four major pulmonary veins (right inferior and superior, left inferior and superior), the middle lobe pulmonary vein, and any anomalous pulmonary veins (common trunks and accessory veins) were measured independently at a workstation. Interreader assessment of pulmonary venous anatomy was evaluated using the Kappa statistic. Interreader variation in measurements of venous diameter and distant to first bifurcation were estimated by Bland-Altman plots and Pitman’s test of difference in variance.
Results
Very good to excellent interreader agreement in detection of anomalous pulmonary venous anatomy, middle lobe pulmonary venous drainage, and other thoracic venous anomalies. No significant variation between readers in pulmonary vein ostial diameter measurements for the four major and middle lobe pulmonary veins, or the anomalous pulmonary veins. Significant interreader variability was noted in measurements of the pulmonary vein distance to first bifurcation for the right inferior ( P = .017), middle lobe ( P = .005), and left inferior ( P = .015) pulmonary veins.
Conclusions
There is excellent interobserver agreement when evaluating normal and anomalous pulmonary venous drainage patterns, and when measuring normal or anomalous pulmonary vein diameters. However, measurements of distances to first bifurcation were less reliable across readers.
Atrial fibrillation is the most commonly sustained cardiac arrhythmia, and its prevalence increases with age. It is a major cause of stroke and is associated with significant morbidity and mortality. Atrial ectopic beats within the pulmonary veins have been shown to initiate atrial fibrillation in most patients. The importance of the pulmonary veins pulmonary veins in the initiation of atrial fibrillation (AF) was first demonstrated by Haissaguerre et al ( ). They also demonstrated that pulmonary vein isolation could eliminate this arrhythmia, which represented a major therapeutic advance. Numerous studies have demonstrated the role of the posterior left atrium as well as the pulmonary veins in atrial fibrillation ( ). Subsequently, various catheter-based pulmonary vein ablation techniques, such as radiofrequency ablation and cryoablation, have been developed and used clinically, to electrically confine pulmonary veins triggers ( ). Two ablation strategies have been developed: segmental ostial isolation ( ) and circular extraostial isolation ( ), each with its own advantages and disadvantages ( ).
Many imaging modalities are employed to delineate the anatomy of the pulmonary veins and the left atrium, both pre- and postablation. These include computed tomography (CT) ( ), three-dimensional (3D) magnetic resonance angiography (MRA) ( ), pulmonary vein angiography ( ), and intracardiac ultrasound ( ). CT has the advantage of being fast, widely available, easy for patients to tolerate, and has a high spatial resolution, but has the disadvantage of using ionizing radiation. MRA has the advantage of being free of ionizing radiation, but it also has been shown to be particularly effective in providing detailed and complete imaging of the anatomy of the pulmonary veins and left atrium ( ), but has several disadvantages, including many atrial fibrillation patients have pacemakers or defibrillators and therefore have a contraindication to MRA. Also, magnetic resonance (MR) imaging cannot be performed in patients with claustrophobia or in patients who, because of their clinical conditions, cannot tolerate the considerably long imaging times of MR imaging ( ). Pulmonary vein venography also has the disadvantage of using ionizing radiation and the fluoroscopy times of these procedures are substantial, in part because of the laborious visualization of the pulmonary veins and can not adequately depict this anatomy ( ).
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Methods and materials
Subjects
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Imaging
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Statistical Analysis
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Results
Pulmonary Vein Anatomy
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Table 1a
Absence or Presence of Normal Pulmonary Veins (Kappa Statistic)
Absence or Presence of Normal Pulmonary Vein Readers RSPV RIPV MLPV LSPV LIPV MLPV Drainage Pattern First vs. second reader 1.0 1.0 1.0 1.0 1.0 0.88 (0.82–0.94)
RSPV: right superior pulmonary vein; RIPV: right inferior pulmonary vein; MLPV: middle lobe pulmonary vein; LSPV: left superior pulmonary vein; LIPV: left inferior pulmonary vein.
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Table 1b
Absence or Presence of Variant Pulmonary Veins (Kappa Statistic)
Absence or Presence of Variant Pulmonary vein Readers CRT CLT ARPV ALPV OAPV First vs. second reader 1.0 0.84 (0.56–1.0) 0.92 (0.75–1.0) 1.0 1.0
CRT: common right trunk; CLT: common left trunk; ARPV: accessory right pulmonary vein; ALPV: accessory left pulmonary vein; OAPV: other accessory pulmonary vein.
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Pulmonary Vein Diameter
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Table 2a
Interobserver Variability of Normal Pulmonary Vein Diameters (Bland-Altman Plots and Pitman Coefficients)
Pulmonary Vein Pulmonary Vein Diameter (in mm) Pitman’s Test of Difference in Variance ( r ) Reader 1 (SD) Reader 2 (SD) Mean Difference Right superior 17.9 (4.6) 16.9 (4.2) 2.0 (2.5) 0.12 Right inferior 16.9 (3.5) 16.7 (3.8) 1.8 (2.5) −0.10 Right middle 8.6 (2.3) 8.3 (2.4) 1.3 (1.5) −0.09 Left superior 16.4 (3.6) 15.9 (3.7) 1.8 (2.2) −0.08 Left inferior 14.2 (3.6) 14.7 (3.6) 2.1 (2.5) 0.01
RSPV: right superior pulmonary vein; RIPV: right inferior pulmonary vein; MLPV: middle lobe pulmonary vein; LSPV: left superior pulmonary vein; LIPV: left inferior pulmonary vein.
*Statistically significant difference, P < .05.
Table 2b
Interobserver Variability of Anomalous Pulmonary Vein Diameters (Bland-Altman Plots and Pitman Coefficients)
Pulmonary Vein Pulmonary Vein Diameter (in mm) Pitman’s test of Difference in Variance ( r ) Reader 1 (SD) Reader 2 (SD) Mean Difference Common right trunk 35.3 (11.7) 35.0 (14.1) ‡ Common left trunk 21.8 (5.4) 25.9 (4.1) 0.13 Accessory right 8.4 (1.2) 7.7 (1.8) −0.75
CRT: common right trunk; CLT: common left trunk; ARPV: accessory right pulmonary vein.
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Distance to First Bifurcation
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Table 3a
Interobserver Variability of Normal Pulmonary Vein Distance to First Bifurcation (Bland-Altman Plots and Pitman Coefficients)
Pulmonary Vein Pulmonary Vein Distance to First Bifurcation (in mm) Pitman’s test of difference in variance ( r ) Reader 1 (SD) Reader 2 (SD) Mean Difference Right superior 15.6 (6.4) 16.4 (6.7) 3.3 (3.9) −0.08 Right inferior 8.2 (3.7) 8.6 (4.4) 2.9 (3.6) −0.17 ⁎ Right middle 9.2 (5.6) 10.8 (6.6) 3.4 (4.6) −0.21 ⁎ Left superior 18.4 (6.8) 18.3 (6.7) 3.4 (4.4) 0.01 Left inferior 14.1 (4.7) 15.2 (5.4) 2.9 (3.9) −0.18 ⁎
RSPV: right superior pulmonary vein; RIPV: right inferior pulmonary vein; MLPV: middle lobe pulmonary vein; LSPV: left superior pulmonary vein; LIPV: left inferior pulmonary vein.
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Table 3b
Interobserver Variability of Anomalous Pulmonary Vein Distance to First Bifurcation (Bland-Altman Plots and Pitman Coefficients)
Pulmonary Vein Pulmonary Vein Distance to First Bifurcation (in mm) Pitman’s test of Difference in Variance ( r ) Reader 1 (SD) Reader 2 (SD) Mean Difference Common right trunk 9.0 (11.2) 13.5 (2.1) ‡ Common left trunk 10.7 (7.0) 11.9 (7.7) −0.35 Accessory right 10.0 (4.7) 8.6 (5.9) −0.35
CRT: common right trunk; CLT: common left trunk; ARPV: accessory right pulmonary vein.
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Discussion
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Limitations
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Conclusion
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