Implementation of a zero fluoroscopic workflow using a simplified intracardiac echocardiography guided method for catheter ablation of atrial fibrillation, including repeat procedures

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

The use of Intracardiac Echocardiography in Catheter Ablation of Atrial Fibrillation

PURPOSE OF THE REVIEW

Intracardiac echocardiography (ICE) provides real-time, fluoroless imaging of cardiac structures, allowing optimal catheter positioning and energy delivery during ablation procedures. This review summarizes the use of ICE in catheter ablation of atrial fibrillation (AF).

RECENT FINDINGS

Growing evidence suggests that the use of ICE improves procedural safety and facilitates radiofrequency and cryoballoon AF ablation. ICE-guided catheter ablation is associated with reduced procedural duration and fluoroscopy use. Recent studies have examined the role of ICE in guiding novel ablation techniques, such as pulsed field ablation. Finally, the use of ICE allows for early detection and timely management of potentially serious procedural complications. Intracardiac echocardiography offers significant advantages during AF ablation procedures and its use should be encouraged to improve procedural safety and efficacy.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Comparison of safety and effectiveness of different sheaths in ablation of focal atrial tachycardia: a retrospective study

Background

A novel visualized steerable sheath, referred to as the Vizigo sheath, has been utilized in clinical interventions. The objective of this study was to evaluate and contrast the efficacy and safety of the Vizigo sheath with other sheaths in the catheter ablation (CA) for focal atrial tachycardia (FAT).

Methods

A retrospective cohort study was conducted on consecutive patients with CA for FAT from March 2019 to February 2022. Objectives were to assess the impact of the Vizigo sheath on acute and long-term ablation success rates, procedural and fluoroscopy times, and contact force (CF).

Results

A total of 164 patients, mean age 50±15 years, 97 (59.1%) women, underwent CA of FAT using the Vizigo sheath (N=42), non-visualized steerable sheath (N=36), or other conventional sheath (N=86). Age, sex, body mass index (BMI), presence of hypertension, heart failure, and diabetes mellitus were not significantly different among the three groups. The acute success rate of 94.0% was similar among the three groups. Over a follow-up of 14±2 months, the Vizigo sheath was associated with superior arrhythmia-free survival (88.1%) when compared to non-visualized steerable (69.4%; P=0.04) and other conventional (72.1%, P=0.046) sheaths. Procedural duration, number of ablation lesions, and ablation times were similar among the three groups. However, the Vizigo sheath was associated with lower fluoroscopy times (e.g., 145 vs. 250 s with Vizigo versus non-visualized steerable sheaths, P=0.03) and higher CF (e.g., average CF 12.0 versus 8.0 g with Vizigo versus non-visualized steerable sheaths, P=0.003).

Conclusions

The application of Vizigo sheath can improve the long-term success rate of FAT and reduce the radiation exposure of patients and medical staff in our single-center limited sample study. More research may be needed in the future to confirm our findings.

Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

The Fluoroless Future in Electrophysiology: A State-of-the-Art Review

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.

Practical guidance to reduce radiation exposure in electrophysiology applying ultra low-dose protocols: a European Heart Rhythm Association review

Interventional electrophysiology offers a great variety of treatment options to patients suffering from symptomatic cardiac arrhythmia. Catheter ablation of supraventricular and ventricular tachycardia has globally evolved a cornerstone in modern arrhythmia management. Complex interventional electrophysiological procedures engaging multiple ablation tools have been developed over the past decades. Fluoroscopy enabled interventional electrophysiologist throughout the years to gain profound knowledge on intracardiac anatomy and catheter movement inside the cardiac cavities and hence develop specific ablation approaches. However, the application of X-ray technologies imposes serious health risks to patients and operators. To reduce the use of fluoroscopy during interventional electrophysiological procedures to the possibly lowest degree and to establish an optimal protection of patients and operators in cases of fluoroscopy is the main goal of modern radiation management. The present manuscript gives an overview of possible strategies of fluoroscopy reduction and specific radiation protection strategies.

Zero fluoroscopy catheter ablation for atrial fibrillation: a systematic review and meta-analysis

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.

Treatment Options in AF Patients with Cancer; Focus on Catheter Ablation

Longer life expectancy along with advancements in cancer and atrial fibrillation (AF) therapies and treatment strategies have led to an increase in the number of individuals with both diseases. As a result, the complicated management of these patients has become crucial, necessitating individualised treatment that considers the bi-directional relationship between these two diseases. On the one hand, giving appropriate pharmaceutical therapy is exceptionally difficult, considering the recognised thromboembolic risk posed by AF and malignancy, as well as the haemorrhagic risk posed by cancer. The alternative pulmonary vein isolation (PVI) ablation, on the other hand, has been inadequately explored in the cancer patient population; there is yet inadequate data to allow the clinician to unambiguously select patients that can undertake this therapeutic intervention. The goal of this review is to compile the most valuable data and supporting evidence about the characteristics, care, and therapy of cancer patients with AF. Specifically, we will evaluate the pharmaceutical options for a proper anticoagulant therapy, as well as the feasibility and safety of PVI in this population.

Temporary Trends Concerning the Extent and Efficacy of Atrial Fibrillation Ablation Using Radiofrequency Energy in a Polish Single-Center Experience

Background and Objectives: Atrial fibrillation (AF) is the most common supraventricular arrhythmia. Currently, catheter ablation is a preferred treatment strategy. The main objective of our study was a temporary trends analysis of patients’ data undergoing a single AF ablation procedure using radiofrequency energy (RF). The efficacy of the procedure underwent assessment during a 12-month follow-up. Materials and Methods: We analyzed 585 consecutive patients with symptomatic, recurrent, and drug-refractory AF hospitalized in our department between 2013 and 2018 who underwent RF ablation supported by a 3D electroanatomical system. The baseline characteristics, periprocedural parameters, and efficacy of the procedure at 6-, 9- and 12-month follow-ups were analyzed over the years. Results: The number of patients undergoing ablation increased. Patients with paroxysmal AF predominated (71.5%). However, the number of patients with the persistent type of arrhythmia increased over the years. The percentage of patients with chronic heart failure (CHF) increased to 27.5% in 2018, and patients presented with increasingly larger left atria (LA). In all patients, circumferential pulmonary vein isolation was performed. The percentage of patients who underwent arrhythmogenic substrate modification and cavotricuspid isthmus ablation increased. Over the years, the efficacy of a single procedure at the 12-month follow-up remained without significant differences between the years (72.0%, 69.6%, 75.5%, 74.8%, 71.7%, 71.7%). Conclusions: The rate of patients with CHF and advanced LA disease undergoing more extensive ablation increased over the years. The efficacy of a single procedure remained without significant differences between the years.

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.

Effects of the visualized steerable sheath applied to catheter ablation of paroxysmal atrial fibrillation

PURPOSE

A new type of visualized steerable sheath (Vizigo sheath; Biosense Webster Inc., Irvine, CA, USA) has been employed in clinical treatment. This study aimed to compare the effectiveness and safety of the Vizigo sheath to a fixed sheath (Swartz sheath; St. Jude Inc., St. Paul, MN, USA) for catheter ablation of paroxysmal atrial fibrillation (PAF).

METHODS

We analyzed the procedural time, fluoroscopy time, contact force (CF), and initial pulmonary vein isolation (PVI) rate. After 6 months of follow-up, the success rate of ablation between the two groups was compared.

RESULTS

Compared to the Swartz sheath, using the Vizigo sheath can significantly reduce the total procedural time and fluoroscopy time and increase the overall average CF, especially in the anterior left pulmonary vein (LPV), superior LPV, posterior right pulmonary vein (RPV), and superior RPV. The proportion of CF within a reasonable range in the Vizigo group was significantly higher than that in the Swartz group, especially in the anterior LPV, posterior RPV, and superior RPV. Besides, the left, right, and bilateral initial PVI rates in the Vizigo group were significantly higher.

CONCLUSIONS

The visualized steerable sheath for PAF catheter ablation not only reduced radiation exposure but also significantly improved CF and initial PVI rate, all of which indicated an increased rate of successful ablation.