Electroanatomic guidance versus conventional fluoroscopy during transseptal puncture for atrial fibrillation ablation

The use of cardiac imaging in patients undergoing atrial fibrillation ablation

Cardiac imaging (CI), including echocardiography, multidetector computed tomography (MDCT), and cardiac magnetic resonance (CMR), is gaining increasing interest to aid atrial fibrillation (AF) ablation procedures, from pre-procedural planning to intra-procedural guidance. Transthoracic echocardiography is widely used for imaging, especially for preprocedural assessment, while transesophageal and intracardiac echocardiography (ICE) are used for intraprocedural guidance during transseptal puncture. Cardiac MDCT, leveraging its high spatial resolution, offers a detailed anatomical visualization of cardiac chambers and adjacent structures; moreover, left atrial wall thickness assessed by MDCT may guide radiofrequency energy titration to enhance procedural safety and efficiency. At the same time, CMR allows for detailed myocardial tissue characterization and the detection of fibrosis. ICE, MDCT, and CMR also permit intra-procedural image integration with electroanatomical maps, allowing to be aware of a greater amount of intra-procedural real-time information regarding the anatomy and the local characteristics of the tissue in contact with the ablation catheter. One of the primary objectives of performing CI-aided AF ablations is to increase procedural safety and to permit more personalized procedures, according to the characteristics of each patient. This review offers a comprehensive overview of the current applications of CI during the different phases of AF ablation and explores the potential future applications of CI in this context.

Cardioneuroablation for reflex syncope or functional bradyarrhytmias: new insight from a single center experience

Background

Cardioneuroablation (CNA) is a new approach to treat reflex syncope and functional bradyarrhytmias caused by autonomic imbalance. We report our experience using CNA.

Method

From September 2022 to July 2023, we took care of 21 patients (mean age 42 ± 21 years; 62% male) affected by reflex syncope or functional bradyarrhythmias. All patients underwent CNA under conscious sedation targeting the superior and/or inferior paraseptal ganglionated plexus (GPs).

Results

Nine patients were affected by vasovagal syncope (VVS) and twelve by functional bradyarrhythmias. In 3 cases (14%) the ablation was performed only on the GPs of the right atrium, while in the remaining 86% of cases we performed biatrial lesions. As regards the acute results, we highlighted an increase in sinus heart rate (12 ± 15 bpm, p = 0.001), a shortening of the PQ interval (-18 ± 18 msec, p < 0.001), a reduction of the correct sinus node recovery times (cSNRT) (-142 ± 204 msec, p = 0.114), a shortening of the AH interval (-31 ± 26 msec, p = 0.008), a reduction of the effective refractory period of the atrio-ventricular node (-156; interquartile range from -30 to -160 msec, p = 0.042) and an increase in the Wencheback point (27 ± 20 bpm, p < 0.001). At follow-up, a single patient, due to persistent symptoms and bradyarrhythmic disorder, underwent permanent pacemaker implantation; no other patient had recurrence of syncope, and all remained persistently asymptomatic.

Conclusion

Our results confirm the efficacy and safety of CNA for the treatment of VVS and functional bradyarrhythmias, although further studies are needed to support these findings.

Three-dimensional-guided and ICE-guided transseptal puncture for cardiac ablations: A propensity score match study

INTRODUCTION

Transseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three-dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system-guided TSP and ICE-guided TSP techniques.

METHODS

We conducted a prospective observational study of patients undergoing TSP for left atrial catheter ablation procedures (mostly atrial fibrillation ablation). Propensity scoring was used to match patients undergoing 3D-guided TSP with patients undergoing ICE-guided TSP. Logistic regression was used to compare the clinical data, procedural data, fluoroscopy time, success rate, and complications between the groups.

RESULTS

 Sixty-five patients underwent 3D-guided TSP, and 151 propensity score-matched patients underwent ICE-guided TSP. The TSP success rate was 100% in both the 3D-guided and ICE-guided groups. Median needle time was 4.00 min (interquartile range [IQR]: 2.57-5.08) in patients with 3D-guided TSP compared to 4.02 min (IQR: 2.83-6.95) in those with ICE-guided TSP (p = .22). Mean fluoroscopy time was 0.2 min (IQR: 0.1-0.4) in patients with 3D-guided TSP compared to 1.2 min (IQR: 0.7-2.2) in those with ICE-guided TSP (p < .001). There were no complications related to TSP in both group.

CONCLUSIONS

Three-dimensional mapping-guided TSP is as safe and effective as ICE-guided TSP without additional cost.

Transseptal puncture during catheter ablation associated with higher radiation exposure

BACKGROUND

Electroanatomic mapping systems are increasingly used during ablations to decrease the need for fluoroscopy and therefore radiation exposure. For left-sided arrhythmias, transseptal puncture is a common procedure performed to gain access to the left side of the heart. We aimed to demonstrate the radiation exposure associated with transseptal puncture.

METHODS

Data were retrospectively collected from the Catheter Ablation with Reduction or Elimination of Fluoroscopy registry. Patients with left-sided accessory pathway-mediated tachycardia, with a structurally normal heart, who had a transseptal puncture, and were under 22 years of age were included. Those with previous ablations, concurrent diagnostic or interventional catheterisation, and missing data for fluoroscopy use or procedural outcomes were excluded. Patients with a patent foramen ovale who did not have a transseptal puncture were selected as the control group using the same criteria. Procedural outcomes were compared between the two groups.

RESULTS

There were 284 patients in the transseptal puncture group and 70 in the patent foramen ovale group. The transseptal puncture group had a significantly higher mean procedure time (158.8 versus 131.4 minutes, p = 0.002), rate of fluoroscopy use (38% versus 7%, p < 0.001), and mean fluoroscopy time (2.4 versus 0.6 minutes, p < 0.001). The acute success and complication rates were similar.

CONCLUSIONS

Performing transseptal puncture remains a common reason to utilise fluoroscopy in the era of non-fluoroscopic ablation. Better tools are needed to make non-fluoroscopic transseptal puncture more feasible.

Zero Fluoroscopy Arrhythmias Catheter Ablation: A Trend Toward More Frequent Practice in a High-Volume Center

Background

Awareness of radiation exposure risks associated to interventional cardiology procedures is growing. The availability of new technologies in electrophysiology laboratories has reduced fluoroscopy usage during arrhythmias ablations. The aim of this study was to describe procedures with and without X-Rays and to assess feasibility, safety, and short-term efficacy of zero fluoroscopy intervention in a high-volume center oriented to keep exposure to ionizing radiation as low as reasonably achievable.

Methods

Cardiac catheter ablations performed in our hospital since January 2017 to June 2021.

Results

A total of 1,853 procedures were performed with 1,957 arrhythmias treated. Rate of fluoroless procedures was 15.4% (285 interventions) with an increasing trend from 8.5% in 2017 to 22.9% of first semester 2021. The most frequent arrhythmia treated was atrial fibrillation (646; 3.6% fluoroless) followed by atrioventricular nodal reentrant tachycardia (644; 16.9% fluoroless), atrial flutter (215; 8.8% fluoroless), ventricular tachycardia (178; 17.4% fluoroless), premature ventricular contraction (162; 48.1% fluoroless), and accessory pathways (112; 31.3% fluoroless). Although characteristics of patients and operative details were heterogeneous among treated arrhythmias, use of fluoroscopy did not influence procedure duration. Moreover, feasibility and efficacy were 100% in fluoroless ablations while the rate of major complications was very low and no different with or without fluoroscopy (0.45 vs. 0.35%).

Conclusion

Limiting the use of X-Rays is necessary, especially when the available technologies allow a zero-use approach. A lower radiation exposure may be reached, reducing fluoroscopy usage whenever possible during cardiac ablation procedures with high safety, full feasibility, and efficacy.

Zero-Fluoroscopy Cardiac Ablation: Technology Is Moving Forward in Complex Procedures—A Novel Workflow for Atrial Fibrillation

Simple Summary

Electrophysiological procedures are mainly performed using fluoroscopy, exposing both healthcare staff and patients to a non-negligible dose of radiation. To date, simple ablation procedures have often been approached with zero fluoroscopy. In complex ablation procedures, such as atrial fibrillation (AF) ablation, zero fluoroscopy is still challenging mainly because of transseptal puncture. We report a workflow to perform a complete zero-fluoroscopy AF ablation using a 3D electro-anatomical mapping system, intracardiac echocardiography and a novel steerable guiding sheath visible on the mapping system. We describe two cases, one with paroxysmal AF and the other with persistent AF during which this novel workflow was successfully applied with complete zero-fluoroscopy exposure and achieving pulmonary vein isolation.

Abstract

Background and Rationale. A fluoroscopy-based approach to an electrophysiological procedure is widely validated and has been recognized as the gold standard for a long time. The use of fluoroscopy exposes both the healthcare staff and the patient to a non-negligible dose of radiation. To minimize the risks associated with the use of fluoroscopy, it would be reasonable to perform ablation procedures with zero fluoroscopy. This approach is widely used in simple ablation procedures, but not in complex procedures. In atrial fibrillation (AF) ablation procedures, fluoroscopy remains the main technology used, in particular to guide the transseptal puncture. Main results and Implications. We present a workflow to perform a complete zero-fluoroscopy ablation for AF ablation procedures using a 3D electro-anatomical mapping system, intracardiac echocardiography and a novel steerable guiding sheath that can be visualized on the mapping system. We present two cases, one with paroxysmal AF and the other one with persistent AF during which we applied this novel workflow achieving a successful pulmonary vein isolation without complications and complete zero-fluoroscopy exposure.