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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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Purtell CS, Kipp RT, Eckhardt LL. Into a Fluoroless Future: an Appraisal of Fluoroscopy-Free Techniques in Clinical Cardiac Electrophysiology. Curr Cardiol Rep 2021; 23:28. [PMID: 33655436 PMCID: PMC7925460 DOI: 10.1007/s11886-021-01461-y] [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] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
Purpose of Review There are risks to both patients and electrophysiology providers from radiation exposure from fluoroscopic imaging, and there is increased interest in fluoroscopic reduction. We review the imaging tools, their applications, and current uses to eliminate fluoroscopy. Recent Findings Multiple recent studies provide supporting evidence for the transition to fluoroscopy-free techniques for both ablations and device implantation. The most frequently used alternative imaging approaches include intracardiac echocardiography, cardiac MRI guidance, and 3D electroanatomic mapping systems. Electroanatomic mapping and intracardiac echocardiography originally used to augment fluoroscopy imaging are now replacing the older imaging technique. The data supports that the future of electrophysiology can be fluoroscopy-free or very low fluoroscopy for the vast majority of cases. Summary As provider and institution experience grows with these techniques, many EP labs may choose to completely forego the use of fluoroscopy. Trainees will benefit from early experience with these techniques.
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Affiliation(s)
- Christopher S Purtell
- Department of Medicine, Division of Cardiovascular Medicine, Electrophysiology Service, University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI, 53792, USA
| | - Ryan T Kipp
- Department of Medicine, Division of Cardiovascular Medicine, Electrophysiology Service, University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI, 53792, USA.,William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Lee L Eckhardt
- Department of Medicine, Division of Cardiovascular Medicine, Electrophysiology Service, University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI, 53792, USA. .,Cellular and Molecular Arrhythmia Research Program, Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin-Madison, Madison, WI, USA.
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Wise B, Albarrán-Rincón R, De Lossada Juste A, Aio AE, Klesius A, Biundo E, Maes E, Cordon A, Ramos P, García-Bolao I. Economic evaluation of an ultra-high density mapping system compared to non-ultra-high density mapping systems for radiofrequency catheter ablation procedures in patients with atrial fibrillation. J Interv Card Electrophysiol 2021; 63:103-108. [PMID: 33547523 DOI: 10.1007/s10840-021-00951-x] [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: 11/09/2020] [Accepted: 01/24/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Advanced non-fluoroscopic mapping systems for radiofrequency ablation (RFA) have shown to be an effective treatment of atrial fibrillation. This study analyzes the resource usage and subsequent costs associated with the implementation of an ultra-high density mapping system (UHDMS) compared to non-ultra-high density mapping systems (NUHDMS). METHODS This retrospective observational study included 120 patients (18 years or older) with paroxysmal or persistent atrial fibrillation who underwent RFA for de novo pulmonary vein isolation guided either by an UHDMS (n=63) or NUHDMS (n=57) for their index procedure. We compared patient characteristics, short- and long-term procedural outcomes, resource usage, and clinical outcomes followed up to 16 months between the two treatment groups. The cost analysis was conducted from the perspective of a single center in Spain (Clinica Universidad de Navarra). RESULTS Neither baseline patient characteristics nor complication rate differed between groups. Repeat RFAs following recurrent arrhythmia at 16 months was lower in the UHDMS patient group than in the NUHDMS group (6 vs. 14, respectively; P=0.027). The average total cost per patient was €1,600 lower in the UHDMS group, compared to the NUHDMS group (€11,061 and €12,661, respectively; P=0.03). CONCLUSION In patients treated with an NUHDMS, 25% had a repeat ablation for recurrent arrhythmia, whereas only 9% of patients treated with a UHDMS had one (61% relative risk reduction), resulting in an average cost saving per patient of €1,600.
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Affiliation(s)
- Bernardo Wise
- Department of Cardiology and Cardiac Surgery, IdiSNA, Navarra Institute for Health Research, Arrhythmia Unit, Clinica Universidad de Navarra, University of Navarra and School of Medicine, Avda Pio XII sn, 31008, Pamplona, Spain
| | - Ramón Albarrán-Rincón
- Department of Cardiology and Cardiac Surgery, IdiSNA, Navarra Institute for Health Research, Arrhythmia Unit, Clinica Universidad de Navarra, University of Navarra and School of Medicine, Avda Pio XII sn, 31008, Pamplona, Spain
| | | | | | | | - Eliana Biundo
- Health Economics and Outcomes Research Team, Deloitte Consulting & Advisory, Zaventem, Belgium
| | - Edith Maes
- Health Economics and Outcomes Research Team, Deloitte Consulting & Advisory, Zaventem, Belgium
| | - Audrey Cordon
- Health Economics and Outcomes Research Team, Deloitte Consulting & Advisory, Zaventem, Belgium
| | - Pablo Ramos
- Department of Cardiology and Cardiac Surgery, IdiSNA, Navarra Institute for Health Research, Arrhythmia Unit, Clinica Universidad de Navarra, University of Navarra and School of Medicine, Avda Pio XII sn, 31008, Pamplona, Spain
| | - Ignacio García-Bolao
- Department of Cardiology and Cardiac Surgery, IdiSNA, Navarra Institute for Health Research, Arrhythmia Unit, Clinica Universidad de Navarra, University of Navarra and School of Medicine, Avda Pio XII sn, 31008, Pamplona, Spain.
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Percell RL, Pike JL, Olmsted RK, Beideck JE, Nunes HL, Johnson KN, Schaffer M, Vachok LB, Sveen SM, Keim EJ, Mohr-Burt SO, Saalfeld RM, Beran CA, Allison TW, Stock JF. The Grand SANS FLUORO (SAy No Series to FLUOROsopy) Study: Examining Fluoroscopy Use in More than 1,000 Ablation Procedures. J Innov Card Rhythm Manag 2020; 11:4224-4232. [PMID: 32983591 PMCID: PMC7510468 DOI: 10.19102/icrm.2020.1100903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The majority of electrophysiologists routinely use fluoroscopy (FLUORO) during ablation procedures for common arrhythmias despite the known complications of radiation exposure and protective lead use. This study assessed the safety of catheter ablation (CA) with FLUORO versus without FLUORO (SANS FLUORO) in patients with the following common arrhythmias: atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, and ventricular tachycardia. A total of 1,258 CA procedures were performed in 816 consecutive patients over a 53-month period (SANS FLUORO CA: 609 patients; FLUORO CA: 209 patients). The secondary outcome was the efficacy of AF ablation in FLUORO versus SANS FLUORO patients. Ultimately, there was no statistically significant difference found concerning the safety of CA in the SANS FLUORO and FLUORO groups in terms of procedure time, vascular complications, tamponade, stroke, or death. FLUORO patients had markedly increased FLUORO time, increased radiation exposure, and increased dose-area product (all p < 0.0001). AF development after SANS FLUORO CA of AF was not different from that after FLUORO CA regardless of the pulmonary vein isolation (PVI) modality used (cryoablation versus radiofrequency) at 24 months (p = 0.21). Additionally, women fared just as well as men after CA ablation for AF. At 36 months, 58% of SANS FLUORO AF device patients were free from AF. As such, SANS FLUORO CA of common arrhythmias appears to be as safe as FLUORO CA but with a markedly reduced level of radiation exposure. Also, SANS FLUORO CA remains as effective as FLUORO CA in the prevention of AF for up to 24 months.
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Affiliation(s)
- Robert L Percell
- SANS FLUORO Institute, Electrophysiology Department, Bryan Heart Institute, Lincoln, NE, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Casey A Beran
- Abbott Medical, Abbott Laboratories, Abbott Park, IL, USA
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