Catheter ablation of atrial fibrillation with nonfluoroscopic catheter visualization—a prospective randomized comparison

  • Sascha RolfEmail author
  • Katharina Schoene
  • Simon Kircher
  • Boris Dinov
  • Livio Bertagnolli
  • Andreas Bollmann
  • Sergio Richter
  • Arash Arya
  • Gerhard Hindricks
  • Philipp Sommer



The application of a novel platform for nonfluoroscopic catheter sensor tracking within pre-recorded x-ray loops in the context of catheter ablation of atrial fibrillation (AF) demonstrated significant potential for reduction of fluoroscopy. We sought to provide the first prospective randomized comparison of fluoroscopy needs, procedure times, and complications in AF catheter ablation with or without additional use of nonfluoroscopic catheter visualization (NFCV).


Patients with AF were randomized into two groups before scheduled radiofrequency ablation: (1) using established mapping systems and fluoroscopy as needed (CONV group) or (2) with additional NFCV (NFCV group). All procedures were performed in the same lab using the same ablation catheter tip technology and the same mapping and ablation strategies. Primary endpoints were radiation time and dose. Secondary endpoints were procedural parameters, complications, and long-term success.


A total of 80 patients (48 male patients, mean age 60 years, 46 patients with paroxysmal AF) were randomized into the two groups. Clinical parameters between both groups were similar. NFCV use reduced mean fluoroscopy time (1.9 vs. 13.2 min, p < 0.001) and mean dose (510 vs. 1549 Gycm2, p < 0.001) significantly. Procedural parameters were similar in the two groups. One conservatively treated groin complication occurred (1.3%).


Radiation exposure can be significantly reduced by using the novel NFCV technology in addition to standard AF ablation technologies without negative effects on procedure durations, success rates, or complication rates. With the use of the technology, abandonment of lead protection for EP staff is possible following transseptal puncture.


Catheter ablation Atrial fibrillation Nonfluoroscopic Radiation exposure MediGuide 



Atrial fibrillation


Electro-anatomical mapping system


Left atrium


Nonfluoroscopic catheter visualization


Pulmonary vein





The authors thank Craig Markovitz for proofreading the manuscript.

Compliance with ethical standards

Conflict of interest

S. R. and P. S. received modest honoraria for speaking at symposia.

Ethical approval

The institutional ethics committee approved the study.

Informed consent

All study participants provided written and verbal informed consent.


  1. 1.
    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18(11):1609–78. Scholar
  2. 2.
    Venneri L, Rossi F, Botto N, Andreassi MG, Salcone N, Emad A, et al. Cancer risk from professional exposure in staff working in cardiac catheterization laboratory: insights from the National Research Council’s biological effects of ionizing radiation VII report. Am Heart J. 2009;157(1):118–24. Scholar
  3. 3.
    Heidbuchel H, Wittkampf FH, Vano E, Ernst S, Schilling R, Picano E, et al. Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures. Europace. 2014;16(7):946–64. Scholar
  4. 4.
    Rolf S, Sommer P, Gaspar T, John S, Arya A, Hindricks G, et al. Ablation of atrial fibrillation using novel 4-dimensional catheter tracking within autoregistered left atrial angiograms. Circ Arrhythm Electrophysiol. 2012;5(4):684–90. Scholar
  5. 5.
    Rolf S, John S, Gaspar T, Dinov B, Kircher S, Huo Y, et al. Catheter ablation of atrial fibrillation supported by novel nonfluoroscopic 4D navigation technology. Heart Rhythm. 2013;10(9):1293–300. Scholar
  6. 6.
    Sommer P, Bertagnolli L, Kircher S, Arya A, Bollmann A, Richter S, et al. Safety profile of near-zero fluoroscopy atrial fibrillation ablation with non-fluoroscopic catheter visualization: experience from 1000 consecutive procedures. Europace. 2018.
  7. 7.
    Rolf S, Kircher S, Arya A, Eitel C, Sommer P, Richter S, et al. Tailored atrial substrate modification based on low-voltage areas in catheter ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2014;7(5):825–33. Scholar
  8. 8.
    Eitel C, Hindricks G, Sommer P, Gaspar T, Kircher S, Wetzel U, et al. Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: the pace-and-ablate approach. Heart Rhythm. 2010;7(2):157–64. Scholar
  9. 9.
    Pillai A, Reddy M, Heard M, Vallakati A, Berenbom L, Lakkireddy D. Atrial flutter ablation using MediGuide(TM) non-fluoroscopic catheter tracking system: a novel technology to reduce radiation exposure. J Atr Fibrillation. 2012;5(3):730. Scholar
  10. 10.
    Ballesteros G, Ramos Ardanaz P, Neglia R, Palacio Solis M, Diaz Fernandez C, Lopez Gonzalez G, et al. Mediguide-assisted transseptal puncture without echocardiographic guidance. Pacing Clin Electrophysiol. 2017;40(5):545–50. Scholar
  11. 11.
    Mansour M, Afzal MR, Gunda S, Pillarisetti J, Heist K, Acha MR, et al. Feasibility of transseptal puncture using a nonfluoroscopic catheter tracking system. Pacing Clin Electrophysiol. 2015;38(7):791–6. Scholar
  12. 12.
    Mettler FA Jr, Bhargavan M, Faulkner K, Gilley DB, Gray JE, Ibbott GS, et al. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources--1950-2007. Radiology. 2009;253(2):520–31. Scholar
  13. 13.
    McFadden SL, Mooney RB, Shepherd PH. X-ray dose and associated risks from radiofrequency catheter ablation procedures. Br J Radiol. 2002;75(891):253–65. Scholar
  14. 14.
    Lickfett L, Mahesh M, Vasamreddy C, Bradley D, Jayam V, Eldadah Z, et al. Radiation exposure during catheter ablation of atrial fibrillation. Circulation. 2004;110(19):3003–10. Scholar
  15. 15.
    Doody MM, Freedman DM, Alexander BH, Hauptmann M, Miller JS, Rao RS, et al. Breast cancer incidence in U.S. radiologic technologists. Cancer. 2006;106(12):2707–15. Scholar
  16. 16.
    Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111(9):1368–72. Scholar
  17. 17.
    Buchanan GL, Chieffo A, Mehilli J, Mikhail GW, Mauri F, Presbitero P, et al. The occupational effects of interventional cardiology: results from the WIN for safety survey. EuroIntervention. 2012;8(6):658–63. Scholar
  18. 18.
    Thibault B, Macle L, Mondesert B, Dubuc M, Shohoudi A, Dyrda K, et al. Reducing radiation exposure during procedures performed in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 2018;29(2):308–15. Scholar
  19. 19.
    Christoph M, Wunderlich C, Moebius S, Forkmann M, Sitzy J, Salmas J, et al. Fluoroscopy integrated 3D mapping significantly reduces radiation exposure during ablation for a wide spectrum of cardiac arrhythmias. Europace. 2015;17(6):928–37. Scholar
  20. 20.
    Bulava A, Hanis J, Eisenberger M. Catheter ablation of atrial fibrillation using zero-fluoroscopy technique: a randomized trial. Pacing Clin Electrophysiol. 2015;38(7):797–806. Scholar
  21. 21.
    Lyan E, Tsyganov A, Abdrahmanov A, Morozov A, Bakytzhanuly A, Tursunbekov A, et al. Nonfluoroscopic catheter ablation of paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2018;41(6):611–9. Scholar
  22. 22.
    Reddy VY, Morales G, Ahmed H, Neuzil P, Dukkipati S, Kim S, et al. Catheter ablation of atrial fibrillation without the use of fluoroscopy. Heart Rhythm. 2010;7(11):1644–53. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Sascha Rolf
    • 1
    Email author
  • Katharina Schoene
    • 2
  • Simon Kircher
    • 3
  • Boris Dinov
    • 3
  • Livio Bertagnolli
    • 3
  • Andreas Bollmann
    • 3
  • Sergio Richter
    • 3
  • Arash Arya
    • 3
  • Gerhard Hindricks
    • 3
  • Philipp Sommer
    • 3
  1. 1.Department of CardiologyDRK Kliniken Berlin WestendBerlinGermany
  2. 2.Leipzig Heart Institute, LHIHeart CenterLeipzigGermany
  3. 3.Department of Electrophysiology, Heart CenterUniversity of LeipzigLeipzigGermany

Personalised recommendations