ABSTRACT. This was a retrospective, single-center, single-operator study examining the safety, feasibility, and short-term efficacy of treating patients with predominantly persistent atrial fibrillation (AF) undergoing pulmonary vein isolation (PVI) with or without cavo-tricuspid isthmus (CTI) ablation by a first-year electrophysiologist (EP) with and without fluoroscopy. The study included 72 consecutive patients undergoing PVI for symptomatic drug refractory paroxysmal (30%) and persistent (70%) AF from August 1, 2015 to August 1, 2016. Fifty-two patients who underwent traditional PVI (30 with radiofrequency (RF) and 22 with cryoablation) with fluoroscopy were compared to 20 patients who underwent RF PVI without fluoroscopy. RF PVI utilized the CARTO s 3-D mapping system (Biosense Webster Inc, Diamond Bar, CA) with a contact force-sensing catheter. All transseptal access was achieved with intracardiac ultrasound (ICE). More patients in the NO fluoroscopy group had coronary artery disease (CAD), but there were no significant differences for other clinical variables. Overall, procedure time was less in the NO fluoroscopy group despite similar ablation times. There was no significant difference in complication rates including vascular complications, tamponade, stroke, and death. Maintenance of sinus rhythm was the same in both groups (70% in the Fluoro group and 68% in the NO Fluoro group). AF ablation with PVI in predominantly persistent patients using RF with NO fluoroscopy in a new operator is feasible and safe with similar short-term efficacy with 3-D electroanatomic mapping in conjunction with contact force-sensing catheters.

Regular atrial tachycardia (AT) is one of the most important proarrhythmic complications that may occur following left atrial pulmonary vein isolation (PVI). These tachycardias that develop after atrial fibrillation ablation may lead to worse symptoms than those from the original arrhythmia existing prior to the index ablation procedure. Ablation of various types of supraventricular tachycardias without the use of fluoroscopy has been shown to be feasible in both children and adults using three-dimensional mapping systems. We describe the case of a 71-yearold woman who developed a focal AT after a successful PVI procedure. The initial ablation failed with one mapping system. Repeat electrophysiologic study despite antiarrhythmic medications revealed the same focal AT, which was successfully ablated with a different mapping system. Both ablations were performed without fluoroscopy.

The majority of electrophysiologists routinely use fluoroscopy (FLUORO) during ablation procedures for common arrhythmias despite the known complications of radiation exposure and protective lead use. This study assessed the safety of catheter ablation (CA) with FLUORO versus without FLUORO (SANS FLUORO) in patients with the following common arrhythmias: atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, and ventricular tachycardia. A total of 1,258 CA procedures were performed in 816 consecutive patients over a 53-month period (SANS FLUORO CA: 609 patients; FLUORO CA: 209 patients). The secondary outcome was the efficacy of AF ablation in FLUORO versus SANS FLUORO patients. Ultimately, there was no statistically significant difference found concerning the safety of CA in the SANS FLUORO and FLUORO groups in terms of procedure time, vascular complications, tamponade, stroke, or death. FLUORO patients had markedly increased FLUORO time, increased radiation exposure, and increased dose-area product (all p < 0.0001). AF development after SANS FLUORO CA of AF was not different from that after FLUORO CA regardless of the pulmonary vein isolation (PVI) modality used (cryoablation versus radiofrequency) at 24 months (p = 0.21). Additionally, women fared just as well as men after CA ablation for AF. At 36 months, 58% of SANS FLUORO AF device patients were free from AF. As such, SANS FLUORO CA of common arrhythmias appears to be as safe as FLUORO CA but with a markedly reduced level of radiation exposure. Also, SANS FLUORO CA remains as effective as FLUORO CA in the prevention of AF for up to 24 months.

Background: Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. No atrioesophageal fistula (AEF) has been reported to date with active esophageal cooling, and only one pericardio-esophageal fistula has been reported; however, a formal analysis of the AEF rate with active esophageal cooling has not previously been performed. Methods: Atrial fibrillation ablation procedure volumes before and after adoption of active cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were determined across 25 hospital systems with the highest total use of esophageal cooling during RF ablation. The number of AEFs occurring in equivalent time frames before and after adoption of cooling were then determined, and AEF rates were compared using generalized estimating equations robust to cluster correlation. Results: Throughout the 25 hospital systems, which included a total of 30 separate hospitals, 14,224 patients received active esophageal cooling during RF ablation, with the earliest adoption beginning in March 2019 and the most recent beginning in March 2022. In the time frames prior to adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In this pre-adoption cohort a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates of <0.1% to 0.25%. No AEFs were found in the cohort treated after adoption of active esophageal cooling, yielding an AEF rate of 0% (P<0.0001). Conclusion: Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.