Effect of Non-fluoroscopic Catheter Tracking on Radiation Exposure during Pulmonary Vein Isolation: Comparison of Four ablation systems

Metal interference alert guided septal approach with 3 catheter positions on intracardiac echocardiography for a near-zero fluoroscopy catheter ablation of atrial fibrillation

Background

Attempting to minimize radiation exposure during catheter ablation of atrial fibrillation (AF) for patients, operators and medical staffs should be performed. This study aimed to investigate the feasibility and safety of a metal interference alert guided septal approach using 3 intracardiac echocardiography viewing positions for near-zero fluoroscopy AF ablation procedures.

Methods/results

A total of 668 procedures among 608 consecutive patients with AF (67.2 ± 7.3 years, 408 males) who underwent catheter ablation were retrospectively evaluated and divided into 2 groups, near-zero group (n = 42) and conventional group (n = 595). In the near-zero group, a metal interference alert guided septal approach with 3 different catheter intracardiac echocardiography positions to minimize the fluoroscopy time was applied, and a left atrial access with 2 long sheaths from a single septal puncture without fluoroscopy was successfully achieved in 41 out of 42 cases. The total fluoroscopy time was significantly shorter in the near-zero group than that in the conventional group (0.5 ± 2.0 vs. 21.4 ± 12.9 min p < 0.0001). The total procedure time and time to the septal puncture were both significantly longer in the near-zero group than those in the conventional group (131.4 ± 40.2 vs. 116.6 ± 46.4p = 0.0453, 31.6 ± 9.2 vs. 19.9 ± 10.2 min, p < 0.0001), The ablation time did not differ between the 2 groups (Near-zero: 99.8 ± 41.0 vs. Conventional: 96.8 ± 44.3 min, p = 0.6663). There were no significant differences in the complication rate between the 2 groups (Near-zero: 0 vs. Conventional 14 case, p = 0.6151).

Conclusion

A metal interference alert guided septal approach using 3 intracardiac echocardiography viewing positions was feasible and safe for a near-zero fluoroscopy catheter ablation of AF.

A modified fluoroscopy protocol to minimize radiation exposure during pulmonary vein isolation with second-generation cryoballoon

BACKGROUND

Pulmonary vein isolation (PVI) using second-generation cryoballoon (CB2) is considered to be safe and effective in the treatment of atrial fibrillation (AF). Reported radiation exposure during PVI with CB2 is higher if compared with other technologies. We investigated acute and mid-term effects of a modified fluoroscopy protocol to minimize radiation exposure during CB2 PVI with regard to safety and efficacy.

METHODS

The study comprised 180 consecutive patients undergoing CB2 PVI. In the first 100 patients, PVI was performed using conventional fluoroscopy settings (group 1), while the following 80 patients (group 2) received PVI with a modified protocol. The protocol consisted of (a) general reduction of fluoroscopy frame rate to 3/s, (b) avoidance of cine runs and selective PV angiograms, and (c) enhanced radiation awareness. Retrospective data analysis was performed in respect to dose area product (DAP), fluoroscopy time, and freedom from AF during a 12-month follow-up.

RESULTS

Group 2 patients had lower DAP (426 ± 433 vs 3334 ± 2271 cGycm² ), fluoroscopy time (13.8 ± 6.3 vs 16.7 ± 5.6 minutes), LA dwell time (49.3 ± 15.5 vs 61.6 ± 16.2 minutes), and procedure time (85.5 ± 22.9 vs 94.9 ± 23.6 minutes); P < .01 for all. One-year freedom from AF was comparable between both groups (71% group 1 vs 73% group 2, ns).

CONCLUSION

Radiation exposure and procedure time during CB2 PVI can be significantly reduced by using a modified fluoroscopy protocol and increased radiation awareness without compromising acute and 1-year freedom from AF if performed by experienced operators.

Meta-analysis of pulmonary vein isolation ablation for atrial fibrillation conventional vs low- and zero-fluoroscopy approaches

INTRODUCTION

Radiation exposure during catheter ablation procedures is a significant hazard for both patients and operators. Atrial fibrillation (AF) ablation procedures have been historically associated with higher fluoroscopy usage than other electrophysiology procedures. Recent efforts have been made to reduce dependence on fluoroscopy during pulmonary vein isolation (PVI) ablation procedures using alternative techniques.

METHODS

We performed a meta-analysis of studies comparing zero or low fluoroscopy (LF) vs conventional fluoroscopy (CF) approaches for AF ablation. Outcomes of interest included acute and 12-month procedural efficacy, safety, procedure duration, fluoroscopy time, and dose area product. Aggregated data were analyzed with random-effects models, using a Bayesian hierarchical approach.

RESULTS

A total of 2228 participants (LF, n = 1190 vs CF, n = 1038) from 15 studies were included in the meta-analysis. Risk of AF recurrence in 12 months (odds ratio [OR], 95% confidence interval [95% CI] = 1.343 [0.771-2.340]; P = .297), redo-ablation procedures (OR [95% CI] = 0.521 [0.198-1.323]; P = .186), and procedural complications (OR [95% CI] = 0.99 [0.485-2.204]; P = .979) were similar between LF- and CF-ablation groups. In comparison to CF ablation, LF ablation led to shorter procedure duration (weighted mean differences [WMDs] [95% CI] = -14.6 minutes [-22.5 to -6.8]; P < .001), fluoroscopy time (WMD [95% CI] = -8.8 minutes [-11.9 to -5.9]; P < .001), and dose area product (WMD [95% CI] = -1946 mGy/cm² [-2685 to 1207]; P < .001).

CONCLUSION

LF approaches have similar clinical efficacy and safety as CF approaches for PVI. LF approaches are associated with shorter procedure time, fluoroscopy usage, and dose area product during PVI.