Fluoroscopy-free AF ablation using transesophageal echocardiography and electroanatomical mapping technology



Guidelines recommend that radiation exposure during AF catheter ablation procedures should be ‘as low as reasonably achievable’ (ALARA), particularly since many patients may have multiple procedures. Consequently, avoiding radiation exposure altogether must, if safe to do so, be the ultimate goal. The primary objective was to determine the feasibility and efficacy of fluoroscopy-free AF ablation compared to the fluoroscopy-assisted procedure.


Patients underwent AF ablation using commercially available technology with no routine pre-procedural imaging. The use of non-fluoroscopic imaging/mapping technologies permitted us to initially reduce x-ray exposure before eliminating its use altogether. This evolution of our practice proceeded in two stages: a 9-month period of optimising our fluoroscopy-free ablation protocol followed by a 9-month period during which we set out to complete the whole procedure routinely without fluoroscopy. We describe the protocol developed and report salient endpoints, such as complications, procedure times, patient experience, and procedural success rates.


During the study period, fluoroscopy-free AF ablation was attempted in 69 patients: 24 in the 9-month ‘development phase’ and 45 in the ‘implementation phase’. During the development phase, 13 of 24 patients (54%) were treated without the use of fluoroscopy. In the implementation phase, 45 patients underwent AF ablation of which 42 (93.3%) were fluoroscopy-free. A detailed description is given of the three cases in which fluoroscopy had to be used despite an intention not to.


Fluoroscopy-free complex ablation procedures for the treatment of atrial fibrillation are safe and feasible in most patients.

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We are grateful to our colleagues helping to administer the audit, Senior Nurse Practitioner Claire Chitty, Office managers Cristina Thorne and Melanie Todd.

We want to thank the allied health professionals and nurses working in our catheter laboratories, supporting our ongoing quest to improve care for patients suffering atrial fibrillation.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

RS and BOB conceived the paper. DB collated and analysed the data. BOB drafted the manuscript. DB, RH, and RS critically revised the manuscript.

Correspondence to Benjamin O’Brien.

Ethics declarations

Conflict of interest

Richard Schilling has received research grants for Biosense Webster, Medtronic, St Jude Medical, Boston Scientific, Biotronik, Speaker fees for Biosense, Medtronic, Boeringher Ingleheim.

Ethical approval

This fluoro-free ablation protocol was developed to achieve best practice by following published ALARA guidance. Our analysis was performed retrospectively. For this type of study, formal consent is not required.

Additional information

Benjamin O’Brien, Damian C. Balmforth, Ross J. Hunter, and Richard J. Schilling are the authors who take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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O’Brien, B., Balmforth, D.C., Hunter, R.J. et al. Fluoroscopy-free AF ablation using transesophageal echocardiography and electroanatomical mapping technology. J Interv Card Electrophysiol 50, 235–244 (2017) doi:10.1007/s10840-017-0288-9

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  • Atrial fibrillation
  • Ablation
  • Fluoroscopy
  • Radiation
  • ALARA (as low as reasonably achievable)