Catheter Ablation of Atrial Fibrillation Without Fluoroscopy Using Intracardiac Echocardiography and Electroanatomic Mapping

Background—Catheter ablation of atrial fibrillation is currently guided by x-ray fluoroscopy. The associated radiation risk to patients and medical staff may be significant. We report an atrial fibrillation ablation technique using intracardiac echocardiography (ICE) and electroanatomic mapping without fluoroscopy. Methods and Results—Twenty-one patients with atrial fibrillation (age, 42 to 73 years; 14 male; 14 paroxysmal, 7 persistent; body mass index, 26 to 38) underwent ablation. A decapolar catheter was advanced through the left subclavian vein until stable coronary sinus electrograms appeared on all electrodes. Two 9F sheaths were advanced transfemorally over a guide wire to the right atrium. A rotational ICE catheter was advanced through a deflectable sheath. Double transseptal puncture was performed with ICE guidance and facilitated by electrocautery. A 3D MRI left atrial image was registered to the ostia of the pulmonary veins using ICE. Catheter ablation was performed using ICE and electroanatomic mapping navigation. In 19 cases, no fluoroscopy was used and the staff did not wear protective lead. In 2 cases, 2 to 16 minutes of fluoroscopy was used to assist transseptal puncture. Median procedure time was 208 (188 to 221) minutes; coronary sinus cannulation took 5 (2 to 26) minutes; double transseptal took 26 (17 to 40) minutes; left atrial ablation time was 103 (90 to 127) minutes. All patients underwent circumferential pulmonary vein ablation and 8 patients underwent additional left atrial ablation. There were no procedure-related complications. Conclusions—Catheter ablation of atrial fibrillation without fluoroscopy is feasible and merits further attention. This technique may be especially helpful in preventing x-ray exposure in children, pregnant women, and obese patients undergoing left atrial ablation.

[1]  M. Walsh,et al.  Radiation safety in the practice of cardiology , 1998 .

[2]  John M. Clark,et al.  Use of Three‐Dimensional Catheter Guidance and Trans‐Esophageal Echocardiography to Eliminate Fluoroscopy in Catheter Ablation of Left‐Sided Accessory Pathways , 2008, Pacing and clinical electrophysiology : PACE.

[3]  P. Tchou,et al.  The Use of a Standard Radiofrequency Energy Delivery System to Facilitate Transseptal Puncture , 2009, Journal of cardiovascular electrophysiology.

[4]  V. Santinelli,et al.  Robotic magnetic navigation for atrial fibrillation ablation. , 2006, Journal of the American College of Cardiology.

[5]  Burr Hall,et al.  Catheter Ablation for Paroxysmal Atrial Fibrillation: Segmental Pulmonary Vein Ostial Ablation Versus Left Atrial Ablation , 2003, Circulation.

[6]  H. Calkins,et al.  Acute Radiation Dermatitis Following Radiofrequency Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia , 1997, Pacing and clinical electrophysiology : PACE.

[7]  M. Walsh,et al.  ACC expert consensus document. Radiation safety in the practice of cardiology. American College of Cardiology. , 1998, Journal of the American College of Cardiology.

[8]  F. Drago,et al.  Exclusion of Fluoroscopy During Ablation Treatment of Right Accessory Pathway in Children , 2002, Journal of cardiovascular electrophysiology.

[9]  Hakan Oral,et al.  Pulmonary Vein Isolation for Paroxysmal and Persistent Atrial Fibrillation , 2002, Circulation.

[10]  M. Earley,et al.  Catheter ablation of permanent atrial fibrillation: medium term results , 2005, Heart.

[11]  David E Haines,et al.  Intracardiac echocardiography-guided, anatomically based radiofrequency ablation of focal atrial fibrillation originating from pulmonary veins. , 2002, Journal of the American College of Cardiology.

[12]  D. Schwartzman,et al.  Echocardiographically guided left atrial ablation: characterization of a new technique. , 2006, Heart rhythm.

[13]  J. Dimarco,et al.  Real‐Time Rotational ICE Imaging of the Relationship of the Ablation Catheter Tip and the Esophagus During Atrial Fibrillation Ablation , 2009, Journal of cardiovascular electrophysiology.

[14]  J. Langberg,et al.  Radiation Exposure During Radiofrequency Catheter Ablation of Accessory Atrioventricular Connections , 1991, Circulation.

[15]  Hugh Calkins,et al.  Radiation Exposure During Catheter Ablation of Atrial Fibrillation , 2004, Circulation.

[16]  N. Theocharopoulos,et al.  Occupational exposure in the electrophysiology laboratory: quantifying and minimizing radiation burden. , 2006, The British journal of radiology.

[17]  F. Sacher,et al.  Catheter Ablation of Long‐Lasting Persistent Atrial Fibrillation: Critical Structures for Termination , 2005, Journal of cardiovascular electrophysiology.

[18]  John M. Clark,et al.  Elimination of Fluoroscopy Use in a Pediatric Electrophysiology Laboratory Utilizing Three‐Dimensional Mapping , 2007, Pacing and clinical electrophysiology : PACE.

[19]  Kim Rajappan,et al.  The Impact of CT Image Integration into an Electroanatomic Mapping System on Clinical Outcomes of Catheter Ablation of Atrial Fibrillation , 2006, Journal of cardiovascular electrophysiology.

[20]  S. Arase,et al.  Severe radiation-induced injury after cardiac catheter ablation: a case requiring free anterolateral thigh flap and vastus lateralis muscle flap reconstruction on the upper arm. , 2008, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.

[21]  A. Ross,et al.  Prevalence of spinal disc disease among interventional cardiologists. , 1997, The American journal of cardiology.

[22]  V. Tuzcu,et al.  A Nonfluoroscopic Approach for Electrophysiology and Catheter Ablation Procedures Using a Three‐Dimensional Navigation System , 2007, Pacing and clinical electrophysiology : PACE.

[23]  J. Brachmann,et al.  Atrial fibrillation ablation using a robotic catheter remote control system: initial human experience and long-term follow-up results. , 2008, Journal of the American College of Cardiology.