Safety and Effectiveness of a Novel Fluoroless Transseptal Puncture Technique for Lead-free Catheter Ablation: A Case Series

Abstract

Increasing awareness of the health risks associated with the exposure of patients and staff in the catheterization laboratory to radiation has encouraged the pursuit of efforts to reduce the use of fluoroscopy during catheter ablation procedures. Although nonfluoroscopic guidance of ablation catheters has been previously described, transseptal access is still perceived as the last remaining barrier to completely fluoroless ablations. This study examined the safety and effectiveness of transseptal puncture and radiofrequency (RF) catheter ablation using a completely fluoroless approach. Three hundred eighty-two consecutive cases that had undergone completely nonfluoroscopic RF catheter ablation were evaluated. Ablation procedures were performed for atrial fibrillation, atrial flutter, atrioventricular reentry tachycardia, and pulmonary vein complex/ ventricular tachycardia. Transseptal puncture and RF ablation were conducted under threedimensional electroanatomic mapping and intracardiac echocardiography image guidance. Fluoroless transseptal puncture and catheter ablation were completed successfully in all cases, with no intraoperative complications. One patient required minimal use of fluoroscopy to visualize sheath advancement through an existing inferior vena cava filter. Procedural time was approximately 2.2 hours from transvenous access until case conclusion; transseptal access was obtained within 28 minutes of procedure initiation. Arrhythmia was found to recur in 27% of cases on average three months after the procedure. We demonstrate the safety and effectiveness of a completely fluoroless transseptal puncture and RF ablation technique that eliminates radiation exposure and enables complex electrophysiology procedures to be performed in a lead-free environment.

Fluoroless left atrial access for radiofrequency and cryoballoon ablations using a novel radiofrequency transseptal wire

“…This was achieved regardless of septal anatomy, prior history of transseptal catheterization, or the presence of cardiac implanted devices, and with no procedure-related complications. These results are similar to what has been observed using the RF needle [ 18 ]. With easy visualization of the RF wire using EAM and/or ICE, all procedures were conducted without any fluoroscopy from start to finish.…”

“…With easy visualization of the RF wire using EAM and/or ICE, all procedures were conducted without any fluoroscopy from start to finish. The first transseptal puncture, including catheters placement, RA ablation, and/or echocardiographic measurements, took an average of 16 min from vascular access, which is an improvement relative to current standard methods using RF needle of up to 28 min [ 18 ], and significantly faster than conventional fluoroscopic procedures using a mechanical needle [ 32 ]. Transseptal puncture from RF wire insertion into the femoral introducer took an average of 3.0 min, with 2.8 min for RFA, and 3.5 min for CBA.…”

“…Several studies have demonstrated the use of 3-dimensional (3D) electroanatomic mapping (EAM) systems and intracardiac echocardiography (ICE) to decrease or completely eliminate fluoroscopy usage during catheter ablation [ 12 – 18 ]. Although the feasibility of transseptal puncture using EAM guidance has also been reported [ 19 , 20 ], difficulty with visualizing the transseptal devices led to the use of fluoroscopy in 30 to 60% of the cases [ 17 , 21 ].…”

“…The visualization of a conventional needle on ICE or EAM is not performed as it requires the exposure of the sharp needle tip, presenting the risk of tissue injury and unintended puncture during dropdown and tenting. Recent studies have demonstrated that the use of a radiofrequency (RF) transseptal needle connecting with the 3D EAM system can safely allow for fluoroless catheter ablation procedures [ 13 , 18 , 22 – 27 ]. Despite growing evidence of the benefits of fluoroless catheter ablation, concern still remains regarding the safety and added procedure time associated with fluoroless procedures, mainly due to inability to confirm the location of the needle tip.…”

How to Achieve Near Zero Fluoroscopy During Radiofrequency Ablation of Atrial Fibrillation: A Strategy Used at Two Centers

“…Physicians have learned to limit the use of fluoroscopy and rely more on 3D mapping and ICE during various electrophysiology procedures [ 1 - 3 ]. In the recent past, there are multiple reports on Radiofrequency Ablation (RFA) being performed with either minimal or completely without the use of fluoroscopy [ 4 - 12 ].…”