Fluoroscopy-Free Pulmonary Vein Isolation in Patients with Atrial Fibrillation and a Patent Foramen Ovale Using Solely an Electroanatomic Mapping System

Abstract

IntroductionThe advent of electroanatomical mapping (EAM) systems for pulmonary vein isolation (PVI) has dramatically decreased radiation exposure. However, the need for some fluoroscopy remains for obtaining left atrial (LA) access. The aim was to test the feasibility of fluoroscopy-free PVI in patients with atrial fibrillation (AF) and a patent foramen ovale (PFO) guided solely by an EAM system.MethodsConsecutive patients with AF undergoing PVI and documented PFO were studied. An EAM-guided approach without fluoroscopy and ultrasound was used. After completing the map of the right atrium, the superior vena cava and the coronary sinus, a catheter pull-down to the PFO was performed allowing LA access. The map of the LA and subsequent PVI was also performed without fluoroscopy.Results30 patients [age 61±12 years, 73% male, ejection fraction 0.64 (0.53–0.65), LA size in parasternal long axis 38±7 mm] undergoing PVI were included. The time required for right atrial mapping including transseptal crossing was 9±4 minutes. Total procedure time was 127±37 minutes. Fluoroscopy-free PVI was feasible in 26/30 (87%) patients. In four patients, fluoroscopy was needed to access (n = 3) or to re-access (n = 1) the LA. In these four patients, total fluoroscopy time was 5±3 min and the DAP was 14.9±13.4 Gy*cm2. Single-procedure success rate was 80% (24/30) after a median follow-up of 12 months.ConclusionIn patients with a documented PFO, completely fluoroscopy-free PVI is feasible in the vast majority of cases.

Fluoroscopy-free Atrial Transseptal Puncture

“…Second, in this small group of patients, there were no significant complications, though the technique should be validated and refined in larger cohorts in the future. Additionally, the TSP fluoroscopy times in this small group of patients were higher than previously reported values; 5,9,10,12 this may be due to the assistance of general cardiology fellows, who generally require longer fluoroscopy times for TSP than an experienced cardiologist, and the addition of patients with either paroxysmal or persistent AF, the latter of which may require longer procedure times and fluoroscopy use.…”

“…4–7,9–13,15–19 Kühne et al advocate using transesophageal echocardiography (TEE) prior to TSP access, 10 whereas several groups describe intra-procedural TEE-guided TSP access with a high degree (97–100%) of AF-free event rates during respective follow-up periods. 13,16,17 Other groups have described TEE-guided TSP in combination with fluoroscopy to minimise radiation exposure, however reported outcomes from this approach demonstrated comparatively reduced AF-free success rates (75–85%).…”

Nonfluoroscopic catheter ablation of paroxysmal atrial fibrillation

“…Kuhne et al. described a case series in which nonfluoroscopic LA access was obtained through the patent foramen ovale . We did not use this approach for our patients, even if they had a foramen ovale, because its cranial and anterior locations compromise the catheter contact and stability.…”

“…However, concerns about the safety of this approach have been raised. A few single‐center studies with relatively small cohorts have shown that the zero‐fluoroscopy approach using 3D mapping systems, ICE, and computed tomography (CT) imaging integration does not compromise the safety and efficacy of PV isolation (PVI) . The aim of this multicenter study was to assess the safety and clinical efficacy of nonfluoroscopic radiofrequency (RF) catheter ablation without CT or magnetic resonance imaging (MRI) integration and without using contrast media for the treatment of AF in a large cohort of patients.…”

Feasibility of zero or near zero fluoroscopy during catheter ablation procedures

“…Other groups have shown feasibility of fluoroscopy-free pulmonary vein isolation in 26 out of 30 consecutive patients with a documented PFO [15]. Bulava et al [16] demonstrated the feasibility of zero fluoroscopy ablation in 40 patients with paroxysmal AF using ICE imaging and three-dimensional EAM mapping with contact force measurements.…”