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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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Coluccia G, Accogli M, Guido A, Chiarillo MV, Panico V, Sergi C, Chiuri MD, Ria I, Zonno FC, Gemma D, Palmisano P. Concomitant His bundle pacing and atrioventricular junction ablation: feasibility of a three-dimensional mapping system-only-guided, zero-fluoroscopy approach. J Cardiovasc Med (Hagerstown) 2021; 22:e21-e23. [PMID: 34009180 DOI: 10.2459/jcm.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Michele Accogli
- Cardiology Unit, 'Card. Giovanni Panico' Hospital, Tricase, Italy
| | - Alessandro Guido
- Cardiology Unit, 'Card. Giovanni Panico' Hospital, Tricase, Italy
| | | | - Vincenzo Panico
- Cardiology Unit, 'Card. Giovanni Panico' Hospital, Tricase, Italy
| | - Cesario Sergi
- Cardiology Unit, 'Card. Giovanni Panico' Hospital, Tricase, Italy
| | | | | | | | - Daniele Gemma
- Anaesthesia and Intensive Care Unit, 'Card. Giovanni Panico' Hospital, Tricase, Italy
| | - Pietro Palmisano
- Cardiology Unit, 'Card. Giovanni Panico' Hospital, Tricase, Italy
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A standardized stepwise zero-fluoroscopy approach with transesophageal echocardiography guidance for atrial fibrillation ablation. J Interv Card Electrophysiol 2021; 64:629-639. [PMID: 34757547 DOI: 10.1007/s10840-021-01086-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE There is growing interest in performing fluoroless radiofrequency ablation (RFA) for atrial fibrillation (AF) due to the increasing awareness of risk associated with radiation exposure of patients and professional staff. The present study aimed to evaluate the feasibility, safety, and efficacy of a stepwise transesophageal echocardiography (TEE)-guided zero-fluoroscopy approach (ZFA) for RFA. METHODS Consecutive patients (n = 111) referred for AF-ablation were prospectively enrolled with intention to RFA with ZFA. Procedural outcomes were compared with historical controls (HCs) after 1:1 propensity score matching. ZFA success was considered when no X-ray was utilized to perform the whole procedure. RESULTS ZFA success was achieved in 80 (72%) procedures. BMI > 35 kg/m2 resulted in the only independent predictor of ZFA failure (OR = 6.10, 95% CI 1.15-46.49, p = 0.04). In comparison to HCs, a significant reduction in radiation exposure was observed in the ZFA group: fluoroscopy time (3 vs. 63 s, p < 0.001), total emitted fluoroscopy dose (0.2 vs. 6.0 mGy, p < 0.001), dose area product (0.04 vs. 1.4 Gy*cm2, p < 0.001), and effective dose (0.8 vs. 27.2 mSv*100, p < 0.001). Complete pulmonary vein isolation was achieved in all procedures. No difference was observed between the groups in in-hospital complication rate (0.9% vs. 1.8%, p = 0.99). CONCLUSIONS This is the largest study proving procedural feasibility, safety, and efficacy of TEE-guided AF-ablation with a complete or near-complete avoidance of radiological exposure, without using intracardiac echocardiography.
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Anselmino M, Ballatore A, Giaccardi M, Agresta A, Chieffo E, Floris R, Racheli M, Scaglione M, Casella M, Maines M, Marini M, De Ferrari GM, De Ponti R, Del Greco M. X-ray management in electrophysiology: a survey of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). J Cardiovasc Med (Hagerstown) 2021; 22:751-758. [PMID: 34009182 DOI: 10.2459/jcm.0000000000001210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists. METHODS AND RESULTS A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (P = 0.009) and working in centers performing pediatric procedures (P = 0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, P = 0.022), registration of the delivered dose in each procedure (92% vs. 67%, P = 0.009), and X-ray equipment optimization (50% vs. 36%, P = 0.006). CONCLUSION Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health.
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Affiliation(s)
- Matteo Anselmino
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Andrea Ballatore
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Marzia Giaccardi
- Cardiology and Electrophysiology Unit, Department of Medicine, 'Santa Maria Nuova' Hospital, Florence
| | | | | | - Roberto Floris
- Ospedale di Nostra Signora di Bonaria, San Gavino Monreale
| | | | - Marco Scaglione
- Division of Cardiology, 'Cardinal Massaia' Hospital, Asti, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital, Ancona
| | | | | | - Gaetano Maria De Ferrari
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo-University of Insubria, Varese, Italy
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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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