Catheter navigation by intracardiac echocardiography enables zero-fluoroscopy linear lesion formation and bidirectional cavotricuspid isthmus block in patients with typical atrial flutter

Abstract

Introduction One of the most helpful aspects of intracardiac echocardiography (ICE) implementation in electrophysiological studies (EPS) is the real-time visualisation of catheters and cardiac structures. In this prospective study, we investigated ICE-guided zero-fluoroscopy catheter navigation during radiofrequency (RF) ablation of the cavotricuspid isthmus (CTI) in patients with typical atrial flutter (AFL). Methods and results Thirty consecutive patients (mean age 72.9 ± 11.4 years, 23 male) with ongoing (n = 23) or recent CTI-dependent AFL underwent an EPS, solely utilizing ICE for catheter navigation. Zero-fluoroscopy EPS could be successfully accomplished in all patients. Mean EPS duration was 41.4 ± 19.9 min, and mean ablation procedure duration was 20.8 ± 17.1 min. RF ablation was applied for 6.0 ± 3.1 min (50W, irrigated RF ablation). Echocardiographic parameters, such as CTI length, prominence of the Eustachian ridge (ER), and depth of the CTI pouch on the ablation plane, were assessed to analyse their correlation with EPS- or ablation procedure duration. The CTI pouch was shallower in patients with an ablation procedure duration above the median (4.8 ± 1.1 mm vs. 6.4 ± 0.9 mm, p = 0.04), suggesting a more lateral ablation plane in these patients, where the CTI musculature is stronger. CTI length or ER prominence above the respective median did not correlate with longer EPS duration. Conclusions Zero-fluoroscopy CTI ablation guided solely by intracardiac echocardiography in patients with CTI-dependent AFL is feasible and safe. ICE visualisation may help to localise the optimal ablation plane, detect and correct poor tissue contact of the catheter tip, and recognise early potential complications during the ablation procedure. Graphical Abstract

Local impedance and contact force guidance to predict successful cavotricuspid isthmus ablation with a zero-fluoroscopy approach

“…In the last years, guidance by ICE has demonstrated reducing not only fluoroscopy times but also ablation and procedure times ( 31 ) and allowing successful ablation in some challenging cases ( 32 ). More recently, zero-fluoroscopy guided exclusively by ICE has been described in two studies ( 10 , 33 ) as an effective and safe approach, without impacting procedural times and helping to recognize early potential complications. Thus, ICE could constitute a valuable alternative for zero-fluoroscopy CTI ablation, but further and larger studies are needed to confirm these preliminary findings.…”

Intracardiac Echocardiography: An Invaluable Tool in Electrophysiological Interventions for Atrial Fibrillation and Supraventricular Tachycardia

“…Two studies have investigated the feasibility and safety of zero-fluoroscopy CTI ablation under the guidance of ICE alone [ 94 , 95 ]. Luani et al .…”

“…Luani et al . [ 95 ] reported that CTI ablation guided only by ICE imaging was feasible and safe, based on a single-center study. Debreceni et al .…”

Feasibility and safety of reprocessing of intracardiac echocardiography catheters for electrophysiology procedures – a large single center experience

“…ICE imaging markedly increases the safety of various cardiac interventions, especially the trans-septal punctures (TSP) and related procedures [ 1 ]. Furthermore, ICE is a crucial tool for zero-fluoroscopy interventions [ 2 , 3 ] and it has the potential to improve the efficacy of EP procedures [ 4 ]. Furthermore, ICE catheters are crucial for fluoroscopy reduction in various EP procedures especially for “single shot” devices such as cryoballoon or, more recently, for pulse filed catheters [ 5 ].…”