Noninvasive Visualization of the Atrioventricular Conduction System Using Cardiac Computed Tomography

Importance Noninvasive localization of the compact atrioventricular node and the proximal specialized conduction system (AVCS) would enhance planning for transcatheter aortic valve and complex or congenital heart disease surgical procedures. Objective To test the hypothesis that preprocedure contrast-enhanced cardiac computed tomography (CECT) can accurately localize the AVCS by identification of the fat that insulates the conductive myocardium. Design, Setting, and Participants This was a prospective cohort study that took place at an academic tertiary care center. Included in the study were patients with CECT acquired less than 1 month before atrial fibrillation ablation and electroanatomic localization of the His electrogram signal on electroanatomic mapping (EAM) between January 2022 and January 2023. Exposures Preprocedure CECT. Main Outcomes and Measures The distance from the His electrogram signal to the fat segmentation encompassing the AVCS on CECT, after registration of the images to EAM. Results Among 20 patients (mean [SD] age, 66 [10] years; 15 male [75%]) in the cohort, the mean (SD) attenuation of the AVCS fat segmentation was 2.9 (21.5) Hounsfield units. The mean (SD) distance from the His electrogram to the closest AVCS fat voxel was 3.3 (1.6) mm. Conclusions and Relevance Results of this cohort study suggest that CECT could accurately localize the fatty tissue that insulates the AVCS from surrounding atrial and ventricular myocardium and may enhance the efficacy and safety of procedures targeting the conduction system and structures in its proximity.