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Journal of Interventional Cardiac Electrophysiology

Published in:

01-12-2017 | MULTIMEDIA REPORT

Fluoroscopy-free AF ablation using transesophageal echocardiography and electroanatomical mapping technology

Authors: Benjamin O’Brien, Damian C. Balmforth, Ross J. Hunter, Richard J. Schilling

Published in: Journal of Interventional Cardiac Electrophysiology | Issue 3/2017

Abstract

Purpose

Guidelines recommend that radiation exposure during AF catheter ablation procedures should be ‘as low as reasonably achievable’ (ALARA), particularly since many patients may have multiple procedures. Consequently, avoiding radiation exposure altogether must, if safe to do so, be the ultimate goal. The primary objective was to determine the feasibility and efficacy of fluoroscopy-free AF ablation compared to the fluoroscopy-assisted procedure.

Methods

Patients underwent AF ablation using commercially available technology with no routine pre-procedural imaging. The use of non-fluoroscopic imaging/mapping technologies permitted us to initially reduce x-ray exposure before eliminating its use altogether. This evolution of our practice proceeded in two stages: a 9-month period of optimising our fluoroscopy-free ablation protocol followed by a 9-month period during which we set out to complete the whole procedure routinely without fluoroscopy. We describe the protocol developed and report salient endpoints, such as complications, procedure times, patient experience, and procedural success rates.

Results

During the study period, fluoroscopy-free AF ablation was attempted in 69 patients: 24 in the 9-month ‘development phase’ and 45 in the ‘implementation phase’. During the development phase, 13 of 24 patients (54%) were treated without the use of fluoroscopy. In the implementation phase, 45 patients underwent AF ablation of which 42 (93.3%) were fluoroscopy-free. A detailed description is given of the three cases in which fluoroscopy had to be used despite an intention not to.

Conclusions

Fluoroscopy-free complex ablation procedures for the treatment of atrial fibrillation are safe and feasible in most patients.

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Lickfett L, Mahesh M, Vasamreddy C, Bradley D, Jayam V, Eldadah Z, et al. Radiation exposure during catheter ablation of atrial fibrillation. Circulation. 2004;110(19):3003–10. https://doi.org/10.1161/01.cir.0000146952.49223.11.CrossRefPubMed

Scaglione M, Ebrille E, Caponi D, Siboldi A, Bertero G, Di Donna P, et al. Zero-fluoroscopy ablation of accessory pathways in children and adolescents: CARTO3 electroanatomic mapping combined with RF and cryoenergy. Pacing Clin Electrophysiol. 2015;38(6):675–81. https://doi.org/10.1111/pace.12619.CrossRefPubMed

Clark J, Bockoven JR, Lane J, Patel CR, Smith G. Use of three-dimensional catheter guidance and trans-esophageal echocardiography to eliminate fluoroscopy in catheter ablation of left-sided accessory pathways. Pacing Clin Electrophysiol. 2008;31(3):283–9. https://doi.org/10.1111/j.1540-8159.2008.00987.x.CrossRefPubMed

Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace. 2012;14(4):528–606. https://doi.org/10.1093/europace/eus027.CrossRefPubMed

Limacher MC, Douglas PS, Germano G, Laskey WK, Lindsay BD, McKetty MH, et al. ACC expert consensus document. Radiation safety in the practice of cardiology. American College of Cardiology. J Am Coll Cardiol. 1998;31(4):892–913.CrossRefPubMed

The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP. 2007;37(2–4):1–332. https://doi.org/10.1016/j.icrp.2007.10.003.

Natale A, Reddy VY, Monir G, Wilber DJ, Lindsay BD, McElderry HT, et al. Paroxysmal AF catheter ablation with a contact force sensing catheter: results of the prospective, multicenter SMART-AF trial. J Am Coll Cardiol. 2014;64(7):647–56. https://doi.org/10.1016/j.jacc.2014.04.072.CrossRefPubMed

Perisinakis K, Damilakis J, Theocharopoulos N, Manios E, Vardas P, Gourtsoyiannis N. Accurate assessment of patient effective radiation dose and associated detriment risk from radiofrequency catheter ablation procedures. Circulation. 2001;104(1):58–62.CrossRefPubMed

Bulava A, Hanis J, Eisenberger M. Catheter ablation of atrial fibrillation using zero-fluoroscopy technique: a randomized trial. Pacing Clin Electrophysiol. 2015;38(7):797–806. https://doi.org/10.1111/pace.12634.CrossRefPubMed

10.

Lee G, Hunter RJ, Lovell MJ, Finlay M, Ullah W, Baker V, et al. Use of a contact force-sensing ablation catheter with advanced catheter location significantly reduces fluoroscopy time and radiation dose in catheter ablation of atrial fibrillation. Europace. 2016;18(2):211–8. https://doi.org/10.1093/europace/euv186.CrossRefPubMed

11.

Earley MJ, Showkathali R, Alzetani M, Kistler PM, Gupta D, Abrams DJ, et al. Radiofrequency ablation of arrhythmias guided by non-fluoroscopic catheter location: a prospective randomized trial. Eur Heart J. 2006;27(10):1223–9. https://doi.org/10.1093/eurheartj/ehi834.CrossRefPubMed

12.

Kistler PM, Rajappan K, Harris S, Earley MJ, Richmond L, Sporton SC, et al. The impact of image integration on catheter ablation of atrial fibrillation using electroanatomic mapping: a prospective randomized study. Eur Heart J. 2008;29(24):3029–36. https://doi.org/10.1093/eurheartj/ehn453.CrossRefPubMed

13.

Caponi D, Corleto A, Scaglione M, Blandino A, Biasco L, Cristoforetti Y, et al. Ablation of atrial fibrillation: does the addition of three-dimensional magnetic resonance imaging of the left atrium to electroanatomic mapping improve the clinical outcome? a randomized comparison of Carto-Merge vs. Carto-XP three-dimensional mapping ablation in patients with paroxysmal and persistent atrial fibrillation. Europace. 2010;12(8):1098–104. https://doi.org/10.1093/europace/euq107.CrossRefPubMed

14.

Rolf S, John S, Gaspar T, Dinov B, Kircher S, Huo Y, et al. Catheter ablation of atrial fibrillation supported by novel nonfluoroscopic 4D navigation technology. Heart Rhythm. 2013;10(9):1293–300. https://doi.org/10.1016/j.hrthm.2013.05.008.CrossRefPubMed

15.

Kuhne M, Knecht S, Muhl A, Reichlin T, Pavlovic N, Kessel-Schaefer A, et al. Fluoroscopy-free pulmonary vein isolation in patients with atrial fibrillation and a patent foramen ovale using solely an electroanatomic mapping system. PLoS One. 2016;11(1):e0148059. https://doi.org/10.1371/journal.pone.0148059.CrossRefPubMedPubMedCentral

16.

Raju H, Whitaker J, Taylor C, Wright M. Electroanatomic mapping and transoesophageal echocardiography for near zero fluoroscopy during complex left atrial ablation. Heart Lung Circ. 2016;25(7):652–60. https://doi.org/10.1016/j.hlc.2016.01.018.CrossRefPubMed

17.

Razminia M, Manankil MF, Eryazici PL, Arrieta-Garcia C, Wang T, D'Silva OJ, et al. Nonfluoroscopic catheter ablation of cardiac arrhythmias in adults: feasibility, safety, and efficacy. J Cardiovasc Electrophysiol. 2012;23(10):1078–86. https://doi.org/10.1111/j.1540-8167.2012.02344.x.CrossRefPubMed

18.

Razminia M, Willoughby MC, Demo H, Keshmiri H, Wang T, D'Silva OJ, et al. Fluoroless catheter ablation of cardiac arrhythmias: a 5-year experience. Pacing Clin Electrophysiol. 2017. https://doi.org/10.1111/pace.13038.

19.

Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation—developed with the special contribution of the European Heart Rhythm Association. Europace. 2012;14(10):1385–413. https://doi.org/10.1093/europace/eus305.CrossRefPubMed

20.

Della Bella P, Fassini G, Cireddu M, Riva S, Carbucicchio C, Giraldi F, et al. Image integration-guided catheter ablation of atrial fibrillation: a prospective randomized study. J Cardiovasc Electrophysiol. 2009;20(3):258–65. https://doi.org/10.1111/j.1540-8167.2008.01311.x.CrossRefPubMed

21.

Macias R, Uribe I, Tercedor L, Jimenez-Jaimez J, Barrio T, Alvarez M. A zero-fluoroscopy approach to cavotricuspid isthmus catheter ablation: comparative analysis of two electroanatomical mapping systems. Pacing Clin Electrophysiol. 2014;37(8):1029–37. https://doi.org/10.1111/pace.12376.CrossRefPubMed

22.

Fernandez-Gomez JM, Morina-Vazquez P, Morales Edel R, Venegas-Gamero J, Barba-Pichardo R, Carranza MH. Exclusion of fluoroscopy use in catheter ablation procedures: six years of experience at a single center. J Cardiovasc Electrophysiol. 2014;25(6):638–44. https://doi.org/10.1111/jce.12385.CrossRefPubMed

23.

Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17–20.CrossRefPubMed

24.

Meissner I, Whisnant JP, Khandheria BK, Spittell PC, O'Fallon WM, Pascoe RD, et al. Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study. Stroke prevention: assessment of risk in a community. Mayo Clin Proc. 1999;74(9):862–9.CrossRefPubMed

25.

Pavlovic N, Reichlin T, Kuhne M, Knecht S, Osswald S, Sticherling C. Fluoroscopy-free recrossing of the interatrial septum during left atrial ablation procedures. J Interv Card Electrophysiol. 2014;41(3):261–6. https://doi.org/10.1007/s10840-014-9952-5.CrossRefPubMed

26.

Lehrmann H, Schneider J, Jadidi AS, Park CI, Schiebeling-Romer J, Allgeier J, et al. Transseptal access for left atrial ablation: the catheter-probing techniques are not without risk. J Cardiovasc Electrophysiol. 2014;25(5):479–84. https://doi.org/10.1111/jce.12356.CrossRefPubMed

27.

Sporton SC, Earley MJ, Nathan AW, Schilling RJ. Electroanatomic versus fluoroscopic mapping for catheter ablation procedures: a prospective randomized study. J Cardiovasc Electrophysiol. 2004;15(3):310–5. https://doi.org/10.1111/j.1540-8167.2004.03356.x.CrossRefPubMed

28.

Knecht S, Sticherling C, Reichlin T, Pavlovic N, Muhl A, Schaer B, et al. Effective reduction of fluoroscopy duration by using an advanced electroanatomic-mapping system and a standardized procedural protocol for ablation of atrial fibrillation: ‘the unleaded study’. Europace. 2015;17(11):1694–9. https://doi.org/10.1093/europace/euv006. PubMed

29.

Scaglione M, Biasco L, Caponi D, Anselmino M, Negro A, Di Donna P, et al. Visualization of multiple catheters with electroanatomical mapping reduces X-ray exposure during atrial fibrillation ablation. Europace. 2011;13(7):955–62. https://doi.org/10.1093/europace/eur062.CrossRefPubMed

30.

Reddy VY, Morales G, Ahmed H, Neuzil P, Dukkipati S, Kim S, et al. Catheter ablation of atrial fibrillation without the use of fluoroscopy. Heart Rhythm. 2010;7(11):1644–53. https://doi.org/10.1016/j.hrthm.2010.07.011.CrossRefPubMed

31.

Ullah W, McLean A, Tayebjee MH, Gupta D, Ginks MR, Haywood GA, et al. Randomized trial comparing pulmonary vein isolation using the SmartTouch catheter with or without real-time contact force data. Heart Rhythm. 2016;13(9):1761–7. https://doi.org/10.1016/j.hrthm.2016.05.011.CrossRefPubMed

Title: Fluoroscopy-free AF ablation using transesophageal echocardiography and electroanatomical mapping technology
Authors: Benjamin O’Brien
Damian C. Balmforth
Ross J. Hunter
Richard J. Schilling
Publication date: 01-12-2017
Publisher: Springer US
Published in: Journal of Interventional Cardiac Electrophysiology / Issue 3/2017
Print ISSN: 1383-875X
Electronic ISSN: 1572-8595
DOI: https://doi.org/10.1007/s10840-017-0288-9

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Fluoroscopy-free AF ablation using transesophageal echocardiography and electroanatomical mapping technology

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Purpose

Methods

Results

Conclusions

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