Fluoroless Catheter Ablation of Atrial Fibrillation: Integration of Intracardiac Echocardiography and Cartosound Module

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.

Intracardiac Echocardiography-Applications in the Electrophysiology and the Cardiac Catheterization Labs

Background. Intracardiac echocardiography (ICE) is routinely used in cardiac electrophysiology and catheterization labs. It plays a vital role in understanding cardiac anatomy, procedural planning, and early identification of complications. In this review, we describe the utility of ICE for procedures in the electrophysiology lab, including atrial fibrillation ablation, left atrial appendage occlusion device implantation, and cardiac implantable electronic device (CIED) extraction. Intracardiac echocardiography also helps in the identification of complications such as pericardial effusion, pulmonary vein stenosis, and left atrial appendage thrombus. Compared with traditional echocardiographic modalities such as transesophageal echocardiogram (TEE), ICE has equivalent image quality, requires less sedation, and possesses no risk of esophageal injury. The disadvantages of ICE include a learning curve and necessity for central vascular access.

Initial experience with zero-fluoroscopy pulmonary vein isolation in patients with atrial fibrillation: single-center observational trial

Pulmonary vein isolation (PVI) stands as a widely practiced cardiac ablation procedure on a global scale, conventionally guided by fluoroscopy. The concurrent application of electroanatomical mapping systems (EAMS) and intracardiac echocardiography offers a means to curtail radiation exposure. This study aimed to compare procedural outcomes between conventional and our initial zero-fluoroscopy cases in patients with paroxysmal or persistent atrial fibrillation (AF), undergoing point-by-point PVI. Our prospective observational study included 100 consecutive patients with AF who underwent point-by-point radiofrequency PVI. The standard technique was used in the first 50 cases (Standard group), while the fluoroless technique was used in the subsequent 50 patients (Zero group). The zero-fluoroscopy approach exhibited significantly shorter procedural time (59.6 ± 10.7 min vs. 74.6 ± 13.2 min, p < 0.0001), attributed to a reduced access time (17 [16; 20] min vs. 31 [23; 34.5] min, p < 0.001). Comparable results were found for the number of RF applications, total ablation energy, and left atrial dwelling time. In the Zero group, all procedures were achieved without fluoroscopy, resulting in significantly lower fluoroscopy time (0 [0; 0] sec vs. 132 [100; 160] sec, p < 0.0001) and dose (0 [0; 0] mGy vs. 4.8 [4.1; 8.2] mGy, p < 0.0001). The acute success rate was 100%, with no major complications. Zero-fluoroscopy PVI is feasible, safe, and associated with shorter procedure times compared to the standard approach, even in cases without prior experience in zero-fluoroscopy PVI.

Catheter ablation of atrial fibrillation: anticipating and avoiding complications

INTRODUCTION

Atrial fibrillation (AF) ablation is being performed more frequently and more widely at more centers. This stems from several factors including 1) demographic forces leading to an increased prevalence of the arrhythmia; 2) greater availability of ambulatory monitoring making diagnosis more frequent; 3) relative inefficacy of medications; and 4) improved safety and efficacy of the procedure. Ablation has become much more streamlined and reproducible than a decade ago, but life-threatening complications may still arise.

AREAS COVERED

This review will focus on awareness, avoidance, and early recognition and management of complications of AF ablation. This literature review is challenged by differing approaches to ablation of AF both within a center and between centers, the rapid improvement of technology making the outcomes associated with a therapeutic strategy begun a few years prior relatively obsolete, as well as the heterogeneity of the population being studied.

EXPERT OPINION

Newer technologies are on the horizon which will allow us to ablate AF with increasing efficacy, efficiency, and hopefully safety. Such new technology and changing usage mandate vigilance to avoid complications.

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.

[Electromagnetic interference in 3D-mapping procedures]

Catheter-based ablation is nowadays a safe and widespread procedure for the treatment of cardiac arrhythmia. This requires exact anatomical knowledge both before and during the examination and is an important prerequisite for targeted treatment. At the beginning of the era of interventional catheter-based treatment, fluoroscopy was the only and usual means of visualization, whereas in the middle of the 1990s continuous 3D-mapping systems were developed for the non-fluoroscopic examination of patients. The correct use of these 3‑D systems, which non-fluoroscopically visualize the catheter and mostly identify mechanisms of arrhythmia in great detail, nowadays makes an important contribution to successful interventional catheter treatment of arrhythmia; however, it is not uncommon for patients with ventricular arrhythmia to also carry implanted electronic devices, such as pacemakers, defibrillators or less frequently left ventricular hemodynamic support systems. All implantable devices lead to electromagnetic interferences, which can complicate the diagnostics and treatment during electrophysiological examinations and ablation. This article addresses the adversities and experiences associated with magnet-based 3D systems and implantable electromagnetically active cardiac devices.