Comparison of zero fluoroscopy versus fluoroscopy guided ablation for atrial fibrillation: A single center experience

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: With advances in mapping equipment and increased use of intracardiac echocardiography (ICE), atrial fibrillation (AF) ablations can be safely performed without fluoroscopy. Benefits include no radiation exposure to patient and staff and reduced long-term orthopedic complications related to use of lead aprons for staff. Published data comparing zero fluoroscopy ablation (ZFA) and conventional fluoroscopy guided ablation (CFA) for AF is limited to small case series and meta-analysis. AIM: To evaluate the safety and procedural outcomes of a simplified ZFA approach, comparing it to standard of care (CFA). METHODS: Consecutive AF cases from 03/2021 to 09/2022 at our institution were included. 120 cases underwent ZFA (RF ablation, ICE and 3D mapping guided) and 155 cases underwent CFA (Cryo or RF ablation, fluoroscopy, ICE and 3D map guided). For the ZFA group, a simplified ICE based map of relevant anatomical structures was created, in order to guide trans-septal (TS) access and left -sided ablation (See figure) and no pre-procedural imaging was obtained. All CFA cases had pre-procedural cardiac CT or MRI to evaluate left atrial anatomy. Redo ablation cases represented 17% of the ZFA and 23% of the CFA patients. All cases were performed by operators with >12 years of experience, and all cases underwent general anesthesia. Only two ZFA cases required a brief period of fluoroscopy (under 2 min each) to achieve safe trans-septal access (including one case with a prior ASD closure device). RESULTS: Mean age was 67 for ZFA and 69 for CFA groups respectively (p=NS). 69% of ZFA and 71% of CFA cases were men. Persistent AF cases more frequently underwent posterior wall isolation in the ZFA group (98% vs 68%, P<0.01), but despite this, procedural times were similar for both groups (168±55 min ZFA vs 172±51 min CFA, P=NS). Procedural success (pulmonary vein isolation ± posterior wall isolation) was achieved in all ZFA and 99% of CFA cases. At a mean follow up 12 months, Freedom for AF was 81% for paroxysmal AF and 74% for persistent AF cases in the ZFA group, and 79% for paroxysmal AF cases and 71% for persistent AF cases in the CFA group (p=NS). Procedural complications included one TIA in the ZFA group and 2 pericardial effusions in the CFA group (p=NS). Use of antiarrhythmic drugs post ablation did not differ between the ZFA and the CFA groups (23% vs 27%, p=NS). CONCLUSION: Our ZFA approach for AF was safe, effective and produced similar outcomes compared to a traditional CFA approach. ZFA has considerable health benefits for personnel and patients without compromising procedural outcomes. The cost of ICE catheters may be offset by eliminating the need for pre-procedural imaging (CT or MRI) commonly used prior to AF ablations. Our study adds to the growing literature supporting the safety of catheter ablation in a non-fluoroscopy environment. [Figure: see text]