Minimising radiation exposure in catheter ablation of ventricular arrhythmias

Abstract

Background Conventional fluoroscopy guided catheter ablation (CA) is an established treatment option for ventricular arrhythmias (VAs). However, with the complex nature of most procedures, patients and staff bare an increased radiation exposure. Near-zero or zero-fluoroscopy CA is an alternative method which could substantially reduce or even eliminate the radiation dose. Our aim was to analyse procedural outcomes with fluoroscopy minimising approach for treatment of VAs in patients with structurally normal hearts (SNH) and structural heart disease (SHD). Methods Fifty-two (age 53.4 ± 17.8 years, 38 male, 14 female) consecutive patients who underwent CA of VAs in our institution between May 2018 and December 2019 were included. Procedures were performed primarily with the aid of the three-dimensional electro-anatomical mapping system and intra-cardiac echocardiography. Fluoroscopy was considered only in left ventricular (LV) summit mapping for coronary angiography and when epicardial approach was planned. Acute and long-term procedural outcomes were analysed. Results Sixty CA procedures were performed. Twenty-five patients had SHD-related VAs (Group 1) and 27 patients had SNH (Group 2). While Group 1 had significantly higher total procedural time (256.9 ± 71.7 vs 123.6 ± 42.2 min; p < 0.001) compared to Group 2, overall procedural success rate [77.4% (24/31) vs 89.7% (26/29); p = 0.20)] and recurrence rate after the first procedure [8/25, (32%) vs 8/27, (29.6%); p = 0.85] were similar in both groups. Fluoroscopy was used in 3 procedures in Group 1 where epicardial approach was needed and in 4 procedures in Group 2 where LV summit VAs were ablated. Overall procedure-related major complication rate was 5%. Conclusions Fluoroscopy minimising approach for CA of VAs is feasible and safe in patients with SHD and SNH. Fluoroscopy could not be completely abolished in VAs with epicardial and LV summit substrate location.

Aegrescit medendo: orthopedic disability in electrophysiology - call for fluoroscopy elimination—review and commentary

“…There was no device interrogation evidence of dislodgement in all 46 patients with CRM devices that underwent AF ablation. Further obstacles to zero fluoroscopy in select patient groups have been identified in those that may require epicardial forms of VT ablation [7,46].…”

How Imaging Techniques Improve Ventricular Arrhythmia Ablation: A Multimodality-Based Approach

“…Additionally, ICE enables the monitoring of possible procedural complications (especially pericardial effusion, steam pops, thrombi, air embolism and various causes for intra-procedural hypotension) and the direct imaging of anatomical variations and intracavitary structures (i.e., papillary muscles, false chordae and moderator band) (Figure 3) that cannot be adequately imaged with the 3D EAM systems [67,68]. Previous studies showed that a completely zero-fluoro approach to catheter ablation is feasible and safe in most types of VAs even when SHD is present [69,70]. As anticipated, there are other advantages of ICE during the VAs mapping and ablation procedure given by the early detection of complications.…”

“…Its planning includes choice of access (endocardial vs. epicardial; transeptal vs. retroaortic) to the chamber of interest and ablation strategy. For example, for structural heart disease-related VTs, we usually use a transseptal approach to access the left ventricle with the aim of reducing or abolishing fluoro exposure, as previously described [69,93].…”

Zero-Fluoroscopy Cardiac Ablation: Technology Is Moving Forward in Complex Procedures—A Novel Workflow for Atrial Fibrillation

“…Despite the meaningful improvements in the field of arrhythmia mapping and ablations, ventricular tachycardia and AF still represent a great challenge for electrophysiologists. Although these arrhythmias are characterized by a greater complexity in terms of procedural maneuvers and activation mapping, newer mapping systems proved to be safe and effective approaches even for these arrhythmias [ 5 ]. Recently, catheter ablation has become increasingly adopted for symptomatic AF.…”