Zero-fluoroscopy Catheter Ablation Research Articles

The best practices for safety and effectiveness in pregnant: zero-fluoroscopy arrhythmias catheter ablation

Abstract Background Arrhythmias are common during gestation. While the safety and effectiveness of zero-fluoroscopy arrhythmias catheter ablation has been studied, the effects of it in pregnant poorly understood. Purpose The aim of our single-center, prospectively study is explore feasibility, efficacy and safety of zero-fluoroscopy catheter ablation in pregnant. Methods Characteristic, obstetric and neonatal outcomes of 47 cases of zero-fluoroscopy catheter ablation during gestation (main group) within 24 month follow-up were compared with group of pregnant with antiarrhythmic therapy (control group, p=54). Ablation was performed under the guidance of CARTO (n=21; 44.7%) and Ensite Precision systems (n=26; 55.3%) and intracardiac echocardiography without using fluoroscopy in all cases. Results Mean age of pregnant and mean gestation age were comparable in both groups (25.3±3.9 vs. 27.3±3.9 years, p=0.093 and 23.7 ±3.1 vs. 23.8 ±3.2 weeks, p=0.123). Atrioventricular nodal reentrant tachycardia was the most common indications for ablation during gestation (n=21; 44.7%), which was followed by Wolff–Parkinson–White syndrome (n=15; 31.9%). Cases of combination of accessory pathways with slow conduction ways (n=3, 6.4%), ventricular tachycardia (n=3, 6.4%) and premature ventricular contraction (n=5; 10.6%) were rare. Acute procedural success of zero-fluoroscopy ablation was in 100% with mean procedural time 71.9±14.5 minutes. Complication (ileofemoral thrombosis) was in one pregnant (2.1%). Further course of pregnancy characterized by occurring increased uterine contractile activity and placental abruption only in main group (4.54%, p=0.464 and 2.3%, p=0.414 respectively), while uterine blood flow violation and preeclampsia were in both groups (15.9% vs. 13%, p=0.234 and 4.55% vs. 3.7%, p=0.730 respectively). Obstetric outcomes characterized by prevalence of vaginal delivery and delivery in term in both groups (76.6% vs.81.5%, p=0.241 and 95.7% vs. 96.3%, p=0.743). There were live births in all cases with normal range of fetal birth weight in both groups (3207.4±485 vs 3142.2±214.1 grams and 8.4±1.6 vs. 8.6±1.3 respectively). There were no incidence of mortality and arrhythmia recurrence at follow up. Conclusions Zero-fluoroscopy ablation is feasible and can be safety performed during gestation with good outcomes.

Zero-Fluoroscopy Catheter Ablation of Supraventricular Tachycardias in the Pediatric Population.

Catheter ablation (CA) of supraventricular tachycardias (SVTs) is conventionally performed with the aid of X-ray fluoroscopy. Usage of a three-dimensional (3D) electro-anatomical mapping (EAM) system and intracardiac echocardiography (ICE) enables zero-fluoroscopy ablation, eliminating the harmful effects of radiation. We retrospectively analyzed the feasibility, effectiveness and safety of zero-fluoroscopy radiofrequency and cryoablation of various types of SVTs in pediatric patients. Overall, in 171 consecutive patients (12.5 ± 3.9 years), 175 SVTs were diagnosed and 201 procedures were performed. The procedural success rate was 98% (193/197), or more precisely, 100% (86/86) for AVNRT, 95.8% (91/95) for AVRT, 94.1% (16/17) for AT and 100% (2/2) for AFL. No complications were recorded. Follow-up was complete in 100% (171/171) of patients. During the mean follow-up period of 488.4 ± 409.5 days, 98.2% of patients were arrhythmia-free with long-term success rates of 98.7% (78/79), 97.5% (78/80), 100% (13/13) and 100% (2/2) for AVNRT, AVRT, AT and AFL, respectively. Zero-fluoroscopy CA of various types of SVTs in the pediatric population is a feasible, effective and safe treatment option.

A focus on pregnancy course and outcomes of women with zero-fluoroscopy catheter ablation during gestation: a 2-year follow-up study

Abstract Funding Acknowledgements Type of funding sources: None. Background Arrhythmias in pregnant are common clinical problem. Catheter ablation may be required in cases of drug refractory and hemodynamically unstable arrhythmias. Data on further course of pregnancy, perinatal outcomes and results of zero-fluoroscopy catheter ablation in pregnant patients is limited. Purpose we aimed to determine efficacy and safety of zero-fluoroscopy catheter ablation during gestation. Methods 54 pregnant indicated for catheter ablation (Mean age of women was 26.2±3.2 years, mean gestation age 23.3 ±2.4 weeks) due to drug refractory. Further course of pregnancy, perinatal outcomes, complications and arrhythmia recurrence checked during 2-year follow-up. Results Atrioventricular nodal reentrant tachycardia was the most common arrhythmia (n=21; 38.9%). This was followed by Wolff–Parkinson–White syndrome (n=18; 33.3%). In five pregnant was combination of accessory pathways with slow conduction ways (9.3%). Cases of zero-fluoroscopy catheter ablation of ventricular tachycardia (n=2; 3.7%) and premature ventricular contraction (n=8; 14.8%) during gestation were rare. Zero-fluoroscopy catheter ablation successfully performed in all cases (median procedural time was 73±13 minutes). Procedural complication was in one cases (ileofemoral thrombosis). There was no termination of pregnancy after ablation. In five women were increased uterine contractility and uterine blood flow violation (n=5; 9.3%). Preterm delivery was in two cases (3.7%) at 35 and 36 weeks of gestation. Type of delivery was vaginal in the majority (n=42; 77.7%). There were three cases of placental abruption and preeclampsia (5.6%). There were 55 live births (in one case were twins). Fetal birth weight was 3238.7±559.2 grams, 5 minute Apgar was 8.5±1.1. There were no maternal and fetal mortality. At 2-year follow-up there were no arrhythmia recurrence. Conclusions Zero-fluoroscopy catheter ablation during gestation may be safe and effective. It is associated with benign pregnancy course, perinatal and neonatal outcomes.

Long-term results of zero-fluoroscopy catheter ablation in pregnant patients with arrhythmias: a 2-year follow-up study

Abstract Funding Acknowledgements Type of funding sources: None. Background Incidences of rhythm disturbance in pregnant are commonly seen. Catheter ablation of arrhythmias has been shown to be effective and safe. Data on perinatal outcomes and results of zero-fluoroscopy catheter ablation in pregnant patients is limited. Purpose the aim of our study is to observe long-term results and perinatal outcomes in pregnant women with arrhythmias, treated by zero-fluoroscopy catheter ablation method. Methods There were 48 pregnant women, who underwent zero-fluoroscopy catheter ablation (Mean age of pregnant was 25.7±4.3 years, mean gestation age 24.1 ±3.2 weeks). Procedure-related complications, perinatal outcomes and arrhythmia recurrence were documented during 24 months follow-up. Results The most common arrhythmias were atrioventricular nodal reentrant tachycardia (n=21; 43.75%). This was followed by Wolff–Parkinson–White syndrome (n=15; 31.25%). Combination of accessory pathways with slow conduction ways were found in 3 cases (6.25%). In six cases were ablation due to frequent premature ventricular contraction (12.5%). Ventricular tachycardia was rare during pregnancy (n=3; 6.25%). Zero-fluoroscopy catheter ablation was performed under the guidance of CARTO (n=21; 43.75%) and Ensite Precision systems (n=27; 56.25%). The median procedural time was 71±15 minutes. Interventions were effective in all cases (100%). Procedural complication was in one patient (2.1%), who developed an ileofemoral thrombosis. Pregnancy course after ablation procedure was benign in all patients. Perinatal outcomes: spontaneus vaginal delivery was in the majority of cases (n=36; 75%). Twelve pregnancies (25%) were delivered by cesarean section due to obstetric indicators. Intrapartum hemorrhage was 335.2±228.92 ml. Two women had placental abraption and preeclampsia (4.2%). Maternal adverse cardiac events were none declared. There were 48 live births (in all cases). Fetal birth weight was 3324.7±684.4 grams, 5 minute Apgar was 8.4±1.3. There were no maternal and fetal mortality. At 24 months there were no arrhythmia recurrence. Conclusions Zero-fluoroscopy catheter ablation method is safe and effective in pregnant women with arrhythmias. Pregnancy course and outcomes after this procedure is bening in the majority of cases.

Arrhythmia in pregnant women: what management is better?

Abstract Background Arrhythmias in pregnant women are commonly seen but have not been extensively studied. Drug therapy or catheter ablation during pregnancy may be required in cases of maternal arrhythmias. However, the studies did not examine the outcomes of pregnancy in cases with different management of arrhythmias. Objective We aimed to determine if there are any differences in pregnancy outcomes in women with disparate types of arrhythmia treatment. Methods We conducted a prospective study of all pregnant patients who were admitted to our hospital with arrhythmias from 2017–2020. For patients with benign arrhythmias drug therapy was not required (n=11; 14.5%, 1st group). Antiarrhythmic treatment was justified in cases with frequent symptoms and haemodynamic instability (n=65; 85.5%). Patients with effective antiarrhythmic therapy were included in 2nd group (n=31; 40.8%). In patients with drug refractory and dangerous rhythm disturbances (n=34; 44.7%, 3d group) were performed zero-fluoroscopy catheter ablation. Results A total of 76 pregnant women were admitted with arrhythmias. Mean age was 27.24±5.15 years, mean gestation age 21.27±5.34 weeks. Supraventricular tachycardia was the most common arrhythmias (n=41; 53.9%) This was followed by premature contractions (n=27; 35.6%) and ventricular tachycardia (n=8; 10.5%). There was significant difference in frequency of performed catheter ablation for disparate types of arrhythmia: 70.7% for cases of supraventricular tachycardia, 25% - ventricular tachycardia and 11.1% - premature contractions (p=0.000). Ablations were effective in all cases without adverse outcome. All ablations were performed without fluoroscopy. Vaginal delivery was in the majority in all groups (75.6% vs 62.5% vs 74.1%, p=0.736). Similarly, no differences were noted in obstetric complication (14.6% vs 12.5% vs 18.5%, p=0.656). None of them had fetal mortality. Conclusions Some patients with arrhythmias needed catheter ablation during pregnancy. There was no significant difference in type of delivery and neonatal outcomes in women with separate management of arrhythmias. Funding Acknowledgement Type of funding sources: None.

Safety and efficacy of zero-fluoroscopy catheter ablation for paroxysmal supraventricular tachycardia in Chinese children.

ObjectivesTo compare the safety and efficacy of completely zero-fluoroscopy radiofrequency ablation (RFA) with that of conventional RFA guided by three-dimensional mapping in Chinese children with paroxysmal supraventricular tachycardia (PSVT).MethodsThe study had a single-center observational design and included 46 children aged 6–14 years who underwent RFA for PSVT at the Second Hospital of Hebei Medical University between March 2019 and September 2021. The children were divided according to whether they underwent zero-fluoroscopy RFA (zero-fluoroscopy group, n = 26) or routine RFA under X-ray guidance (conventional group, n = 20). Three-dimensional mapping was used in both groups. Baseline characteristics, total procedure time, RFA time, volume and duration of X-ray exposure, target mapping time, the immediate RFA success rate, incidence of complications, and recurrence rate were compared between the two groups.ResultsThe children had a median age of 12 years (interquartile range 10, 13), 47.8% (22/46) were boys, and 52.2% (24/46) were girls. The mean body weight was 48.75 ± 15.26 kg. There was no significant between-group difference in the baseline data (P > 0.05). All children were followed up as outpatients at 1, 3, and 6 months postoperatively. The target mapping time was significantly longer in the zero-fluoroscopy group than in the conventional group (12.96 ± 2.24 min vs. 6.65 ± 2.56 min, P < 0.05); however, there was no significant between-group difference in the immediate success rate (100% vs. 100%), success rate at 6 months postoperatively (92.30% vs. 95.00%), complication rate (0% vs. 0.05%), recurrence rate (7.70% vs. 5.00%), RFA time (212.50 s vs. 214.00 s), or total procedure time (78.50 min vs. 74.00 min) (P > 0.05).ConclusionZero-fluoroscopy catheter ablation can completely avoid fluoroscopy exposure in children without affecting the safety and efficacy of RFA.

Catheter ablation of sustained idiopathic right ventricular outflow tract tachycardia in a pregnant patient without fluoroscopy

In 2020, our department has performed 739 operations on nonpregnant patients. Additionally, 545 highly successful nonfluoroscopic catheter ablation of cardiac arrhythmias were routinely performed using a three-dimensional navigation system, including 47 patients with idiopathic ventricular tachycardia (VT) from the right ventricular outflow tract (RVOT).&#x0D; A 38-year-old female patient with a structurally normal heart was admitted to our hospital in 1011 weeks of her third pregnancy because she sustained recurrent 166 regular heartbeats per minute, wide QRS-complex tachycardia with left bundle branch morphology, and frequent premature ventricular contractions on Holter monitoring with complaints of presyncope and dyspnea. Standard antiarrhythmic drugs failed to control tachycardia. This case report presents our initial successful experience of the rescue zero-fluoroscopy catheter ablation of sustained poorly tolerated idiopathic RVOT tachycardia in a pregnant patient. Our result suggests that this technique may be considered in the few rare cases in which drug-resistant, sustained frequent VT is accompanied by hemodynamic compromise with fluoroscopy contraindication.&#x0D; AIM: Diagnostic algorithm of idiopathic sustained drug-resistant, poorly tolerated VT and the possibility of radiofrequency catheter ablation in the most vulnerable first trimester of pregnancy without fluoroscopy were presented in our case report.

Zero-fluoroscopy catheter ablation in pregnant women: outcomes and prognosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Arrhythmias are common in pregnant. Catheter ablation is effective treatment in cases of drug refractory arrhythmias. However, data are scarce on outcomes and prognosis of catheter ablation in this population of patient. Purpose To define the cohort of pregnant undergoing for catheter ablation for arrhythmias, characterize obstetric and neonatal outcomes and prognosis. Methods This single-center, prospective study included all catheter ablation procedures for arrhythmias performed in pregnant from January 2015 until December 2019. Primary outcome was recurrence of arrhythmia. Baseline clinical characteristics, complication rates, obstetric and neonatal outcomes were also evaluated. Results In total, we included 48 patients (aged 27.04±4.32 years, mean gestation age 21.8±4.22 weeks), indicated for catheter ablation due to drug refractory arrhythmias. The most common arrhythmia was atrioventricular nodal reentrant tachycardia (n=20; 41.7%). Ablation of accessory pathways performed in 16 cases (33.3%): in left free wall (n=8), in right free wall (n=7), posteroseptal (n=1). In 3 cases was observed combination of accessory pathways with slow conduction ways. Ablation of the right ventricular outflow tract was performed in 9 cases (18.7%) of ventricular tachycardia. In all cases catheter ablation was performed successfully without fluoroscopy. One patient developed an ileofemoral thrombosis. No other complication after ablation was noted. Pregnancy course was benign in all cases without termination. Premature birth was in 2 cases at 35 and 36 weeks of gestation. Full-term pregnancy was in the majority. Preeclampsia developed in 2 pregnant women. In 75% of pregnancy was vaginal delivery, in 25% - Cesarean section. Fetal birth weight was 3226.34±623,1 grams, 5 minute Apgar was 8,92±1,8. There were 48 live births without maternal and fetal mortality. During 1 year follow-up there was no arrhythmia recurrence. Conclusions Non-fluoroscopic catheter ablation of arrhythmias in pregnant women is effective treatment options, with a high success rate, low rates of complication, favorable outcomes and prognosis.

Conventional fluorscopy-guided vs zero-fluorscopy catheter ablation of supraventricular tachycardias

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Traditionally, X-ray fluoroscopy is used during catheter ablation procedures. The utilisation of ionising radiation carries non-negligible stochastic and deterministic risks to the health of both the patient and the professional staff. These effects are cumulative and behave in a linear no-threshold manner and, as such, are especially important in paediatric populations (1). The importance of reducing ionising radiation exposure has been recognised by the American College of Cardiology, which recommends the ALARA (as low as reasonably achievable) principle in all interventional laboratories (2). In recent years, advances in three-dimensional electroanatomical mapping systems and their utilisation have enabled the near-zero and zero-fluoroscopy approaches to be studied (3). Purpose The aim of this study was to evaluate the safety and efficacy of zero-fluoroscopy catheter ablation for supraventricular tachycardias (SVT). Methods 584 consecutive patients referred to our institution for catheter ablation of SVT were analysed. Patients were categorised into two groups; zero-fluoroscopy (ZF) group and conventional fluoroscopy (CF) group. Patient characteristics, procedural information, and follow-up data were compared. Results The ZF group had a higher proportion of paediatric patients (42.2% vs 0.0 %; p &amp;lt; 0.001), resulting in a younger age (30.9 ± 20.3 years vs 52.7 ± 16.5 years; p &amp;lt; 0.001) and lower BMI (22.8 ± 5.7 kg/m2 vs 27.0 ± 5.4 kg/m2; p &amp;lt; 0.001). Procedure time was shorter in the ZF group (94.2 ± 50.4 min vs 104.0 ± 54.0 min; p = 0.002). There were no major complications and the rate of minor complications did not differ between groups (0.0% vs 0.4%; p = 0.304). Acute procedural success as well as the long-term success rate when only the index procedure was considered did not differ between groups (92.5% vs 95.4%; p = 0.155; 87.1% vs 89.2%; p = 0.422). When repeated procedures were included, the long-term success rate was higher in the ZF group (98.3% vs 93.5%; p = 0.004). The difference can be partially explained by the operators’ preferences. Conclusion The safety and efficacy of ZF procedures in adult and paediatric populations are comparable to that of CF procedures.

Conventional fluoroscopy-guided versus zero-fluoroscopy catheter ablation of supraventricular tachycardias

PurposeThe aim of this study was to evaluate the safety and efficacy of zero-fluoroscopy (ZF) catheter ablation (CA) for supraventricular tachycardias (SVT).Methods584 consecutive patients referred to our institution for CA of SVT were analysed. Patients were categorised into two groups; zero-fluoroscopy (ZF) group and conventional fluoroscopy (CF) group. The ZF group was further divided into two subgroups (adults and paediatric). Patient characteristics, procedural information, and follow-up data were compared.ResultsThe ZF group had a higher proportion of paediatric patients (42.2% vs 0.0%; p < 0.001), resulting in a younger age (30.9 ± 20.3 years vs 52.7 ± 16.5 years; p < 0.001) and lower BMI (22.8 ± 5.7 kg/m2 vs 27.0 ± 5.4 kg/m2; p < 0.001). Procedure time was shorter in the ZF group (94.2 ± 50.4 min vs 104.0 ± 54.0 min; p = 0.002). There were no major complications and the rate of minor complications did not differ between groups (0.0% vs 0.4%; p = 0.304). Acute procedural success as well as the long-term success rate when only the index procedure was considered did not differ between groups (92.5% vs 95.4%; p = 0.155; 87.1% vs 89.2%; p = 0.422). When repeated procedures were included, the long-term success rate was higher in the ZF group (98.3% vs 93.5%; p = 0.004). The difference can be partially explained by the operators' preferences.ConclusionThe safety and efficacy of ZF procedures in adult and paediatric populations are comparable to that of CF procedures.

Outcome and safety of intracardiac echocardiography guided left atrial appendage closure within zero-fluoroscopy atrial fibrillation ablation procedures.

Simultaneous atrial fibrillation (AF) catheter ablation and left atrial appendage closure (LAAC) are sometimes recommended for both rhythm control and stroke prevention. However, the advantages of intracardiac echocardiography (ICE) guidance for this combined procedure have been scarcely reported. We aim to evaluate the clinical outcomes and safety of ICE-guided LAAC within a zero-fluoroscopy catheter ablation procedure. From April 2019 to April 2020, 56 patients with symptomatic AF underwent concomitant catheter ablation and LAAC. ICE with a multi-angled imaging protocol mimicking the TEE echo windows was used to guide LAAC. Successful radiofrequency catheter ablation and LAAC were achieved in all patients. Procedure-related adverse event rate was 3.6%. During the 12-month follow-up, 75.0% of patients became free of arrhythmia recurrences and oral anticoagulants were discontinued in 96.4% of patients. No ischemic stroke occurred despite two cases of device-related thrombosis versus an expected stroke rate of 4.8% based on the CHA2 DS2 -VASc score. The overall major bleeding events rate was 1.8%, which represented a relative reduction of 68% versus an expected bleeding rate of 5.7% based on the HAS-BLED score of the patient cohort. The incidence of iatrogenic atrial septal defect secondary to single transseptal access dropped from 57.9% at 2 months to 4.2% at 12 months TEE follow-up. The combination of catheter ablation and LAAC under ICE guidance was safe and effective in AF patients with high stroke risk. ICE with our novel protocol was technically feasible for comprehensive and systematic assessment of device implantation.

Minimising radiation exposure in catheter ablation of ventricular arrhythmias

BackgroundConventional 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).MethodsFifty-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.ResultsSixty 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%.ConclusionsFluoroscopy 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.

Zero-fluoroscopy catheter ablation for atrial fibrillation: a transitional period experience.

BackgroundRadiofrequency catheter ablation for atrial fibrillation (AF) without using fluoroscopy has been getting popular. In this study, we reported the transition period experience of the zero‐fluoroscopy procedure by an experienced operator and shared our zero‐fluoroscopy protocol.MethodA total of consecutive 30 AF ablation cases attempted to be treated without fluoroscopy were investigated. Ten serial cases were grouped as fluoroscopy‐guided period, and period 1‐3 in chronological order. All zero‐fluoroscopy attempted cases were assisted with an intracardiac echocardiography device with a three‐dimensional electroanatomical system.ResultsComplete zero‐fluoroscopy procedure was achieved at the 6th case during the transitional period. During the first period, the total procedure time slightly increased in, but afterward, procedure time was continuously decreased, and it became significantly shorter in the third period than the previous fluoroscopy‐guided period. Any additional use of fluoroscopy during the transitional period was mainly for transseptal puncture and diagnostic catheter placement into the coronary sinus. Pulmonary vein isolation was achieved in all patients, and there was one case of hemodynamically insignificant moderate amount pericardial effusion.ConclusionFor an experienced operator, complete zero‐fluoroscopy AF ablation might be achieved safely and feasibly within 5‐10 cases. Fluoroscopy equipment backup might be useful during the learning period for beginners in the zero‐fluoroscopy procedure.

P377Zero-fluoroscopy ablation with ultrasound-guided sheath insertion

Abstract Background Radiation exposure during catheter ablation procedures is a risk for both the patient and electrophysiology staff. Recently, the feasibility and effectiveness of zero-fluoroscopy ablation have been shown. However, ensuring a safe sheath insertion through the venous system toward the heart is a concern in catheter ablation using the zero-fluoroscopy technique. Purpose The objective of this study was to confirm feasibility and safety for zero-fluoroscopy ablation using ultrasound-guided sheath insertion. Methods Zero-fluoroscopy catheter ablation was performed in 220 patients (185 patients with atrial fibrillation (AF), 26 patients with supraventricular tachycardia (SVT), and nine patients with ventricular arrhythmias (VA)) using a 3-dimensional electro-anatomical mapping system, contact force monitoring, and intracardiac echocardiography (ICE) imaging. In all cases, ultrasound-guided sheath insertion was performed through the femoral vein. In 6 cases of VA, the retrograde approach through the femoral artery was performed with ICE imaging and contact-force monitoring. The endpoint of ablation for AF was pulmonary vein ablation in all cases and addition of left atrial posterior wall isolation in persistent AF cases. The endpoint of ablation for SVT and VA was noninducibility after ablation. Results The endpoints of ablation were achieved in all cases. The fluoroscopic time during ablation procedures was 0 seconds. There were two complications (one cardiac tamponade and one acute heart failure). There were no complications related to sheath insertion. Conclusions Zero-fluoroscopy catheter ablation with ultrasound-guided sheath insertion may be feasible and can be performed safely. This method eliminates exposure radiation safely, which is a concern of zero-fluoroscopy endocardial catheter ablation.

P1446Cavo-tricuspid atrial flutter catheter ablation with a real zero fluoroscopic approach

Abstract Funding Acknowledgements none Background Catheter ablation(CA)is the first-line therapy of cavo-tricuspid isthmus(CTI)atrial flutter. Sometimes an inversion of ablation catheter is necessary to obtain a complete bidirectional line block. Purpose.The aim of this study was to describe this CA approach using electro-anatomical mapping(EAM)system with a zero-fluoroscopy(ZF)approach.Methods.Ninety-four patients that performed CA of CTI were retrospectively enrolled since 2017 to 2019.The studied population were divided in two groups.Group1(44patients) was composed of patients who underwent CA using ablation catheter without shaft visualization catheter(NSVC)on EAM.Group2(50patients)was composed of patients who underwent CA using ablation catheter with a shaft visualization(SVC). The catheter was looped at the Eustachian ridge after 200 seconds of RF without elimination of local electrogram. Results.ZF CTI ablation was obtained in all patients of group 2 without fluoroscopy use.In six patients of group 1, the catheter inversion was used to obtain a complete CTI block.In NSVC group, the catheter inversion was obtained using fluoroscopy to avoid damages during loop of catheter ablation.In overall population studied SVC had a linear correlation with ZF approach(β=0.629;p &amp;lt; 0.001). No differences were documented regarding acute and late success,complications.The procedural time between two groups was similar (Group1:83.4 ± 22.4 vs.Group2:80.2 ± 34.7minutes). The detailed results were summarize in table1. Conclusions.A real ZF catheter ablation of atrial flutter is safe and feasible.The use of SVC could improve the reproducibility of a successful zero-fluoroscopy CA.The visualization of the shaft’s catheter permit to invert the catheter safely to overcome anatomic complexity of some CTI without fluoroscopy use. detailed results Detailed results Group 1(44 CA) Group 2(50 CA) p value Procedure time (min) 83.4 ± 22.4 80.2 ± 34.7 NS AFL at begin CA (n.) 36 23 FT (min) 9.1 ± 9.8 0 ± 0 &amp;lt; 0.001 PWRF (W) 32 ±2.5 33.6 ±2.2 NS CA line length (mm) 28.1 ± 4.1 27.9 ± 5.5 NS Total RF (min) 27.8 ± 6.3 13.6 ± 7.2 &amp;lt; 0.01 SR during RF 35 23 Conductional block after 30 min 44 50 NS 6 months recurrences 1 1 NS AFL: atrial flutter; FT: fluoroscopy time; PWRF: power radiofrequencies; CA line length: length of line of radiofrequencies; RF: radiofrequencies; SR: sinus rhythm. Detailed results. Abstract Figure.

233Conventional fluoroscopy guided vs zero-fluoroscopy catheter ablation of supraventricular tachycardias

Abstract Funding Acknowledgements None Introduction Conventionally, catheter movement and placement during catheter ablation (CA) is guided by X-ray fluoroscopy. In recent years, an ‘as low as reasonably possible’ principle was established to minimize the ionizing radiation dose received by the patient and the operator. Zero-fluoroscopy approach is at the extreme end of the spectrum of this principle. With exclusion of X-ray fluoroscopy, three-dimensional electroanatomical mapping system and intracardiac echocardiography are used for catheter guidance during ablation procedures. Purpose The aim of our study was to assess and compare procedural parameters and clinical outcomes of conventional X-ray fluoroscopy guided and zero-fluoroscopy CA for treatment of supraventricular tachycardias. Methods Retrospective analysis included CA procedure between April 2014 and May 2019. Five hundred and thirteen (513) patients were selected for analysis; they had confirmed diagnosis of atrioventricular nodal reentry tachycardia (AVNRT) or atrioventricular reentry tachycardia (AVRT). Patients were divided into two groups based on the use of fluoroscopy (conventional approach group - CG; zero-fluoroscopy group - ZF). Procedural data and clinical outcomes were analyzed. Two groups were compared using chi-squared test or Mann-Whithney U test when appropriate. Results There were 249 patients (44.2% males) in CG group, and 260 patients (47.5% males) in ZF group. ZF group included 113 (43.5%) pediatric patients. The groups differed in mean age (53.4 ± 16.4 years vs 30.0 ± 19.8 years (CG vs ZF), p &amp;lt; 0.001), postprocedural use of antiarrhythmic agents or beta blockers (55.3% vs 17.0% (CG vs ZF), p &amp;lt; 0.001) and type of arrhythmia (72.3% vs 60.6% AVNRT (CG vs ZF), p = 0.003). In CG group, all procedures were performed using radiofrequency (RF) energy, whereas in ZF group, cryoablation was used in 18.3% of procedures at the discretion of the operator. Mean procedural duration was longer in CG group (100.1 ± 48.8 vs 90.4 ± 83.0 minutes, p &amp;lt; 0.001). The mean fluroscopy time was 13.6 ± 9.3 minutes and mean dose area product was 554.1 ± 713.6 mGycm2 in the CG group. Acute success rate was higher in CG group (95.7 vs 90.7%, p = 0.027). However, the arrhythmia-free survival rate after 13.8 ± 11.0 months of follow-up was lower in the CG group (90.9 vs 96.5%, p = 0.009). Mean number of procedures per patient was 1.04 in the CG group and 1.14 in the ZF group (p &amp;lt; 0.001). There were no severe complications. Conclusions Zero-fluoroscopy CA of supraventricular tachycardias is associated with lower procedural success rate, but higher long-term arrhythmia-free survival rate when compared to conventional fluoroscopy guided procedures. It is possible, that these differences are stemming from somewhat different patient populations in both groups.

P338 The road to zero-fluoroscopy catheter ablation in recurrent paroxysmal atrial fibrillation using ICE: training, learning, getting closer

Abstract INTRODUCTION Catheter ablation is the treatment of choice for patients with recurrent paroxysmal atrial fibrillation (AF) in which antiarrhythmic drug therapy has failed to maintain sinus rhythm. Since its first introduction, intracardiac echocardiography (ICE) has proved to increase the efficacy and reduce complications in AF catheter ablation. One of the main advantages of ICE in the electrophysiology laboratory is the reduction of radiation exposure, for both the patient and the physician. Multiple recent studies have shown the feasibility and safety of zero or near-zero fluoroscopy AF ablation, including transseptal puncture, and outlined the importance of using ICE under the support of 3D mapping systems in reducing radiation exposure. PURPOSE The aim of this study was to show whether the use of ICE reduced the radiation exposure and total procedure time in recurrent paroxysmal AF patients undergoing radiofrequency catheter ablation. METHODS Forty patients that undergone radiofrequency catheter ablation for recurrent paroxysmal AF between January 2018 and May 2019 were included. They were divided in two groups: Group 1 – 20 patients in which ICE was performed and Group 2 – 20 patients in which ablation was performed without ICE guidance. We compared the total ablation time and fluoroscopy dose and time between the two groups. The total ablation time was defined as the time from the groin puncture until the withdrawal of all catheters. RESULTS Among the 40 patients included, 28 were men (70%) and the mean age was 57 years old. The mean procedure time was similar between the two groups (175 ± 52.0 for group 1 and 193 ± 49.9 for group 2, p = 0.33). The difference between the two groups was observed in fluoroscopy dose (9914.13 ± 5018.14 vs. 14561.43 ± 7446.1, p = 0.02) and time (26.04 ± 12.5 vs. 40.52 ± 12.6, p = 0.001). We found that in both groups higher fluoroscopy dose was correlated with higher fluoroscopy time (R = 0.74, p = 0.0001 vs. R = 0.57, p = 0.008) and higher total procedure time (R = 0.63, p = 0.002 vs. R = 0.46, p = 0.03). Furthermore, there was also a correlation between higher fluoroscopy dose and time (R = 0.59, p = 0.005 vs. R = 0.58, p = 0.006). No severe procedure-related complications were recorded. CONCLUSIONS This study shows that the use of ICE for recurrent paroxysmal AF catheter ablation reduces radiation exposure by lowering the fluoroscopy dose and the time of exposure. As a result, by increasing the training and learning curve in low-experienced centers it may finally get us closer to the ideal zero or near-zero fluoroscopy ablation. Abstract P338 Figure. ICE-guided transseptal puncture

Combined use of electro-anatomic mapping system and intracardiac echocardiography to achieve zero-fluoroscopy catheter ablation for treatment of paroxysmal atrial fibrillation: a single centre experience.

Fluoroscopy is the principal imaging method for catheter ablation (CA) of atrial fibrillation (AF). However, radiation exposure carries potential health risk to patients and operators alike. Our aim was to study safety and efficacy of zero-fluoroscopy CA of paroxysmal AF with a combined use of electroanatomic mapping system (EAM) and intracardiac echocardiography (ICE). In addition, impact of ICE/EAM automatic integration system and contact force (CF) sensing technology on procedural times were assessed. We included 144 consecutive patients (69% males, age 60 ± 10years, BMI 29 ± 4,6) referred for CA of symptomatic paroxysmal AF. All procedures were performed only with EAM system and ICE. No fluoroscopy was used. The acute procedural success of complete pulmonary vein isolation was achieved in all patients (100%) and adverse events were detected in eight patients (5.6%). In 53 (37%) patients the use of ICE/EAM automatic integration system shortened procedural times compared to those performed without it (148 ± 35 vs. 187 ± 44min, p < 0.05). Similarly, 89 (60%) procedures where CF sensing catheter was used were shorter compared to those performed without it (163 ± 41 vs. 188 ± 46min, p < 0.05). Zero-fluoroscopy approach for treatment of paroxysmal AF seems feasible, safe, and acutely effective. Additional reduction of procedural times could be achieved with the use of ICE/EAM automatic integration system and CF sensing technology.

Transjugular approach for zero-fluoroscopy catheter ablation of the right anterolateral accessory pathway

We present a case of successful zero-fluoroscopy catheter ablation (CA) of the right anterolateral accessory (AP) pathway via a transjugular approach in an 18-year-old patient with a congenital agenesis of inferior vena cava (IVC). Three-dimensional (3D) electroanatomic mapping (EAM) system and intracardiac echocardiography (ICE) were used to navigate the catheters in the heart.

1205Zero-fluoroscopy catheter ablation of right- and left-sided supraventricular tachycardias

Abstract Background Catheter ablation (CA) of supraventricular tachycardias (SVTs) is traditionally performed with the aid of fluoroscopy. However, ionizing radiation is associated with potentially harmful deterministic and stochastic effects to the patient and operator. Many methods have been suggested to reduce the radiation exposure, one of the methods, which completely eliminates ionizing radiation exposure, is zero-fluoroscopy catheter ablation. Purpose Our aim was to assess feasibility, success rate and safety of zero-fluoroscopy CA for treatment of various right and left-sided SVTs with the use of three-dimensional (3D) electroanatomical mapping system (EAM) and intracardiac echocardiography (ICE). Methods Consecutive 274 patients (140 male, mean age 33.5±21.8 years) with documented SVTs underwent CA in our center from April 2014 to May 2018. All procedures were performed with the 3D EAM without any use of fluoroscopic guidance. ICE was used as primary visual modality when left-sided approach was required. The procedural endpoint for atrioventricular nodal reentrant tachycardia (AVNRT) was nodal rhythm during radiofrequency (RF) energy delivery and non-inducibility. The procedural endpoint for focal atrial tachycardia (AT) was termination and non-inducibility. The procedural endpoint for accessory pathway (AP) mediated tachycardia was absence of bidirectional conduction over the AP. The procedural endpoint for typical atrial flutter (AFL) was bidirectional block over the cavo-tricuspid isthmus. Results One hundred thirty two patients had AVNRT, 79 had AP mediated tachycardia (47 left-sided, 25 septal and 7 right-sided), 31 patients had AT (8 left-sided), 32 patients had AFL. Cryo-ablation was used in 14 (14/132, 10.6%) patients with AVNRT and 5 patients with septal AP (5/25, 20%), RF was used in the rest. The procedural endpoint was achieved in all procedures (100%). During the mean follow-up of 343±253 days the recurrence rate for AVNRT, AP mediated tachycardia, focal AT, AFL was 7.5%, 16.4%, 32.3% and 9.4%, respectively. No procedural complications were observed. Conclusions Zero-fluoroscopy CA of right and left-sided SVTs with the use of the 3DEAM and ICE is feasible, safe and results in promising long-term success rates after single CA procedure. Acknowledgement/Funding None