Implementation of a zero fluoroscopic workflow using a simplified intracardiac echocardiography guided method for catheter ablation of atrial fibrillation, including repeat procedures

Abstract

Objective Pulmonary vein isolation (PVI) is the cornerstone of the interventional treatment of atrial fibrillation (AF). Traditionally, during these procedures the catheters are guided by fluoroscopy, which poses a risk to the patient and staff by ionizing radiation. Our aim was to describe our experience in the implementation of an intracardiac echocardiography (ICE) guided zero fluoroscopic (ZF) ablation approach to our routine clinical practice. Methods We developed a simplified ICE guided technique to perform ablation procedures for AF, with the aid of a 3D electroanatomical mapping system. The workflow was implemented in two phases: (1) the Introductory phase, where the first 16 ZF PVIs were compared with 16 cases performed with fluoroscopy and (2) the Extension phase, where 71 consecutive patients (including repeat procedures) with ZF approach were included. Standard PVI (and redoPVI) procedures were performed, data on feasibility of the ZF approach, complications, acute and 1-year success rates were collected. Results In the Introductory phase, 94% of the procedures could be performed with complete ZF with a median procedure time of 77.5 (73.5–83) minutes. In one case fluoroscopy was used to guide the ICE catheter to the atrium. There was no difference in the complication, acute and 1-year success rates, compared with fluoroscopy guided procedures. In the Extension phase, 97% of the procedures could be completed with complete ZF. In one case fluoroscopy was used to guide the transseptal puncture and in another to position the ICE catheter. Acute success of PVI was achieved in all cases, 64.4% patients were arrhythmia free at 1-year. Acute major complications were observed in 4 cases, all of these occurred in the redo PVI group and consisted of 2 tamponades, 1 transient ischemic attack and 1 pseudoaneurysm at the puncture site. The procedures were carried out by all members of the electrophysiology unit in the Extension phase, including less experienced operators and electrophysiology fellows (3 physicians) under the supervision of the senior electrophysiologist. Consequently, procedure times became longer [90 (75–105) vs 77.5 (73.5–85) min, p = 0.014]. Conclusions According to our results, a ZF workflow of AF ablations can be successfully implemented into the routine practice of an electrophysiology laboratory, without compromising safety and effectivity.

Zero fluoroscopy catheter ablation for atrial fibrillation: a systematic review and meta-analysis

“…In addition to the technological aspects, operators' experience is also of paramount importance when implementing Z/MF procedures. For obvious reasons, total fluoroless or minimal fluoroscopic PVI procedures have a learning curve of 20-40 cases (33,34).…”

Temporary Trends Concerning the Extent and Efficacy of Atrial Fibrillation Ablation Using Radiofrequency Energy in a Polish Single-Center Experience

“…All patients included in this analysis underwent ablation using the above system. However, the search for alternative methods leading to the elimination of fluoroscopy as the standard management is a current challenge due to the serial occurrence of subsequent procedures with cumulative exposure of medical staff [35].…”

Treatment Options in AF Patients with Cancer; Focus on Catheter Ablation

“…In recent years, the development and widespread use of electro-anatomical mapping systems in conjunction with the transesophageal or intracardiac echocardiography during PVI ablation with RF has resulted in a significant reduction in ionizing radiation exposure, leading to a decreased risk of cancer incidence and mortality [ 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ]. Recently, for the first time, the zero-fluoroscopic approach was described in consecutive patients scheduled for AF ablation, eliminating the potential risk of cancer that are procedure-related [ 59 ].…”