Near-Zero-Fluoroscopy Ablation of Atrial fibrillation without ICE or non-fluoroscopic tracking systems: Procedural insights from the SHORT LOOK registry

Background: Catheter ablation for atrial fibrillation (AF) is a cornerstone of rhythm-preserving therapy. While effective, the use of fluoroscopy during these procedures presents risks of radiation exposure. Technological advancements have reduced fluoroscopy time, yet the high costs of systems like intracardiac echocardiography (ICE) and non-fluoroscopic tracking systems (NCTS) limit their widespread use. The SHORT LOOK study aims to evaluate the efficiency and safety of a streamlined, near-zero fluoroscopy workflow for initial pulmonary vein isolation (PVI) without additional expensive adjunctive technologies.

Methods: The SHORT LOOK registry is an investigator-driven, all-comer, all-operator, prospective study that enrolled 550 consecutive patients undergoing their first PVI for AF. Additional lesions could be performed at the operator's discretion. Due to the withdrawal of consent and the exclusion of patients with incomplete data sets, 450 patients were included in the final analysis. This streamlined workflow, performed by all operators in the study center, utilized low-dose fluoroscopy protocols on an Artis zee angiography system, with no additional ICE or NCTS and a near-zero fluoroscopy ablation workflow. Baseline evaluations included medical history, physical examination, laboratory tests, ECG, and transthoracic echocardiogram (Tab. 1). Procedural parameters, fluoroscopy time, and radiation dose were meticulously recorded (Tab. 3). Outcomes were compared with a historical cohort ablated using MediGuide (NCTS). Propensity score matching (PSM) was applied to ensure comparability between groups.

Results: The SHORT LOOK cohort (n=450) demonstrated a median (IQR) procedural time of 57 (49-70) minutes and a fluoroscopy time of 26 (14-41) seconds, with a fluoroscopy dose of 9.1 (4.4-17.1)  µGym². Notably, the fluoroscopy duration for vascular access, coronary sinus intubation, and transseptal puncture was significantly minimized.

Compared to the NCTS control group (n=77 post-PSM), the SHORT LOOK workflow achieved significantly lower fluoroscopy times (0.45 [0.20-0.68] vs. 1.10 [0.50-2.60] minutes, p<0.001) and doses (9 [3.75-15.21] vs. 282 [156.5-743.6] µGym², p<0.001). The complication rate was under 1%, with no pericardial effusions, myocardial infarctions, or strokes reported. The near-zero fluoroscopy workflow proved to be both efficient and safe, with a complication rate comparable to or better than historical controls.

Conclusion: The streamlined near-zero fluoroscopy workflow for initial AF ablation demonstrates significant reductions in fluoroscopy duration and dose, maintaining a high safety profile. This approach is feasible for implementation in any electrophysiology lab, potentially broadening access to safer AF ablation procedures and reducing radiation exposure risks.