Near-zero Fluoroscopic Approach for Laser Balloon Pulmonary Vein Isolation Ablation: A Case Study

Prospective study of zero-fluoroscopy laser balloon pulmonary vein isolation for the management of atrial fibrillation

BACKGROUND

In recent years, there has been increased focus on the development of safe and effective strategies to minimize and ultimately eliminate fluoroscopy use in the electrophysiology lab due to the inherent risks to patients and staff associated with this imaging source. However, studies examining these innovative fluoroless strategies for pulmonary vein isolation (PVI) using catheters without direct 3D mapping system integration are lacking. We sought to develop a method to perform zero-fluoroscopy laser balloon PVI for patients with atrial fibrillation (AF), and to test the safety and efficacy of this approach.

METHODS

We developed a standardized method for performing PVI using the X3 laser balloon (LB) system, 3-dimensional electroanatomic mapping (3D-EAM) and intracardiac echocardiography (ICE) in a cohort of patients with symptomatic AF. The primary endpoint of the study was the ability to perform PVI without the use of fluoroscopy. Secondary outcomes were rate of successful transseptal puncture on first attempt, first pass isolation of target PVs, mean procedural time, active laser time to achieve PVI, need for use of supplemental energy sources, and procedural complication rates.

RESULTS

Two hundred consecutive patients undergoing PVI were recruited in the study. In the zero-fluoroscopy group, LB PVI was successfully performed in 100% of participants (n = 100) without the need for fluoroscopy. Transseptal access was achieved in 100% of cases on the first attempt. Successful first pass PVI was achieved in 360 of the 387 pulmonary veins attempted (93%). Mean procedural time was 68.2 ± 16.2 min in the zero-fluoroscopy group versus 67.5 ± 17.0 min in the conventional fluoroscopy group. PVI was able to be achieved in 100% of cases in both groups without need for use of supplemental energy sources. In the zero-fluoroscopy group there were minimal complications, with 3% of all cases having groin complications and 1 patient with a pericardial effusion noted post-procedure which was managed conservatively.

CONCLUSIONS

We demonstrated that successful zero-fluoroscopy LB PVI could be performed at a single high-volume center by experienced operators in an effective manner, without significant complications.

How to Perform a Completely Fluoroless Ablation

Radiation exposure related to electrophysiology catheter ablation procedures carries small but non-negligible stochastic and deterministic effects on health. Lead aprons can also place considerable pressure on the spinal column, resulting in potentially detrimental consequences. Fortunately, however, advancements in tools used for arrhythmia mapping and ablation have made it feasible to reduce or essentially eliminate the need for fluoroscopy, with no impact on the efficacy or safety of such procedures, as demonstrated by several long-term outcome studies. In this review, we describe our stepwise approach to safely and efficiently perform a completely fluoroless ablation.

Intracardiac Echocardiography to Guide Non-fluoroscopic Electrophysiology Procedures

Intracardiac echocardiography (ICE) is the most practical method for online imaging during electrophysiological procedures. It allows guiding of complex catheter ablation procedures together with electroanatomical mapping systems, either with minimal or with zero fluoroscopy exposure. Besides safe and reproducible transseptal puncture, ICE helps to assess location and contact of the tip of the ablation catheter relative to specific anatomical structures. Another option is visualization of the arrhythmogenic substrate in patients with ventricular arrhythmias. This article describes the clinical utility of ICE in non-fluoroscopic electrophysiology procedures more in detail.

Safety and Efficacy of Minimal- versus Zero-fluoroscopy Radiofrequency Catheter Ablation for Atrial Fibrillation: A Multicenter, Prospective Study

Radiofrequency catheter ablation (CA) is an effective treatment for atrial fibrillation (AF) that traditionally requires fluoroscopic imaging to guide catheter movement and positioning. However, advances in electroanatomic mapping (EAM) technology and intracardiac echocardiography (ICE) have reduced procedural reliance on fluoroscopy. We conducted a prospective registry study of 162 patients enrolled at five centers proficient in high-volume, minimal-fluoroscopy CA between March 2016 and March 2018 for the CA of symptomatic, drug-refractory paroxysmal, or persistent AF that sought to assess the safety and efficacy of minimal- versus zero-fluoroscopy AF CA. We evaluated procedural details, acute procedural outcomes and complications, and one-year follow-up data. All operators used an EAM system (CARTO^®; Biosense Webster, Irvine, CA, USA) and ICE. Ultimately, two patients did not pursue CA postenrollment. A total of 104 (66%) patients had paroxysmal AF with a mean ejection fraction of 58% ± 9%. Twenty-six (16.3%) patients were scheduled for repeat ablation. A total of 100 (63%) procedures were performed with zero fluoroscopy. The mean fluoroscopy time in the minimal-fluoroscopy group was 1.7 minutes ± 2.8 minutes. Further, the mean procedure duration was 192 minutes ± 37 minutes in the zero-fluoroscopy group and 201 minutes ± 29 minutes in the minimal-fluoroscopy group (p = 0.96). Pulmonary vein isolation was achieved in 153 patients (100%), with an acute procedural complication rate of 1.8%. One-year follow-up data were available for 152 (95%) patients with a mean follow-up time of 11.3 months ± 1.8 months. A total of 118 (76%) patients remained free from arrhythmia for up to 12 months, with no difference between the minimal- and zero-fluoroscopy cohorts (p = 0.18).