Skip to main content
SpringerLink
Log in

Radiation dose reduction in the setting of cryoballoon ablation for atrial fibrillation: the value of optimized fluoroscopy settings and intracardiac echocardiography

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Cryoballoon (CB) has proven to be very effective in the percutaneous treatment of atrial fibrillation (AF). CB ablation is still hampered by X-ray exposure and the doses applied are consistently higher if compared to radiofrequency ablation. All patients who underwent CB ablation between 2015 and 2020 were analysed. Intracardiac echography was consistently used for transeptal puncture. To demonstrate the differences in radiation exposure 3 groups of 50 consecutive patients were selected. In the first group (G1) 3D rotational angiography (3DRA) was used as an intraprocedural imaging method. In the second group (G2), traditional X-ray imaging was used and frame rates both for fluoro and cine modes of diascopy were lowered. In the third group (G3) only 2–3 frames per second were used, cine mode was abandoned and the grid was removed from the X-ray detector. A total of 150 patients were included (76% males, mean age 57.3 ± 11.5 years). A dramatic reduction of radiation dose was obtained from 9585 ± 5610 µGy/m2 in G1 to 2469 ± 2002 µGy/m2 in G2 and finally 227.1 ± 360 µGy/m2 in G3 (p < 0.0001). There was also a significant decrease of procedural and fluoroscopy times. No difference in major complications and midterm outcomes was found between the groups. By following a few relatively simple steps (omitting the pre-procedural imaging, removing grid from the X-ray detector and using very low frame rates) CB ablation could be performed with ultralow radiation exposure without compromising the safety of efficacy of the procedure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

No associated data.

References

  1. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, ESC Scientific Document Group et al (2021) 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 42(5):373–498

    Article  Google Scholar 

  2. Velagić V, de Asmundis C, Mugnai G, Hünük B, Hacioğlu E, Ströker E et al (2017) Learning curve using the second-generation cryoballoon ablation. J Cardiovasc Med (Hagerstown) 18(7):518–527

    Article  Google Scholar 

  3. Aryana A, Singh SM, Kowalski M, Pujara DK, Cohen AI, Singh SK et al (2015) Acute and long-term outcomes of catheter ablation of atrial fibrillation using the second-generation cryoballoon versus open-irrigated radiofrequency: a multicenter experience. J Cardiovasc Electrophysiol 26(8):832–839

    Article  Google Scholar 

  4. Murray MI, Arnold A, Younis M, Varghese S, Zeiher AM (2018) Cryoballoon versus radiofrequency ablation for paroxysmal atrial fibrillation: a meta-analysis of randomized controlled trials. Clin Res Cardiol 107:658–669

    Article  Google Scholar 

  5. Fortuni F, Casula M, Sanzo A, Angelini F, Cornara S, Somaschini A et al (2020) Meta-analysis comparing cryoballoon versus radiofrequency as first ablation procedure for atrial fibrillation. Am J Cardiol 125(8):1170–1179

    Article  Google Scholar 

  6. Antolič B, Kajdič N, Vrbajnščak M, Jan M, Žižek D (2021) Integrated 3D intracardiac ultrasound imaging with detailed pulmonary vein delineation guided fluoroless ablation of atrial fibrillation. Pacing Clin Electrophysiol 44(9):1487–1496

    Article  Google Scholar 

  7. Buiatti A, von Olshausen G, Barthel P, Schneider S, Luik A, Kaess B et al (2017) Cryoballoon vs. radiofrequency ablation for paroxysmal atrial fibrillation: an updated meta-analysis of randomized and observational studies. Europace 19(3):378–384

    Article  Google Scholar 

  8. Lickfett L, Mahesh M, Vasamreddy C, Bradley D, Jayam V, Eldadah Z et al (2004) Radiation exposure during catheter ablation of atrial fibrillation. Circulation 110:3003–3010

    Article  Google Scholar 

  9. Reissmann B, Maurer T, Wohlmuth P, Krüger M, Heeger C, Lemes C et al (2018) Significant reduction of radiation exposure in cryoballoon-based pulmonary vein isolation. Europace 20(4):608–613

    Article  Google Scholar 

  10. Holl MJ, Bhagwandien RE, Firouzi M, de Ruiter WA, Szili-Torok T, Yap SC (2020) Reducing radiation exposure in second-generation cryoballoon ablation without compromising clinical outcome. J Interv Cardiac Electrophysiol. https://doi.org/10.1007/s10840-020-00737-7

    Article  Google Scholar 

  11. Wieczorek M, Hoeltgen R (2020) A modified fluoroscopy protocol to minimize radiation exposure during pulmonary vein isolation with second-generation cryoballoon. Pacing Clin Electrophysiol 43(12):1538–1545

    Article  Google Scholar 

  12. Razminia M, Demo H, Arrieta-Garcia C, D’Silva OJ, Wang T, Kehoe RF (2014) Nonfluoroscopic ablation of atrial fibrillation using cryoballoon. J Atr Fibrillation 7(1):1093

    Google Scholar 

  13. Reiss J, O’Connell H, Getman MK (2020) Achieving contrast-free ultra-low radiation exposure without compromising safety and acute efficacy through evolving AF cryoballoon ablation procedure techniques. Int J Cardiol 15(299):153–159

    Article  Google Scholar 

  14. Ciconte G, Mugnai G, Sieira J, Velagić V, Saitoh Y, Irfan G et al (2015) On the quest for the best freeze: predictors of late pulmonary vein reconnections after second-generation cryoballoon ablation. Circ Arrhythm Electrophysiol 8(6):1359–1365

    Article  Google Scholar 

  15. Ghosh J, Singarayar S, Kabunga P, McGuire MA (2015) Subclavian vein pacing and venous pressure waveform measurement for phrenic nerve monitoring during cryoballoon ablation of atrial fibrillation. Europace 17:884–890

    Article  Google Scholar 

  16. Orlov MV (2009) How to perform and interpret rotational angiography in the electrophysiology laboratory. Heart Rhythm 6(12):1830–1836

    Article  Google Scholar 

  17. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L et al (2018) 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 20(1):e1–e160

    Article  Google Scholar 

  18. Sagone A, Iacopino S, Pieragnoli P, Arena G, Verlato R, Molon G et al (2019) Cryoballoon ablation of atrial fibrillation is effectively feasible without previous imaging of pulmonary vein anatomy: insights from the 1STOP project. J Interv Card Electrophysiol 55(3):267–275

    Article  CAS  Google Scholar 

  19. Providencia R, Defaye P, Lambiase PD, Pavin D, Cebron JP, Halimi F et al (2017) Results from a multicentre comparison of cryoballoon vs. radiofrequency ablation for paroxysmal atrial fibrillation: is cryoablation more reproducible? Europace 19:48–57

    Google Scholar 

  20. Velagic V, Mugnai G, Kardum D, Prepolec I, Pasara V, Puljevic M et al (2021) Intra-procedural three-dimensional rotational angiography in cryoballoon ablation for atrial fibrillation. Int J Cardiovasc Imaging 37(2):389–397

    Article  Google Scholar 

  21. Kautzner J, Haskova J, Lehar F (2021) Intracardiac echocardiography to guide non-fluoroscopic electrophysiology procedures. Card Electrophysiol Clin 13(2):399–408

    Article  Google Scholar 

  22. Rubesch-Kütemeyer V, Molatta S, Vogt J, Gutleben KJ, Horstkotte D, Nölker G (2017) Reduction of radiation exposure in cryoballoon ablation procedures: a single-centre study applying intracardiac echocardiography and other radioprotective measures. Europace 19(6):947–953

    Google Scholar 

  23. Duncker D, Svetlosak M, Guerra F, Nagy KV, Vanduynhoven P, Mikhaylov EN et al (2021) Reprocessing of electrophysiology material in EHRA countries: an EHRA young EP survey. Europace 23(3):479–485

    Article  Google Scholar 

  24. Partridge J, McGahan G, Causton S, Bowers M, Mason M, Dalby M et al (2006) Radiation dose reduction without compromise of image quality in cardiac angiography and intervention with the use of a flat panel detector without an antiscatter grid. Heart 92(4):507–510

    Article  CAS  Google Scholar 

Download references

Funding

No funding was received.

Author information

Authors and Affiliations

  1. Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Kišpatićeva 12, 10000, Zagreb, Croatia

    Vedran Velagic, Ivan Prepolec, Vedran Pasara, Mislav Puljevic, Borka Pezo-Nikolic, Davor Puljević & Davor Milicic

  2. Electrophysiology and Cardiac Pacing, Division of Cardiology, University Hospital of Verona, Verona, Italy

    Giacomo Mugnai

  3. Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium

    Carlo de Asmundis & Gian-Battista Chierchia

Authors
  1. Vedran Velagic
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Giacomo Mugnai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ivan Prepolec
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vedran Pasara
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mislav Puljevic
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Borka Pezo-Nikolic
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Davor Puljević
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Carlo de Asmundis
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Gian-Battista Chierchia
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Davor Milicic
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

VV and GM were responsible for conception of the study and drafting of the manuscript. VP, IP, BPN and MP were responsible for acquisition and analysis of the data. DP, CdA, GBC and DM were responsible for critical revision of the manuscript and important intellectual content.

Corresponding author

Correspondence to Vedran Velagic.

Ethics declarations

Conflict of interest

VV received proctoring and lecture fees from Medtronic and Biosense-Webster. GBC and CdA received compensation for teaching purposes and proctoring from Medtronic, Acutus Medical, Biosense-Webster, Biotronik, Abbott Medical, Boston Scientific and Philips. All other authors have no financial interests.

Ethical approval

Ethical approval was waived by the local Ethics Committee of University Hospital Centre Zagreb in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Velagic, V., Mugnai, G., Prepolec, I. et al. Radiation dose reduction in the setting of cryoballoon ablation for atrial fibrillation: the value of optimized fluoroscopy settings and intracardiac echocardiography. Int J Cardiovasc Imaging 39, 245–254 (2023). https://doi.org/10.1007/s10554-022-02717-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-022-02717-6

Keywords

Search

Navigation