Background

Catheter ablation of left atrial arrhythmias is an irreplaceable part of modern rhythm-preserving therapy. It is safe and effective, yet the use of fluoroscopy still carries the risk of deterministic or stochastic radiation damage. By improving the imaging protocol and motivating us to use the least possible fluoroscopy time in left atrial ablation, we were able to establish a near zero fluoroscopy ablation workflow with fluoroscopy time less than 1 minute without the addition of ICE or MediGuide. The aim of this study was to investigate how many of left atrial procedures can be performed with less than 1 minute fluoroscopy time and whether the complication rate is increased or not.

Methods

We compared the first 100 patients with fluoroscopy duration < 1 minute after improving the ablation workflow in August 2018 with 100 patients before and analyzed mean fluoroscopy duration, mean fluoroscopy dose and procedure duration as efficacy endpoints. All major and minor complications were analyzed and compared between groups. All patients received transseptal puncture and ablation of atrial fibrillation or left atrial flutter (including PVI)using the CARTO3 mapping system. Both groups were treated with the same very low dose imaging protocol (Siemens AG) on an Artis zee angiography system operated at 8 nGy detector entrance dose per fluoroscopy pulse and 3 frames per second. 

Results

24% of all patients undergoing left atrial ablation procedure could be performed with less than 1 minute fluoroscopy time. Both groups did not differ in baseline characteristics. Mean fluoroscopy duration was significant lower in the intervention group (0.5 min vs. 5.9 min; p<0.0001). Mean fluoroscopy dose was also significant lower (19.2 cGy · cm² vs. 149.7 cGy · cm²; p<0.0001). Procedure duration was significantly lower in the intervention group (80.3 min vs. 98.8 min, p<0.0001). There was no difference in complication rates between intervention and control group (1.1 vs 3.0%, p=0.62). All patients could be discharged without long-term impairments.

Conclusions

Without availability of ICE or catheter tracking systems like MediGuide, Near-Zero Fluoroscopy Ablation procedures in the left atrium were possible in almost every fourth patient.  These procedures were not associated with increased complications rates.

Table 1. Data are given for control group and for low fluoroscopy group (LFG). LV-EF, left ventricular ejection fraction; SEM, standard error of mean. P>0.05 is considered non-significant (ns).

Table 2. Data are given for control group and for low fluoroscopy group (LFG). SEM, standard error of mean. P>0.05 is considered non-significant (ns).

 

Table 3. Data are given for control group and for low fluoroscopy group (LFG). P>0.05 is considered non-significant (ns).

Figure 1. Workflow for Near-Zero-Fluoroscopic Ablation of AF. Single Pulse Fluoroscopy is only used for visualization of the steps for transseptal puncture. Positioning of CS catheter (2) is often possible without the use of fluoroscopy. With the certainty of the correct position (4, LAO 40°; 5, RAO 30°), the transseptal puncture is performed (6) followed by passage of ablation catheter guided by the wire (7). After reaching the final position of the ablation catheter and the steerable sheath (8,9) there is no need for further fluoroscopy. 1-4; 6-8: LAO 40°, 5: RAO 30 °, 9: AP 0°.