Abstract
Increasing awareness of the health risks associated with the exposure of patients and staff in the catheterization laboratory to radiation has encouraged the pursuit of efforts to reduce the use of fluoroscopy during catheter ablation procedures. Although nonfluoroscopic guidance of ablation catheters has been previously described, transseptal access is still perceived as the last remaining barrier to completely fluoroless ablations. This study examined the safety and effectiveness of transseptal puncture and radiofrequency (RF) catheter ablation using a completely fluoroless approach. Three hundred eighty-two consecutive cases that had undergone completely nonfluoroscopic RF catheter ablation were evaluated. Ablation procedures were performed for atrial fibrillation, atrial flutter, atrioventricular reentry tachycardia, and pulmonary vein complex/ventricular tachycardia. Transseptal puncture and RF ablation were conducted under three-dimensional electroanatomic mapping and intracardiac echocardiography image guidance. Fluoroless transseptal puncture and catheter ablation were completed successfully in all cases, with no intraoperative complications. One patient required minimal use of fluoroscopy to visualize sheath advancement through an existing inferior vena cava filter. Procedural time was approximately 2.2 hours from transvenous access until case conclusion; transseptal access was obtained within 28 minutes of procedure initiation. Arrhythmia was found to recur in 27% of cases on average three months after the procedure. We demonstrate the safety and effectiveness of a completely fluoroless transseptal puncture and RF ablation technique that eliminates radiation exposure and enables complex electrophysiology procedures to be performed in a lead-free environment.
Highlights
Fluoroscopic guidance is routinely used in electrophysiology procedures, such as catheter ablation treatments for cardiac arrhythmias, to facilitate the delivery of catheters and other devices
A total of 382 RF catheter ablation procedures were performed on 324 patients with atrial fibrillation (57% paroxysmal, 43% persistent) between February 2015 and October 2018
There was a history of previous transseptal puncture in 30.9% of patients; further, 15.2% of cases within this series were repeat ablation procedures
Summary
Fluoroscopic guidance is routinely used in electrophysiology procedures, such as catheter ablation treatments for cardiac arrhythmias, to facilitate the delivery of catheters and other devices. Conventional catheter ablation exposes patients to approximately 15 mSv of radiation, equivalent to 750 chest X-rays,[1] presenting a risk of fatal malignancies[2,3] or skin injuries that may occur after merely 60 minutes of low-level fluoroscopy.[1]. The recent adoption of fluoroscopy with an ultralow frame rate for ablation procedures has reduced patient radiation exposure to as low as 0.45 mSv,[4] operators and staff still face a significant lifetime cumulative effect of radiation. Novel Fluoroless Transseptal Puncture Technique for Lead-free Catheter Ablation cardiac electrophysiologists, which is estimated to be three times greater than that of diagnostic radiologists and nuclear medicine professionals, averages approximately 5 mSv per year[5] Lead apparel is intended to protect staff from the effects of radiation exposure, up to 44% of interventional cardiologists and electrophysiologists who wear these heavy shields experience spine, hip, knee, and ankle pain,[13,14,15] affecting work performance.[14,16]
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