Integrated ALARA approach to atrial fibrillation radiofrequency ablation: combined use of transesophageal echocardiography, 3D mapping system and X-Ray sparing fluoroscopy settings

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: 3D mapping guided ablation of atrial fibrillation (AF) demonstrated its value in increasing procedural safety and reducing the total patient and team radiation exposure. An ALARA (as low as reasonably achievable) approach can be reached through the use of transesophageal echocardiography (TEE) to guide transeptal puncture, a 3D mapping system and low fluoroscopy settings of the X-Ray System. PURPOSE: Investigation of radiation exposure during an ALARA optimized AF Ablation with 3D mapping System METHODS: We included 112 consecutive patients in the years 2021-2022 undergoing radiofrequency (RF) AF Ablation with 3D mapping system. Fluoroscopy was routinely performed with a Siemens Arctic Zee X Ray System at factory low setting of 1 to 3 pulses per second, pulse width of 6,4 ms, collimation and with the secondary radiation grid in situ. Fluoroless 3D mapping of right atrium, His region, superior vena cava, septum and coronary sinus was performed in all cases except 5 patients with pace-maker or ICD. The wire, connected with alligator clip to the 3D mapping system and the transseptal puncture sheath were fluoroless positioned in the superior vena cava. Thereafter, double transseptal puncture was guided by TEE and fluoroscopy if necessary. Only in one case intracardiac echo (ICE) was used to guide the transeptal puncture. 93% of the procedures were performed with a BRK needle connected with an alligator clip to the 3D mapping system, a - RF-needle was used in 8 (7%) patients. All further steps were performed with a contact -force catheter and a multipolar diagnostic catheter with use of radiation only if necessary. Usually, after mapping of the left atrium the staff worked without lead protection for the rest of the procedure. Circumferential pulmonary vein isolation (PVI) was performed in all cases adding a substrate modification in re-do procedures. RESULTS: One hundred and twelve patients (age 63±10 years) with paroxysmal (n=48, 43%) oder persistent (n=64, 57%) AF scheduled for RF catheter ablation were included. We performed the transseptal maneuver with a very low fluoroscopy exposure (mean 40±95s, DAP 5±13 cGy*cm2), moreover, the mean total radiation time of the complete PVI was under a minute (mean 51 ± 112s, DAP 7±17 cGy*cm2). A completely fluoroless procedure was possible in 52 (46%) procedures. No major complications occured. CONCLUSION: In the years 2021 and 2022 we were able to perform 112 RF ablation procedures using an ALARA approach with a combined TEE- guided transseptal double puncture, a 3D-mapping system and low-fluoroscopy settings of X-Ray System achieving a mean radiation exposure of under a minute without compromising the safety and efficacy of the RF PVIs.