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Skeete J, Huang HD, Mazur A, Sharma PS, Engelstein E, Trohman RG, Larsen TR. Evolving Concepts in Cardiac Physiologic Pacing in the Era of Conduction System Pacing. Am J Cardiol 2024; 212:51-66. [PMID: 38012990 DOI: 10.1016/j.amjcard.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/22/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023]
Abstract
Cardiac physiologic pacing (CPP) has become a well-established therapy for patients with cardiomyopathy (left ventricular ejection fraction <35%) in the presence of a left bundle branch block. In addition, CPP can be highly beneficial in patients with pacing-induced cardiomyopathy and patients with existing cardiomyopathy expected to have a right ventricular pacing burden of >40%. The benefits of CPP with traditional biventricular pacing are only realized if adequate resynchronization can be achieved. However, left ventricular lead implantation can be limited by individual anatomic variation within the coronary venous system and can be adversely affected by underlying abnormal myocardial substrate (i.e., scar tissue), especially if located within the basal lateral wall. In the last 7 years the investigation of conduction system pacing (CSP) and its potential salutary benefits are being realized and have led to a rapid evolution in the field of cardiac resynchronization pacing. However, supportive evidence for CSP for patients eligible for cardiac resynchronization remains limited compared with data available for biventricular cardiac resynchronization, mostly derived from leading CSP investigative centers. In this review, we perform an up-to-date comprehensive review of the available literature on CPP.
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Affiliation(s)
- Jamario Skeete
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Henry D Huang
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Alex Mazur
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Parikshit S Sharma
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Erica Engelstein
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Richard G Trohman
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Timothy R Larsen
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.
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Preda A, Bonvicini E, Coradello E, Testoni A, Gigli L, Baroni M, Carbonaro M, Vargiu S, Varrenti M, Colombo G, Paolucci M, Mazzone P, Guarracini F. The Fluoroless Future in Electrophysiology: A State-of-the-Art Review. Diagnostics (Basel) 2024; 14:182. [PMID: 38248058 PMCID: PMC10814721 DOI: 10.3390/diagnostics14020182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
Fluoroscopy has always been the cornerstone imaging method of interventional cardiology procedures. However, radiation exposure is linked to an increased risk of malignancies and multiorgan diseases. The medical team is even more exposed to X-rays, and a higher incidence of malignancies was reported in this professional group. In the last years, X-ray exposure has increased rapidly, involving, above all, the medical team and young patients and forcing alternative fluoroless imaging methods. In cardiac electrophysiology (EP) and pacing, the advent of 3D electroanatomic mapping systems with dedicated catheters has allowed real-time, high-density reconstruction of both heart anatomy and electrical activity, significantly reducing the use of fluoroscopy. In addition, the diffusion of intracardiac echocardiography has provided high anatomical resolution of moving cardiac structures, providing intraprocedural guidance for more complex catheter ablation procedures. These methods have largely demonstrated safety and effectiveness, allowing for a dramatic reduction in X-ray delivery in most arrhythmias' ablations. However, some technical concerns, as well as higher costs, currently do not allow their spread out in EP labs and limit their use to only procedures that are considered highly complex and time-consuming and in young patients. In this review, we aim to update the current employment of fluoroless imaging in different EP procedures, focusing on its strengths and weaknesses.
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Affiliation(s)
- Alberto Preda
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Eleonora Bonvicini
- Division of Cardiology, Department of Medicine, Verona University Hospital, 37129 Verona, Italy
| | - Elena Coradello
- Division of Cardiology, Department of Medicine, Verona University Hospital, 37129 Verona, Italy
| | - Alessio Testoni
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Lorenzo Gigli
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Matteo Baroni
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marco Carbonaro
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Sara Vargiu
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marisa Varrenti
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Giulia Colombo
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marco Paolucci
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Patrizio Mazzone
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
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Ozcan EE, Turan OE, Yilancioğlu RY, Inevi U, Akdemir B. Combining conventional technique with fluoroscopy integration module in accessory pathway ablation. J Cardiovasc Electrophysiol 2023; 34:2573-2580. [PMID: 37890039 DOI: 10.1111/jce.16110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Accessory pathway (AP) ablation is a straightforward approach with high success rates, but the fluoroscopy time (FT) is significantly longer in conventional technique. Electroanatomical mapping systems (EMS), reduce the FT, but anatomical and activation mapping may prolong the procedure time (PT). The fluoroscopy integration module (FIM) uses prerecorded fluoroscopy images and allows ablation similar to conventional technique without creating an anatomical map. In this study, we investigated the effects of combining the FIM with traditional technique on PT, success, and radiation exposure. METHODS A total of 131 patients who had undergone AP ablation were included in our study. In 37 patients, right and left anterior oblique (RAO-LAO) images were acquired after catheter placement and integrated with the FIM. The ablation procedure was then similar to the conventional technique, but without the use of fluoroscopy. For the purpose of acceleration, anatomical and activation maps have not been created. Contact-force catheters were not used. 94 patients underwent conventional ablation using fluoroscopy only. RESULTS FIM into AP ablation procedures led to a significant reduction in radiation exposure, lowering FT from 7.4 to 2.8 min (p < .001) and dose-area product from 12.47 to 5.8 μGym² (p < .001). While the FIM group experienced a reasonable longer PT (69 vs. 50 min p < .001). FIM reduces FT regardless of operator experience and location of APs CONCLUSION: Combining FIM integration with conventional AP ablation offers reduced radiation exposure without compromising success rates and complication.
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Affiliation(s)
- Emin Evren Ozcan
- Department of Cardiology, Heart Rhythm Management Centre, Dokuz Eylul University, Izmir, Turkiye
| | - Oğuzhan Ekrem Turan
- Department of Cardiology, Heart Rhythm Management Centre, Dokuz Eylul University, Izmir, Turkiye
| | - Reşit Yiğit Yilancioğlu
- Department of Cardiology, Heart Rhythm Management Centre, Dokuz Eylul University, Izmir, Turkiye
| | - Umut Inevi
- Ege Aritmi Medical Product and Engineering, Izmir, Turkey
| | - Barış Akdemir
- Department of Cardiology, Yeni Yuzyil University, Istanbul, Turkey
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Soether C, Boehmer AA, Dobre BC, Kaess BM, Ehrlich JR. Zero-fluoro atrioventricular-nodal reentrant tachycardia ablation. Herzschrittmacherther Elektrophysiol 2023; 34:305-310. [PMID: 37950109 DOI: 10.1007/s00399-023-00977-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Atrioventricular-nodal reentrant tachycardia (AVNRT) is a common supraventricular tachycardia, particularly in younger patients. The treatment of choice is radiofrequency catheter ablation (RFCA), traditionally necessitating ionizing radiation for catheter guidance. OBJECTIVE The authors aimed to demonstrate the feasibility and safety of zero-fluoroscopy RFCA of AVNRT using EnSite™ NavX™ as a three-dimensional (3D) electroanatomical mapping system (EAM). METHODS The authors retrospectively analyzed 68 patients that underwent AVNRT-RFCA. One group was a priori allocated to conventional fluoroscopy mapping (convFluoro, n = 30). In 38 cases, the electrophysiologist chose to use 3D-EAM for ablation. Of these patients, 20 could be ablated without fluoroscopy use (zeroFluoro). In 18 cases that were initially intended as 3D-EAM, additional fluoroscopy use was necessary due to difficult anatomic conditions (convertedFluoro). Procedure duration, fluoroscopy duration and dose, as well as complications were analyzed. RESULTS Procedure duration was similar for the convFluoro and zeroFluoro groups (74 ± 24 min vs. 80 ± 26 min, p = ns). The convertedFluoro group showed longer procedure duration compared to the convFluoro group (94 ± 30 min vs. 74 ± 24 min, p < 0.05). The use of 3D-EAM significantly reduced fluoroscopy duration comparing the convFluoro with the convertedFluoro group (12 ± 9 min vs. 7 ± 6 min, p < 0.05). The difference in fluoroscopy dose between convFluoro and convertedFluoro did not reach significance (169 ± 166 cGycm2 vs. 134 ± 137 cGycm2, p = ns). In zeroFluoro cases, no radiation was used at all. 3D-EAM-guided RFCA was primarily successful in all patients. Overall, there were only few minor complications in the different groups. No major complications occurred. CONCLUSION Zero-fluoro RFCA in patients with AVNRT is feasible and safe. 3D-EAM can reduce radiation exposure in the majority of patients without prolonging procedure duration or increasing complications.
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Affiliation(s)
- Christina Soether
- Department of Cardiology, St. Josefs-Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Germany
| | - Andreas A Boehmer
- Department of Cardiology, St. Josefs-Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Germany
| | - Bianca C Dobre
- Department of Cardiology, St. Josefs-Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Germany
| | - Bernhard M Kaess
- Department of Cardiology, St. Josefs-Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Germany
| | - Joachim R Ehrlich
- Department of Cardiology, St. Josefs-Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Germany.
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Bloom D, Catherall D, Miller N, Southworth MK, Glatz AC, Silva JR, Avari Silva JN. Use of a mixed reality system for navigational mapping during cardiac electrophysiological testing does not prolong case duration: A subanalysis from the Cardiac Augmented REality study. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2023; 4:111-117. [PMID: 37600447 PMCID: PMC10435945 DOI: 10.1016/j.cvdhj.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023] Open
Abstract
Background CommandEP™ is a mixed reality (MXR) system for cardiac electrophysiological (EP) procedures that provides a real-time 3-dimensional digital image of cardiac geometry and catheter locations. In a previous study, physicians using the system demonstrated improved navigational accuracy. This study investigated the impact of the CommandEP system on EP procedural times compared to the standard-of-care electroanatomic mapping system (EAMS) display. Objective The purpose of this retrospective case-controlled analysis was to evaluate the impact of a novel MXR interface on EP procedural times compared to a case-matched cohort. Methods Cases from the Cardiac Augmented REality (CARE) study were matched for diagnosis and weight using a contemporary cohort. Procedural time was compared from the roll-in and full implementation cohort. During routine EP procedures, operators performed tasks during the postablation waiting phase, including creation of cardiac geometry and 5-point navigation under 2 conditions: (1) EAMS first; and (2) CommandEP. Results From a total of 16 CARE study patients, the 10 full implementation patients were matched to a cohort of 20 control patients (2 controls:1 CARE, matched according to pathology and age/weight). No statistical difference in total case times between CARE study patients vs control group (118 ± 29 minutes vs 97 ± 20 minutes; P = .07) or fluoroscopy times (6 ± 4 minutes vs 7 ± 6 minutes; P = .9). No significant difference in case duration for CARE study patients comparing roll-in vs full-implementation cohort (121 ± 26 minutes vs 118 ± 29 minutes; P = .96). CommandEP wear time during cases was significantly longer in full implementation cases (53 ± 24 minutes vs 24 ± 5 minutes; P = .0009). During creation of a single cardiac geometry, no significant time difference was noted between CommandEP vs EAMS (284 ± 45 seconds vs 268 ± 43 seconds; P = .1) or fluoroscopy use (9 ± 19 seconds vs 6 ± 18 seconds; P = .25). During point navigation tasks, there was no difference in total time (CommandEP 31 ± 14 seconds vs EAMS 28 ± 15 seconds; P = .16) or fluoroscopy time (CommandEP 0 second vs EAMS 0 second). Conclusion MXR did not prolong overall procedural time compared to a matched cohort. There was no prolongation in study task completion time. Future studies with experienced CommandEP users directly assessing procedural time and task completion time in a randomized study population would be of interest.
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Affiliation(s)
- David Bloom
- Department of Pediatrics, Division of Cardiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - David Catherall
- School of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Nathan Miller
- Pediatric Cardiology/Electrophysiology, St. Louis Children’s Hospital, St. Louis, Missouri
| | | | - Andrew C. Glatz
- Department of Pediatrics, Division of Cardiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Jonathan R. Silva
- SentiAR, Inc., St. Louis, Missouri
- Department of Biomedical Engineering. Washington University in St. Louis, McKelvey School of Engineering, St. Louis, Missouri
| | - Jennifer N. Avari Silva
- Department of Pediatrics, Division of Cardiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
- SentiAR, Inc., St. Louis, Missouri
- Department of Biomedical Engineering. Washington University in St. Louis, McKelvey School of Engineering, St. Louis, Missouri
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Debreceni D, Janosi K, Bocz B, Turcsan M, Lukacs R, Simor T, Antolič B, Vamos M, Komocsi A, Kupo P. Zero fluoroscopy catheter ablation for atrial fibrillation: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1178783. [PMID: 37396578 PMCID: PMC10313423 DOI: 10.3389/fcvm.2023.1178783] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/07/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Catheter ablation for atrial fibrillation (AF) is the most frequently performed cardiac ablation procedure worldwide. The majority of ablations can now be performed safely with minimal radiation exposure or even without the use of fluoroscopy, thanks to advances in 3-dimensional electroanatomical mapping systems and/or intracardiac echocardiography. The aim of this study was to conduct a meta-analysis to compare the effectiveness of zero fluoroscopy (ZF) versus non-zero fluoroscopy (NZF) strategies for AF ablation procedures. Methods Electronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of ZF vs. NZF approaches in patients undergoing catheter ablation for AF. We used a random-effects model to derive the mean difference (MD) and risk ratios (RR) with a 95% confidence interval (CI). Results Our meta-analysis included seven studies comprising 1,593 patients. The ZF approach was found to be feasible in 95.1% of patients. Compared to the NZF approach, the ZF approach significantly reduced procedure time [mean difference (MD): -9.11 min (95% CI: -12.93 to -5.30 min; p < 0.01)], fluoroscopy time [MD: -5.21 min (95% CI: -5.51 to -4.91 min; p < 0.01)], and fluoroscopy dose [MD: -3.96 mGy (95% CI: -4.27 to -3.64; p < 0.01)]. However, there was no significant difference between the two groups in terms of total ablation time [MD: -104.26 s (95% CI: -183.37 to -25.14; p = 0.12)]. Furthermore, there was no significant difference in the acute [risk ratio (RR): 1.01, 95% CI: 1.00-1.02; p = 0.72] and long-term success rates (RR: 0.96, 95% CI: 0.90-1.03; p = 0.56) between the ZF and NZF methods. The complication rate was 2.76% in the entire study population and did not differ between the groups (RR: 0.94, 95% CI: 0.41-2.15; p = 0.89). Conclusion The ZF approach is a feasible method for AF ablation procedures. It significantly reduces procedure time and radiation exposure without compromising the acute and long-term success rates or complication rates.
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Affiliation(s)
| | - Kristof Janosi
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
| | - Botond Bocz
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
| | - Marton Turcsan
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
| | - Reka Lukacs
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
| | - Tamas Simor
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
| | - Bor Antolič
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Andras Komocsi
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
| | - Peter Kupo
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
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Fluoroless catheter ablation of atrial fibrillation: a step-by-step workflow. JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023:10.1007/s10840-023-01469-0. [PMID: 36725820 DOI: 10.1007/s10840-023-01469-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
Catheter ablation is an important therapeutic strategy for patients with atrial fibrillation (AF). While some critical steps of the procedure have traditionally relied on fluoroscopy, advances in electroanatomic mapping and the growing use of intracardiac echocardiography have made non-fluoroscopic AF ablation a reality. This hands-on review provides an overview on how to perform radiofrequency ablation of AF without the use of fluoroscopy, focusing on technical aspects, new technologies, and troubleshooting.
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8
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Debreceni D, Janosi K, Vamos M, Komocsi A, Simor T, Kupo P. Zero and Minimal Fluoroscopic Approaches During Ablation of Supraventricular Tachycardias: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:856145. [PMID: 35479287 PMCID: PMC9037593 DOI: 10.3389/fcvm.2022.856145] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Catheter ablations for cardiac arrhythmias are conventionally performed under fluoroscopic guidance. To guide these procedures, zero/minimal fluoroscopy (Z/MF) approaches have become available, using three-dimensional electroanatomical mapping systems. Our aim was to conduct a meta-analysis comparing these two different methods for the treatment of paroxysmal supraventricular tachycardia (SVT). Methods Electronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of conventional, fluoroscopy-guided vs. Z/MF approaches in patients undergoing electrophysiology (EP) procedures for SVTs. The random-effects model was used to derive mean difference (MD) and risk ratios (RRs) with 95% confidence interval (CI). Results Twenty-four studies involving 9,074 patients met our inclusion criteria. There was no difference between the groups in terms of acute success rate (RR = 1.00, 95% CI, 0.99–1.01; p = 0.97) and long-term success rate (RR: 1.01, 95% CI, 1.00–1.03; p = 0.13). Compared to the conventional method, zero-and-minimal fluoroscopy (Z/MF) ablation significantly reduced fluoroscopic time [MD: −1.58 min (95% CI, −2.21 to −0.96 min; p < 0.01)] and ablation time [MD: −25.23 s (95% CI: −42.04 to −8.43 s; p < 0.01)]. No difference could be detected between the two groups in terms of the procedure time [MD: 3.06 min (95% CI: −0.97 to 7.08; p = 0.14)] and the number of ablation applications [MD: 0.13 (95% CI: −0.86 to 1.11; p = 0.80)]. The complication rate was 1.59% in the entire study population and did not differ among the groups (RR: 0.68, 95% CI: 0.45–1.05; p = 0.08). Conclusions The Z/MF approach for the catheter ablation of SVTs is a feasible method that reduces radiation exposure and ablation time without compromising the acute and long-term success or complication rates.
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Affiliation(s)
- Dorottya Debreceni
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
- *Correspondence: Dorottya Debreceni
| | - Kristof Janosi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Andras Komocsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Tamas Simor
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Peter Kupo
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
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Rubenstein DS, Holmes BB, Manfredi JA, McKillop MS, Netzler PC, Ward CC. Aegrescit medendo: orthopedic disability in electrophysiology - call for fluoroscopy elimination-review and commentary. J Interv Card Electrophysiol 2022; 64:239-253. [PMID: 35258751 PMCID: PMC9236987 DOI: 10.1007/s10840-022-01173-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Donald S Rubenstein
- Carolina Cardiology Consultants-EP Division, Prisma Health, 701 Grove Rd., Greenville, SC, 29605, USA.
| | - Benjamin B Holmes
- Carolina Cardiology Consultants-EP Division, Prisma Health, 701 Grove Rd., Greenville, SC, 29605, USA
| | - Joseph A Manfredi
- Carolina Cardiology Consultants-EP Division, Prisma Health, 701 Grove Rd., Greenville, SC, 29605, USA
| | - Matthew S McKillop
- Baptist Medical Center Jacksonville, 800 Prudential Dr., Jacksonville, FL, 32207, USA
| | - Peter C Netzler
- Carolina Cardiology Consultants-EP Division, Prisma Health, 701 Grove Rd., Greenville, SC, 29605, USA
| | - Chad C Ward
- Carolina Cardiology Consultants-EP Division, Prisma Health, 701 Grove Rd., Greenville, SC, 29605, USA
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10
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Elvin Gul E, Azizi Z, Alipour P, Haseeb S, Malcolm R, Terricabras M, Sanchez Somonte P, Tsang B, Khaykin Y, Wulffhart Z, Verma A, Pantano A. Fluoroless Catheter Ablation of Atrial Fibrillation: Integration of Intracardiac Echocardiography and Cartosound Module. J Atr Fibrillation 2021; 14:20200477. [PMID: 34950370 DOI: 10.4022/jafib.20200477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/19/2021] [Accepted: 05/18/2021] [Indexed: 12/18/2022]
Abstract
Objective To evaluate the feasibility, safety, and clinical efficacy of non-fluoroscopic radiofrequency catheter ablation of atrial fibrillation (AF) in comparison to traditional fluoroscopy-guided ablation in a local Canadian community cohort. Methods We retrospectively studied consecutive patients with paroxysmal and persistent AF undergoing pulmonary vein isolation (PVI) guided by intracardiac echocardiography (ICE) and Carto system (CartoSound module). ICE-guided PVI without fluoroscopy (Zero-fluoro group) was performed in 116 patients, and conventional fluoroscopy-guided PVI (Traditional group) was performed in 131 patients. Results Two hundred and forty-seven patients with AF (60.7% male; mean age: 62.2 ± 10.6 years; paroxysmal AF =63.1%) who underwent PVI were studied. Mean procedure times were similar between both groups (136.8±33.4 minutes in the zero-fluoro group vs. 144.3±44.9 minutes in the traditional group; p=0.2). Acute PVI was achieved in all patients. Survival from early AF recurrence was 85% and 81% in the zero-fluoro and traditional groups, respectively (p = 0.06). Survival from late AF recurrence (12-months) between the zero-fluoro and traditional groups was also similar (p=0.1). Moreover, there were no significant differences between complication rates, including hematoma (p = 0.2) and tamponade (p = 1),between both groups. Conclusions Zero-fluoroscopy ICE and CartoSound-guided AF ablation may be safe and feasible in patients undergoing PVI compared to conventional fluoroscopy-guided ablation.
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Affiliation(s)
- Enes Elvin Gul
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada.,Contributed equally as first co-authors
| | - Zahra Azizi
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada.,Contributed equally as first co-authors
| | - Pouria Alipour
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sohaib Haseeb
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Rebecca Malcolm
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Maria Terricabras
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Paula Sanchez Somonte
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bernice Tsang
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yaariv Khaykin
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zaev Wulffhart
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Atul Verma
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alfredo Pantano
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
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11
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Kanitsoraphan C, Techorueangwiwat C, Rattanawong P, Kewcharoen J, Ayinapudi K, Bunch TJ, Groh C, Navaravong L. Zero fluoroscopy approach versus fluoroscopy approach for cardiac arrhythmia ablations: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2021; 32:2761-2776. [PMID: 34427955 DOI: 10.1111/jce.15221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/02/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radiofrequency catheter ablation for cardiac arrhythmias has traditionally been guided by fluoroscopy. Fluoroscopy exposes the patient, operator, and staff to ionizing radiation which has no safe dose void of stochastic and deterministic biologic risks. Zero fluoroscopy (ZF) approaches for catheter ablation have been advocated to eliminate these risks. We conducted a meta-analysis comparing acute procedure success, recurrence-free survival, complications, and procedure times between the approaches. METHODS We conducted a literature search from inception through December 2020 in the databases of EMBASE and MEDLINE. We included randomized controlled trials and cohorts that compared the outcomes of interest in ZF and conventional/low fluoroscopy (CF/LF) approaches. The outcomes sought were acute procedure success, recurrence-free survival, complications, and procedure times. Effect estimates were combined, using the random-effects, generic inverse variance method of DerSimonian and Laird. RESULTS Sixteen studies from 2013 to 2020, including 6052 patients (2219 ZF, 3833 CF/LF) were included. There were no significant differences in acute procedure success rate (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 0.75-1.59), recurrence-free survival (OR: 1.08, 95% CI: 0.78-1.49), periprocedural complication rate (OR: 0.72, 95% CI: 0.45-1.16), or total procedure time (weighted mean difference 2.32 min, 95% CI: -2.85-7.50) between ZF and CF/LF approaches, respectively. Overall, only 1.26% of patients crossed over from ZF to CF/LF arm. CONCLUSIONS Periprocedural and postprocedural outcomes with a ZF approach compared favorably with traditional fluoroscopic guidance without increasing procedural times. As comfort with ZF grows, coupled with evolving mapping technologies, this method has potential to become the standard approach for catheter ablation.
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Affiliation(s)
- Chanavuth Kanitsoraphan
- Internal Medicine Residency Program, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Chol Techorueangwiwat
- Internal Medicine Residency Program, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii, USA
| | | | - Jakrin Kewcharoen
- Internal Medicine Residency Program, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Karnika Ayinapudi
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - T Jared Bunch
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christopher Groh
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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12
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Chiang LLW, Li C, Hong KL, Hui WS, Beh SY, Gong M, Liu T, Li G, Xia Y, Ho J, Roever L, Duong S, Huang G, Tse G, Baranchuk A, Glover BM. The use of minimal fluoroscopy for cardiac electrophysiology procedures: A meta-analysis and review of the literature. Clin Cardiol 2021; 44:814-823. [PMID: 33998690 PMCID: PMC8207968 DOI: 10.1002/clc.23609] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/13/2021] [Accepted: 03/31/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Conventional catheter ablation involves prolonged exposure to ionizing radiation, potentially leading to detrimental health effects. Minimal fluoroscopy (MF) represents a safer alternative, which should be explored. Data on the safety and efficacy of this technique are limited. HYPOTHESIS Our hypothesis is that MF is of equal efficacy and safety to conventional catheter ablation with the use of fluoroscopy by performing a meta-analysis of both randomized controlled trials (RCTs) and real-world registry studies. METHODS Pubmed and Embase were searched from their inception to July 2020 for RCTs, cohort and observational studies that assessed the outcomes of catheter ablation using a MF technique versus the conventional approach. RESULTS Fifteen studies involving 3795 patients were included in this meta-analysis. There was a significant reduction in fluoroscopy and procedural time with no difference in acute success (odds ratio [OR]:0.74, 95% CI: 0.50-1.10, p = .14), long-term success (OR:0.92, 95% CI: 0.65-1.31, p = .38), arrhythmia recurrence (OR:1.24, 95% CI: 0.75-2.06, p = .97) or rate of complications. (OR:0.83, 95% CI: 0.46-1.48, p = .65). Additionally sub-group analysis for those undergoing catheter ablation for atrial fibrillation (AF) did not demonstrate a difference in success or complication rates (OR:0.86, 95% CI: 0.30-2.42, p = .77). Multivariate meta-regression did not identify the presence of moderator variables. CONCLUSION This updated meta-analysis demonstrated an overall reduction in procedural and fluoroscopy time for those undergoing a minimal fluoroscopic approach. There was no significant difference in either acute or chronic success rates or complications between a MF approach and conventional approach for the management of all arrhythmias including those undergoing catheter ablation for AF.
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Affiliation(s)
| | - Christien Li
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.,Faculty of Medicine, Newcastle University, Newcastle, UK
| | - Kathryn L Hong
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Winsy Sin Hui
- Faculty of Medicine, Newcastle University, Newcastle, UK
| | - Sze Yi Beh
- Faculty of Medicine, Newcastle University, Newcastle, UK
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jeffery Ho
- Department of Anaesthesia and Intensive care, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Leonardo Roever
- Federal University of Uberlândia, Department of Clinical Research, Uberlândia, Minas Gerais, Brazil
| | - Sophia Duong
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Grace Huang
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Benedict M Glover
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
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13
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Cauti FM, Rossi P, La Greca C, Piro A, Di Belardino N, Battaglia A, Ferraris F, Pecora D, Lavalle C, Scalone A, Rossi L, Di Cori A, Solimene F, Mantovan R, Pedretti S, Iaia L, Bianchi S, Anselmino M. Minimal fluoroscopy approach for right-sided supraventricular tachycardia ablation with a novel ablation technology: Insights from the multicenter CHARISMA clinical registry. J Cardiovasc Electrophysiol 2021; 32:1296-1304. [PMID: 33783875 DOI: 10.1111/jce.15023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/25/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND No data exist on the ability of the novel Rhythmia 3-D mapping system to minimize fluoroscopy exposure during transcatheter ablation of arrhythmias. We report data on the feasibility and safety of a minimal fluoroscopic approach using this system in supraventricular tachycardia (SVT) procedures. METHODS Consecutive patients were enrolled in the CHARISMA registry at 12 centers. All right-sided procedures performed with the Rhythmia mapping system were analyzed. The acquired electroanatomic information was used to reconstruct 3-D cardiac geometry; fluoroscopic confirmation was used whenever deemed necessary. RESULTS Three hundred twenty-five patients (mean age = 56 ± 17 years, 57% male) were included: 152 atrioventricular nodal reentrant tachycardia, 116 atrial flutter, 41 and 16 right-sided accessory pathway and atrial tachycardia, respectively. Overall, 27 481 s of fluoroscopy were used (84.6 ± 224 s per procedure, equivalent effective dose = 1.1 ± 3.7 mSv per patient). One hundred ninety-two procedures (59.1%) were completed without the use of fluoroscopy (zero fluoroscopy, ZF). In multivariate analysis, the presence of a fellow in training (OR = 0.15, 95% CI: 0.05-0.46; p = .0008), radiofrequency application (0.99, 0.99-1.00; p = .0002), and mapping times (0.99, 0.99-1.00; p = .042) were all inversely associated with ZF approach. Acute procedural success was achieved in 97.8% of the cases (98.4 vs. 97% in the ZF vs. non-ZF group; p = .4503). During a mean of 290.7 ± 169.6 days follow-up, no major adverse events were reported, and recurrence of the primary arrhythmia was 2.5% (2.1 vs. 3% in the ZF vs. non-ZF group; p = .7206). CONCLUSIONS The Rhythmia mapping system permits transcatheter ablation of right-sided SVT with minimal fluoroscopy exposure. Even more, in most cases, the system enables a ZF approach, without affecting safety and efficacy.
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Affiliation(s)
- Filippo M Cauti
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Pietro Rossi
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | | | | | | | | | - Federico Ferraris
- Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Turin, Italy
| | | | | | | | - Luca Rossi
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | | | | | | | - Luigi Iaia
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Stefano Bianchi
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Matteo Anselmino
- Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Turin, Italy
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14
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Wakamatsu Y, Nagashima K, Kurokawa S, Otsuka N, Hayashida S, Yagyu S, Hirata S, Ohkubo K, Nakai T, Okumura Y. Impact of the combined use of intracardiac ultrasound and a steerable sheath visualized by a 3D mapping system on pulmonary vein isolation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:693-702. [PMID: 33595100 DOI: 10.1111/pace.14194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/05/2021] [Accepted: 02/14/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND A novel steerable sheath visualized on a three-dimensional mapping system has become available in this era in which a durable pulmonary vein (PV) isolation (PVI) with reduced fluoroscopy is required. METHODS In 60 patients who underwent a PVI with a visualized sheath (n = 30) and non-visualized conventional sheath (n = 30), the fluoroscopic time and catheter stability during the PVI were analyzed. RESULTS The fluoroscopic time during the transseptal access (0 [0, 0.1] vs. 1.4 [0.8, 2.3] minutes, P < .001) and PVI (0 [0, 0.1] vs. 0.4 [0.2, 1.1] minutes, P < .001) were shorter in the visualized sheath group than conventional sheath group. The procedure time during the PVI (32.0 [26.8, 36.3] vs. 41.0 [31.8, 47.3] minutes, P = .01), particularly during the right PVI (15.0 [12.8, 18.0] vs. 23.0 [15.8, 26.3] minutes, P = .009), was shorter in the visualized sheath group than conventional sheath group, however, that during the other steps was equivalent. The standard deviation of the catheter contact force during each radiofrequency application was smaller in the visualized sheath group than conventional sheath group (4.5 ± 2.7 vs. 4.9 ± 3.1 g, P = .001). The impedance drop for each lesion was larger in the visualized sheath group than conventional sheath group (10.7 ± 6.5 vs. 9.8 ± 5.5 ohms, P < .001). The incidence of acute PV reconnections per patient (30% vs. 23%, P = .56) and per PV segment (2.5% vs. 2.3%, P = .83) were similar between the two groups. No major complications occurred in either sheath group. CONCLUSIONS The use of visualized sheaths may reduce the fluoroscopic time and improve the catheter stability during the PVI.
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Affiliation(s)
- Yuji Wakamatsu
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Sayaka Kurokawa
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Naoto Otsuka
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Hayashida
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Seina Yagyu
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Shu Hirata
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Kimie Ohkubo
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiko Nakai
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
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15
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Ali M, Padmanabhan D, Kanjwal K, Ghadei MK, Kottayan A, Banavalikar B, Shenthar J. Effect of fluoroscopy frame rate on radiation exposure and in-hospital outcomes in three-dimensional electroanatomic mapping guided procedures. J Arrhythm 2021; 37:97-102. [PMID: 33664891 PMCID: PMC7896476 DOI: 10.1002/joa3.12496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/05/2020] [Accepted: 12/19/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Fluoroscopic imaging involves exposure of the patients and the laboratory staff to ionizing radiation. One of the strategies that reduce such exposure in an electrophysiology laboratory is using a three-dimensional electroanatomic mapping (3D EAM) system for performing these procedures. In this analysis, we have analyzed the effect of fluoroscopy frame rate on the radiation exposure and in-hospital outcomes in ablation procedures performed under 3D EAM guidance. METHODS We retrospectively analyzed all the ablation procedures performed under 3D EAM guidance at our institute from September 2015 to December 2018. The procedures were divided into two groups based on whether the procedures were performed before (pre) or after (post) January 26, 2018. After January 2018, fluoroscopy was used at a frame rate of 3.75 frames per second (fps). Radiation exposure indices and in-hospital outcomes were compared between the two groups. RESULTS Ablation procedures included in the analysis were ventricular arrhythmias (n = 192), atrial flutter (115), atrial tachycardia (AT) (43), and atrial fibrillation (AF) (30). Over the study period, there was a significant reduction in procedure time, fluoroscopy time, dose area product, and effective dose (ED) (P < .001). Except for AT and AF ablation procedures, there was a significant reduction in the radiation exposure indices when the "post" group was compared with the "pre" group (P ≤ .02). The decrease in the frame rate had no significant effect on in-hospital outcomes. CONCLUSION The use of 3D EAM combined with decreasing the fluoroscopy frame rate significantly reduced the total radiation exposure without adversely affecting in-hospital outcomes.
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Affiliation(s)
- Muzaffar Ali
- Department of Cardiac ElectrophysiologySri Jayadeva Institute of Cardiovascular Sciences and ResearchBangaloreIndia
- Department of CardiologySher‐i‐Kashmir Institute of Medical SciencesSrinagarIndia
| | - Deepak Padmanabhan
- Department of Cardiac ElectrophysiologySri Jayadeva Institute of Cardiovascular Sciences and ResearchBangaloreIndia
| | - Khalil Kanjwal
- Department of CardiologyDivision of Clinical Cardiac ElectrophysiologyMcLaren Greater Lansing HospitalLansingMIUSA
| | - Milan Kumar Ghadei
- Department of Cardiac ElectrophysiologySri Jayadeva Institute of Cardiovascular Sciences and ResearchBangaloreIndia
| | - Anju Kottayan
- Department of Cardiac ElectrophysiologySri Jayadeva Institute of Cardiovascular Sciences and ResearchBangaloreIndia
| | - Bharatraj Banavalikar
- Department of Cardiac ElectrophysiologySri Jayadeva Institute of Cardiovascular Sciences and ResearchBangaloreIndia
| | - Jayaprakash Shenthar
- Department of Cardiac ElectrophysiologySri Jayadeva Institute of Cardiovascular Sciences and ResearchBangaloreIndia
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