BackgroundZero-fluoroscopy procedures have become increasingly popular in electrophysiological interventional surgery. As a core technology for achieving zero-fluoroscopy, traditional transseptal puncture (TSP) under intracardiac echocardiography (ICE) guidance has several limitations that hinder its widespread application and further development. This study aims to introduce and evaluate the efficacy and safety of a modified TSP technique developed based on clinical practice, which has the potential to overcome the shortcomings of traditional ICE-guided TSP.MethodsA total of 77 patients who underwent radiofrequency ablation for atrial fibrillation (AF) between March 1, 2022 and February 28, 2023 were enrolled. Among them, 44 patients underwent traditional ICE-guided TSP, and 33 patients underwent modified ICE-guided TSP. The success rate, numbers of puncture attempts, puncture duration, proportion of ideal puncture location and incidence of puncture-related complications were recorded.ResultsThere were no significant differences in baseline characteristics between the two groups. Compared with the traditional group, the modified group had a significantly lower number of puncture attempts (1.25 ± 0.44 vs.1.06 ± 0.24, p = 0.018) and shorter puncture duration (2.52 ± 0.83 vs.3.94 ± 2.15 min, p = 0.001). No significant differences were observed in TSP success rate, proportion of ideal puncture location or incidence of puncture-related complications between the two groups.ConclusionsThis study presents a modified ICE-guided TSP technique using an ablation catheter for guidance. This technique simplifies the operation of the puncture component and eliminates the need for ICE view tracking. It offers advantages including high success rate, favorable safety profile, simple procedural steps, ease of use, and a short learning curve, making it worthy of clinical promotion and application.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12872-025-05340-0.

Catheter ablation is the key element of rhythm control in atrial fibrillation (AF), yet its reliance on fluoroscopy exposes patients and operators to radiation. A fluoroscopy-free procedure is possible using intracardiac echocardiography (ICE), but due to high cost, the learning curve, and added procedural steps, ICE is rarely used in Europe. Similarly, non-fluoroscopic tracking systems (NCTS) like MediGuide for near-zero fluoroscopy ablation have fallen out of favor. The SHORT LOOK study evaluates the efficiency and safety of a streamlined near-zero fluoroscopy workflow for first-time pulmonary vein isolation (PVI) based solely on advanced 3D mapping and an ultra-low-dose fluoroscopy protocol. The aim was to determine whether near-zero fluoroscopy ablation can be achieved using conventional techniques, enabling broader adoption in modern electrophysiology labs. The SHORT LOOK registry is a single-center, investigator-initiated prospective standard-of-care study enrolling consecutive patients undergoing first-time PVI for AF. A total of 450 patients were included in the final analysis. The workflow used a 3D mapping system (CARTO3, J&J MedTec) with an ultra-low-dose fluoroscopy protocol, without adjunctive technologies. Baseline assessments included medical history, physical examination, labs, ECG, EQ-VAS, and echocardiography. The primary efficacy endpoint was median fluoroscopy time; the primary safety endpoint was a composite of procedure-related death or cardiovascular, neurological, or vascular events. Secondary endpoints included 1-year freedom from atrial arrhythmia > 30 s, skin-to-skin time, fluoroscopy dose, and proportion of procedures with fluoroscopy < 1 min. Patients were followed up for 1 year. The SHORT LOOK cohort (n = 450) achieved a median procedural time of 57 min, with median fluoroscopy time of 26 s and dose of 9.1 µGy*m². The complication rate was < 1% and no major adverse events occurred. Follow-up revealed that for paroxysmal atrial fibrillation, 86.1% were AT/AF-free at 3 months, decreasing to 82.6% at 12 months, while for persistent atrial fibrillation, the rates were 77.3% and 71.7%, respectively, confirming sustained rhythm control. EQ-VAS analyses revealed a significant improvement in health-related quality of life from baseline (p < 0.05). Compared to a historical NCTS group, our workflow leads to similarly low fluoroscopy times and radiation doses. The streamlined workflow for initial atrial fibrillation ablation, which nearly eliminates fluoroscopy, demonstrates a significant reduction in both fluoroscopy time and radiation dose. This approach is feasible in any electrophysiology laboratory and offers a practical method for performing rapid, safe, and effective AF ablations while maintaining minimal radiation exposure-all without the need for additional adjunctive technologies.

Left atrial appendage closure (LAAC) is an established therapy for stroke prevention in patients with nonvalvular atrial fibrillation (AF) who cannot tolerate long-term oral anticoagulation (OAC). In Japan, LAAC was introduced in 2019 and has been performed in more than 10,000 cases a0s of 2025. Although indications remain limited to high-risk patients with OAC contraindications, procedural volume continues to rise. This review outlines the current status, remaining challenges, and future perspectives of LAAC, with emphasis on the WATCHMAN device. The WATCHMAN FLX and FLX Pro have enhanced procedural safety, sealing efficacy, and anatomical adaptability. Large clinical trials and registries have confirmed stroke prevention efficacy comparable to OAC with fewer hemorrhagic complications. However, device-related thrombus (DRT) and peri-device leak (PDL) remain major concerns, underscoring the need to optimize postprocedural antithrombotic therapy. The Amulet device provides superior ostial sealing through its dual-disk design but is technically more complex and associated with higher procedural complication rates. Intracardiac echocardiography (ICE) has emerged as a less invasive alternative to transesophageal echocardiography, reducing anesthesia requirements and enabling same-session LAAC with AF ablation. The development of pulsed field ablation (PFA) further improves the feasibility of such integrated approaches. Future priorities include risk stratification for DRT, individualized antithrombotic strategies, and broader indications encompassing OAC-resistant embolic stroke and other high-risk populations. With advancing technology, ICE-guided, minimally invasive workflows and integrated ablation-occlusion procedures are expected to establish LAAC as a key component of comprehensive AF management.

Catheter ablation of ventricular arrhythmias originating from papillary muscles (PMs) is challenging due to complex anatomical structures, dynamic motion, and potential deep intramural origin. Intracardiac echocardiography (ICE) has emerged as an essential tool for guiding catheter ablation. We report a case of premature ventricular complexes arising from the anterolateral PM of the left ventricle, successfully ablated under intraprocedural ICE guidance. This case underscores the key role of ICE in overcoming the anatomical challenges of PM ablation and ensuring procedural precision and safety.

BackgroundCavotricuspid isthmus (CTI) ablation is the preferred treatment for typical atrial flutter, performed using various techniques. This study aimed to compare procedural and follow-up data between point-by-point and continuous “dragging” radiofrequency (RF) catheter ablation methods.MethodsThis retrospective, single-center study included 121 consecutive patients who underwent first-time RF CTI ablation for typical atrial flutter between January 2023 and August 2024. Patients were assigned to point-by-point (n = 49) or continuous dragging (n = 72) groups. All procedures were performed under conscious sedation using irrigated-tip catheters and intracardiac echocardiography. Patients with prior CTI ablation, cardiac surgery, or concomitant ablation were excluded. Procedural and follow-up outcomes were compared between groups.ResultsThe continuous dragging technique significantly shortened the time from the first to last ablation [12 (6; 27) min vs. 18 (11; 32) min; p < 0.05] and the time from the first ablation to the first CTI block [9 (8; 17) min vs. 13 (8; 25) min; p < 0.01]. Additionally, total ablation time [484 (285; 774) s vs. 704 (449; 955) s; p < 0.01] and energy usage [20,613 (11,191.5; 33,257.3) J vs. 25,717 (17,251.8; 36,420) J; p < 0.05] were lower in the dragging group. The dragging technique also increased the first pass block rate (69.4% vs. 46.2%; p < 0.01). There was no significant difference in overall procedure time [55 (46; 66) min vs. 58.5 (45; 72) min; p = 0.46], fluoroscopy duration (41 ± 6 s vs. 55 ± 8 s; p = 0.14), or acute reconnection rate (27.8% vs. 30.8%; p = 0.80). Both groups achieved a 100% acute success rate with no major complications. There was no significant difference in the rate of recurrence between the two groups (2.77% vs. 2.04%, p = 1.0) during the long-term follow-up (13.4 ± 3.8 months).ConclusionThe continuous “dragging” RF ablation technique for CTI ablation in typical atrial flutter enhances procedural outcomes compared to the point-by-point method, demonstrating reduced ablation time, lower energy consumption, and a higher first pass block rate, all without compromising efficacy or safety.

Ablation in persistent atrial fibrillation: High long-term success with pulsed field ablation using a strict protocol.

Advantages of intravascular ultrasound guidance for TIPS: Systematic review of the literature and a single institution propensity score-matched study.

Visualization of a Novel Tissue Proximity Indicator on a Variable-Loop PFA Catheter with Intracardiac Echocardiography

Percutaneous closure of a left ventricular pseudoaneurysm using a post-infarct VSD Device guided by intracardiac echocardiography

Concomitant pulmonary vein isolation (PVI) and left atrial appendage (LAA) occlusion (LAAO) have become frequently used therapies. Pulsed-field ablation (PFA), will likely be used for combined PVI plus LAAO procedures. However, there may be concerns regarding the malposition of the LAAO device attributed to the potential tissue edema after PVI. We aimed to compare the LAA's size before and after PVI performed with the pentaspline catheter, measured intraprocedural by intracardiac echocardiography or transesophageal echocardiography. We conducted a multicenter, prospective, observational study investigating PVI using the Farapulse system. The anteroposterior diameter of the left-sided pulmonary vein (LPV), left atrial ridge, and LAA were measured before and after the PFA. We enrolled 91 patients aged 63 ± 10 years, 36% were women, and 47% had paroxysmal AF. The most common comorbidities was hypertension (59%). Procedure time and left atrial dwell time were 65 (52-80) min, and 27 (24-32) min, respectively. The diameter of the LAA was not different before and after the PVI (15 [13-18] and 16 [13-19], respectively; p = 0.756). On the other hand, the diameter of the left atrial ridge (7 [6-8] and 8 [6-8]) and the LPV (13 [10-15] and 13 [11-15]) was smaller before ablation compared to the diameter after PVI (p < 0.0001 for both). No major complications occurred. LAA anteroposterior diameter does not change after PVI with PFA. Although there is a significant change in the anteroposterior diameters of the LPV and the left atrial ridge, it does not seem clinically relevant. If significant edema formation is detected in a single case after PVI, postponing the LAAO procedure should be considered.

Multicenter Practice of Non/Minimized Fluoroscopy Ablation for Paroxysmal AF in China: The PAF-ICE Trial.

Comparative outcomes of intracardiac versus transesophageal echocardiography for left atrial appendage occlusion

BMP10 attenuates age-related atrial fibrillation susceptibility through improving mitochondrial function in atrial cardiomyocytes.

Anatomical studies have documented a close topographical relationship between the ganglionated plexi (GP) containing parasympathetic inputs to the sinus node (SN) and atrioventricular node (AVN) and the epicardial fat pads (FPs) within the Waterston's interatrial groove. We aimed to investigate the feasibility and outcomes of a novel anatomical approach to cardioneuroablation (CNA) that targets the atrial areas adjacent to the interatrial FPs identified with intracardiac echocardiography (ICE). About 17 patients [37.3 ± 10.2 years, 47% female] undergoing CNA for recurrent vasovagal syncope and documented sinus pauses (n = 13, 76%) and/or AVN block (AVB, n = 4, 16%) were included. The right superior RS-FP containing the RS-GP (target for SN vagal denervation) and the right inferior RI-FP containing the RI-GP (target for AVN vagal denervation) were identified with ICE and reconstructed on a 3D electroanatomic map. At baseline, all patients had provocable sinus pauses/AVB with extracardiac high-frequency vagal stimulation (ECVS). The target FPs could be identified in all patients and were adjacent to septal LA and RA sites covering an average surface area of 3.7 ± 1.4 cm2 and 2.97 ± 1.21 cm2, respectively. A total of 33 ± 15 RF ablations (30-40W, 60 s) were delivered to cover the target LA/RA area. A > 25% shortening of the PP interval was observed within the first 1-2 RF lesions in all cases. After ablation, complete abolition of sinus pauses/AVB response with ECVS was achieved in all patients, and 2 mg of atropine infusion resulted in no PP/PR interval change. After a median follow-up of 12 months (range 4-25 months), 16 patients (94%) remained free of recurrent symptoms (1 patient underwent repeat CNA for recurrent pre-syncope and AVB, 1 patient underwent PPM implant following ECG recording of asymptomatic diurnal AVB). An ICE-guided anatomical approach to CNA targeting visible FPs at the Waterston's groove is a feasible and effective strategy to achieve SN/AVN vagal denervation, with good outcomes at mid-term follow-up.

ABSTRACT Aims Radiation‐free catheter ablation is feasible with modern electroanatomic mapping systems. We aimed to evaluate the feasibility, safety, and outcomes of non‐fluoroscopic ablation (NFA) in patients with congenital heart disease (CHD). Methods We retrospectively reviewed CHD patients who underwent NFA between November 2016 and January 2025. All procedures were performed using the CARTO 3D electroanatomic mapping system. Atrial, ventricular, and aortic geometries were reconstructed as needed. Catheter navigation and sheath placement were guided without fluoroscopy; intracardiac echocardiography was used selectively. Results Forty‐two patients (23 females) with CHD underwent NFA. The median age was 14 years (range 4–56), and median weight was 55 kg (range 19–145). Twenty‐one patients had mild, 16 moderate complexity and 5 great complexity CHD. Arrhythmia mechanisms included AVNRT (14%), manifest WPW (21%), high‐risk WPW without SVT (5%), concealed pathway AVRT (26%), AFL (12%), AT (14%), and VT (7%). Two patients had both AVNRT and AVRT. Acute success was achieved in all cases without fluoroscopy or acute complications. Over a median 48‐month follow‐up, three patients had recurrences: one with WPW and Ebstein anomaly, one with ASD/PLSVC and concealed pathway, and one with dual arrhythmia substrates. Conclusion Zero‐fluoroscopy ablation of arrhythmias in select patients with mild moderate or great complexity CHD is feasible, safe, and effective, offering high acute success and low recurrence while eliminating radiation exposure.

Background: As left atrial appendage closure (LAAC) becomes more widely adopted for stroke prevention in patients with atrial fibrillation, optimizing peri-procedural imaging has gained increasing clinical relevance. While transesophageal echocardiography (TEE) remains the standard imaging modality, intracardiac echocardiography (ICE) has emerged as a viable alternative. This umbrella review evaluated whether ICE provides comparable procedural outcomes to TEE and examined differences in safety and post-procedural complications based on the current evidence. Methods: To identify relevant studies for inclusion in this umbrella review, a comprehensive search was conducted across databases, including PubMed, Cochrane Library, and Google Scholar. The GRADE (Grading of Recommendations, Assessment, Development and Evaluations) method, a widely accepted tool for assessing the quality of evidence and strength of recommendations in systematic reviews, was utilized to assess the overall certainty of the evidence comprehensively. Furthermore, the quality of the included reviews underwent evaluation by applying the AMSTAR 2 and the New Castle Ottawa scale. Results: This review incorporates findings from seven systematic reviews and meta-analyses. In terms of procedural success, the analysis showed no significant difference between intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) (RR [95% CI]: 1.01 [1.00, 1.02], I2: 0%, p-value: 0.21). Regarding peri-procedural complications, the analysis indicated that ICE was associated with a significantly lower risk compared to TEE (RR [95% CI]: 0.79 [0.67, 0.94], I2: 0%, p-value: 0.008). Regarding the residual interatrial septal defects (IASDs), the analysis revealed that ICE was linked to a significantly higher risk of residual IASDs compared to TEE (RR [95% CI]: 1.97 [1.45, 2.68], I2: 0%, p-value: &lt;0.0001). Conclusion: In conclusion, ICE is a potentially beneficial substitute for TEE in the context of LAAC, as it decreases overall complications. However, whereas literature provides evidence for the advantages of ICE, comparative studies demonstrate that ICE and TEE have equal efficacy and safety profiles. This highlights the need for additional future evidence-based trials to evaluate each strategy comparative advantages in LAAC procedures thoroughly.

Introduction: Transesophageal echocardiography (TEE) has been widely used for imaging guidance during Transcatheter aortic valve replacement (TAVR) . However, the use of intracardiac echocardiography (ICE) is being recognized as a promising alternative imaging modality without the need for general anesthesia while providing high-resolution images. Real-world data on clinical outcomes comparing TEE- and ICE-directed TAVR remains limited. This study aimed to explore the in-hospital outcomes associated with ICE- versus TEE-guided TAVR using the US National Inpatient Sample (NIS). Methods: Using the NIS database from 2020 to 2022, we found adult patients who underwent TAVR with either TEE or ICE guidance. The possible confounders were adjusted through multivariable regression analyses. The evaluated outcomes included all-cause in-hospital mortality and complications such as atrial fibrillation, ventricular fibrillation, cardiogenic shock, acute kidney injury (AKI), stroke, and procedural complications. A p-value of &lt;.05 was considered significant. Results: In a subpopulation of 9,248 patients, 85.9% (n=7,947) had TEE-guided and 14.1% (n=1,301) had ICE-guided TAVR. Majority of the population were males (57% vs 42%) and whites (87%) and the mean age group was 77 years. On unadjusted analysis, ICE-guided TAVR was associated with lower all-cause mortality (0.7% vs 1.7%, p=0.012), ventricular fibrillation (0.1% vs 0.9%, p=0.004), cardiogenic shock (1.3% vs 3.2%, p&lt;0.0001), and AKI (6.7% vs 12.2%, p&lt;0.0001). After adjustment, ICE-guided TAVR remained significantly associated with reduced odds of ventricular fibrillation (adjusted OR 0.22; 95% CI: 0.05–0.91; p=0.037), cardiogenic shock (aOR 0.48; 95% CI: 0.28–0.83; p=0.01), and AKI (aOR 0.65; 95% CI: 0.48–0.87; p=0.004) while the periprocedural complication rates including pericarditis, pericardial effusion and tamponade, pneumothorax, dissection and pacemaker implantation remained similar in both the groups. The ICE group had a mean length of stay that was 1.38 days shorter (2.65 vs 4.03 days, p&lt;0.001), and the total hospitalization cost was significantly lower by $57,595 (ICE: $203,710 vs TEE: $266,105; p&lt;0.001). Conclusions: ICE-guided TAVR was associated with favorable in-hospital outcomes, reflecting lower rates of ventricular fibrillation, cardiogenic shock, and AKI, as well as significantly shorter hospital stays and reduced costs, compared to TEE-guided TAVR.

Introduction: Intracardiac echocardiography (ICE) has emerged as a potentially valuable tool during ventricular tachycardia (VT), offering real-time visualization of cardiac anatomy and the catheter–tissue interface. Despite its theoretical benefits, data on the efficacy of ICE-guided VT ablation remains limited. We conducted a meta-analysis to systematically evaluate the impact of ICE on procedural success, complication rates, and long-term outcomes in VT ablation. Methods: A total of 1,616 studies were identified through a systematic search of PubMed and Embase up to May 2025. Three observational studies met the inclusion criteria and were included in the analysis. Primary outcomes included cardiovascular (CV)-related readmission, ventricular tachycardia (VT)-related readmission, major complications (cardiac tamponade, vascular injury, thromboembolism, major bleeding requiring transfusion), and repeat VT ablation. Using the Mantel-Haenszel method, a random-effects model was employed to calculate odds ratio (ORs) with corresponding 95% confidence intervals (CIs) for statistical significance. Higgins' I^2 was used to analyze heterogeneity. Results: Three studies involving 4,473 patients were included in the analysis. Ventricular tachycardia (VT) ablation guided by intracardiac echocardiography (ICE) was associated with a significantly lower incidence of cardiovascular (CV)-related readmissions (OR 0.78, 95% CI 0.67–0.92; p = 0.002). While VT ablation with ICE did not show any significant difference in major complications (OR 0.79, 95% CI 0.39–1.60; p = 0.5) , VT-related readmissions (OR 0.85, 95% CI 0.69–1.04; p = 0.10), and repeat VT ablation (OR 1.08, 95% CI 0.73–1.58; p = 0.71). Conclusion: Intracardiac echocardiography (ICE) use during catheter ablation of ventricular tachycardia (VT) showed reduced incidence of CV-related readmissions, however there were no significant statistical differences in VT- related readmissions, repeat VT ablation and major complications between the two groups. Further observational studies and RCTs are needed to better understand the benefits of intracardiac echocardiography in catheter ablation of ventricular tachycardia.

Background: Catheter ablation of typical atrial flutter (AFL) typically relies on femoral venous access. Inferior vena cava (IVC) interruption is a congenital anomaly that complicates right heart access. Alternative approaches, including jugular or axillary access have been described, but catheter stability and limited intraprocedural imaging are challenges. We present a novel case of AFL ablation using superior venous access for mapping and ablation paired with femoral access for intracardiac echocardiography (ICE) from the azygous vein. Description of Case: A 66-year-old woman with paroxysmal AFL and dual-chamber pacemaker presented with symptomatic AFL and variable AV block. A prior ablation attempt was aborted after bilateral femoral access attempts revealed interrupted IVC with anomalous SVC return via a dilated azygous vein. CT scan confirmed IVC interruption and azygous continuation coursing posterior to the left atrium. A second ablation attempt succeeded using superior access via the right internal jugular (RIJ) and left axillary vein (LAV) to advance ablation and coronary sinus catheters. An ICE catheter was introduced via femoral vein and navigated to the thoracic azygous vein imaging directly behind the heart. This gave excellent imaging of the right atrium and cavotricuspid isthmus (CTI). Ablation with a contact-force irrigated catheter via the LAV improved catheter stability compared to the RIJ approach. Discussion: This is the first report using ICE from the azygous vein via the femoral route for intraprocedural imaging of CTI ablation. The posterior trajectory of the azygous vein enabled ICE imaging in planes similar to transesophageal echocardiography. Superior access from RIJ and LAV allowed mapping and ablation despite the absence of IVC continuity. Ablation on the CTI with a superior approach is challenging. Reduced catheter contact and stability can result in breakthrough of the lesion set and recurrence of AFL. ICE provides visual feedback to ensure catheter contact and stability. This approach overcomes several limitations in patients with interrupted IVC. Conclusion: In patients with IVC interruption, superior venous access for catheter manipulation combined with transfemoral ICE catheter placement in the azygous vein is a novel, effective strategy for AFL ablation. This technique enables high-resolution imaging and improved catheter stability, expanding options for successful AFL ablation in patients with complex venous anatomy.

Background: Electroanatomic mapping (EAM) guidance for endomyocardial biopsies (EMB) has been suggested to be feasible and safe, but the diagnostic yield remains unclear for cardiomyopathies. Objective: We aimed to evaluate the diagnostic efficacy of EAM and intracardiac echocardiography (ICE)-guided EMBs. Methods: We retrospectively reviewed patients who underwent EMB from August 2018 to July 2024. EMB was guided by EAM using CARTO system (Biosense Webster, Irvine, CA), and ICE. After accessing the right femoral vein, samples (3-6 per suspected site) were collected using a disposable bioptome and steerable sheath. For left ventricular (LV) biopsies, we used a transseptal approach, and for atrial biopsies, we targeted the atrial septum. In cases of abnormal EAM, multiple samples were taken from the identified areas. When EAM was normal, biopsy targeting was guided by adjunctive imaging. EMB was considered positive if pathology demonstrated findings that directly corroborated the diagnosis. Results: Of 87 patients who underwent EMB, the median age was 61 years, and 33% were female. EMB sites included the right ventricle (RV) and LV (15/87), RV only (27/87), LV only (38/87), right atrium (RA) and LV (3/87), and RA only (4/87). Pre-procedural imaging was common: cardiac MRI (80%), cardiac PET (65.6%), and/or pyrophosphate scan (8%). Mean LV ejection fraction was 44%, and mean scar burden was 11% on MRI. The overall diagnostic yield was 18%, encompassing a wide spectrum of pathologies (Figure 1A). Positive biopsy results were significantly associated with pre-procedural suspicion of amyloidosis (Odds Ratio {OR} 6.5, 95% CI 1.2-35.5), myocarditis (OR 6.5, 95% CI 1.2-35.5), or cardiac masses (OR 3.9, 95% CI 1.1-13.9), and sampling from both RA and LV (Figure 1B). EAM and ICE during EMB (Figure 1C) were used in 85% and 99% of cases, respectively. No procedural complications were observed. Conclusions: In our cohort, EAM-guided EMB is a safe diagnostic tool with the best yield for pre-procedural suspicion of amyloidosis, myocarditis, or cardiac masses. Future studies investigating the role of potential tools to optimize biopsies for undifferentiated cardiomyopathies and cardiac sarcoidosis could significantly improve the potential value of EAM-guided EMB.