Atrial fibrillation is the most common heart arrhythmia and a leading cause of stroke. The treatment option of choice is radio-frequency catheter ablation, which is performed in electrophysiology labs using C-Arm X-ray systems for navigation and guidance. The goal is to electrically isolate the pulmonary vein-left atrial junction thereby rendering myocardial fibers responsible for induction and maintenance of AF inactive. The use of overlay images for fluoroscopic guidance may improve the

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... y of the ablation procedure, and can reduce procedure time. Overlay images, acquired using CT, MRI, or C-arm CT, can add soft-tissue information, otherwise not visible under X-ray. MRI can be used to image a wide variety of anatomical details without ionizing radiation. In this paper, we present a method to register a 3-D MRI volume to 2-D biplane X-ray images using the coronary sinus. Current approaches require registration of the overlay images to the fluoroscopic images to be performed after the trans-septal puncture, when contast agent can be administered. We present a new approach for registration to align overlay images before the trans-septal puncture. To this end, we manually extract the coronary sinus from pre-operative MRI and register it to a multi-electorde catheter placed in the coronary sinus.