Catheter Ablation of Atrial Fibrillation Using Zero-Fluoroscopy Technique: A Randomized Trial

Background: Recent advances in 3D mapping systems, such as simultaneous visualization of multiple catheters and contact force measurement, have allowed a significant reduction in fluoroscopic times during radiofrequency (RF) ablation (RFA) procedures. The objective was to investigate whether RFA of paroxysmal atrial fibrillation (PAF) using the CARTO 3 system (Biosense Webster, Diamond Bar, CA, USA) and intracardiac echocardiography (ICE) can be performed safely without fluoroscopy.

Methods and results: Eighty patients with PAF were randomized in a 1:1 ratio to undergo either fluoroscopically guided pulmonary vein isolation (PVI) (X+) or PVI without fluoroscopy (X-). In the X- fluoroscopy group, catheter placement, transseptal puncture, left atrial geometry reconstruction, and PVI were accomplished solely using ICE imaging and CARTO mapping. The total procedure duration and RF application time in both the X- and X+ groups were comparable (92.5 ± 22.9 minutes vs 99.9 ± 15.9 minutes, P = 0.11 and 1785 ± 548 seconds vs 1755 ± 450 seconds, P = 0.79, respectively). Zero fluoroscopic time was achieved in all patients in the X- group with the exception of one patient, where 8 seconds of fluoroscopy was needed to assess proper position of the guide-wire in the femoral vein. No serious procedure-related complications were recorded and no differences in arrhythmia-free survival at 12 months were found between the groups.

Conclusion: RFA using ICE imaging and the CARTO 3 mapping system with contact force measurement is capable of eliminating fluoroscopy in patients undergoing PVI. Exclusion of fluoroscopic imaging does not seem to compromise patient safety and does not affect overall procedure duration, RF application time, or mid-term efficacy.