Zero Fluoroscopy Ablation: Recent Trends in Radiation Exposure in the EP Lab
- 5 Downloads
Purpose of review
Catheter ablation procedures involve fluoroscopy and can result in significant radiation exposure to the patient and staff. From the early 1980s to 2006, there was a 600% increase in the average medical radiation dose per person per year in the USA. Toward the end of this time frame, three-dimensional (3D) mapping systems, which use magnetic or electrical fields to track catheter location and movement, became clinically available. This has allowed reduction in fluoroscopy use. The goal of this manuscript is to review the current state of zero fluoroscopy ablations.
In the early 2000s, the first report of a 3D mapping system, used to replace fluoroscopy, emerged. By 2015, centers were routinely performing fluoroless ablations. Today, most centers use these systems to decrease radiation exposure. Multi-center registries now exist to quantify the changes in patient care.
Increased radiation exposure is associated with increased long-term risk of cancer. Today’s 3D mapping systems allow most ablation procedures to be performed without the use of fluoroscopy. With further refinements in the available tools, coupled with increasing operator experience, radiation exposure will be eliminated for all routine ablation procedures.
KeywordsAblation Fluoroscopy Radiation Three-dimensional mapping SVT Tachycardia
Compliance with Ethical Standards
Conflict of Interest
Chris Anderson declares that he has no conflict of interest. Alaina R. Martinez declares that she has no conflict of interest. Mansour Razminia is a consultant for Abbott. John Clark declares that he has no conflict of interest.
Human and animal rights and informed consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Mettler FA, 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.PubMedCrossRefPubMedCentralGoogle Scholar
- 2.Rottner L, Metzner A, Ouyang F, Heeger C, Hayashi K, Fink T, et al. Direct comparison of point-by-point and rapid ultra-high-resolution electroanatomical mapping in patients scheduled for ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2017;28(3):289–97.PubMedCrossRefPubMedCentralGoogle Scholar
- 3.Hilbert S, Sommer P, Gutberlet M, Gaspar T, Foldyna B, Piorkowski C, et al. Real-time magnetic resonance-guided ablation of typical right atrial flutter using a combination of active catheter tracking and passive catheter visualization in man: initial results from a consecutive patient series. Europace. 2016;18(4):572–7.PubMedCrossRefPubMedCentralGoogle Scholar
- 7.• Drago F, Silvetti MS, Pino AD, Grutter G, Bevilacqua M, Leibovich S. Exclusion of fluoroscopy during ablation treatment of right accessory pathway in children. J Cardiovasc Electrophysiol. 2002;13(8):778–82. The sentinel publication of ablation being done without fluoroscopy. It was too narrow in scope to be broadly applicable in practice.Google Scholar
- 8.• Smith G, Clark JM. Elimination of fluoroscopy use in a pediatric electrophysiology laboratory utilizing three-dimensional mapping. Pacing Clin Electrophysiol. 2007;30(4):510–8. The first publications showing broad usefulness of the Ensite system to eliminate fluoroscopy for right sided substrates.PubMedCrossRefPubMedCentralGoogle Scholar
- 9.• Tuzcu V. A nonfluoroscopic approach for electrophysiology and catheter ablation procedures using a three-dimensional navigation system. Pacing Clin Electrophysiol. 2007;30(4):519–25. The first publications showing broad usefulness of the Ensite system to eliminate fluoroscopy for right sided substrates.PubMedCrossRefPubMedCentralGoogle Scholar
- 10.• Clark J, Bockoven JR, Lane J, Patel CR, Smith G. Use of three-dimensional catheter guidance and trans-esophageal echocardiography to eliminate fluoroscopy in catheter ablation of left-sided accessory pathways. Pacing Clin Electrophysiol. 2008;31(3):283–9. The first publication to add ultrasound to 3D mapping to eliminate fluoroscopy for left-sided substrates.PubMedCrossRefPubMedCentralGoogle Scholar
- 11.• Ferguson JD, Helms A, Mangrum JM, Mahapatra S, Mason P, Bilchick K, et al. Catheter ablation of atrial fibrillation without fluoroscopy using intracardiac echocardiography and electroanatomic mapping. Circ Arrhythm Electrophysiol. 2009;2(6):611–9. Each of the referenced articles, 7–11, represents an important advancement in the movement toward elimination of fluoroscopy.PubMedPubMedCentralCrossRefGoogle Scholar
- 19.Macías R, Uribe I, Tercedor L, Jiménez-Jáimez J, Jiménez J, Barrio T, et al. A zero-fluoroscopy approach to cavotricuspid isthmus catheter ablation: comparative analysis of two electroanatomical mapping systems. Pacing Clin Electrophysiol. 2014;37(8):1029–37.PubMedCrossRefPubMedCentralGoogle Scholar
- 20.• Scaglione M, Ebrille E, Caponi D, Siboldi A, Bertero G, Di Donna P, et al. Zero-fluoroscopy ablation of accessory pathways in children and adolescents: CARTO3 electroanatomic mapping combined with RF and Cryoenergy. Pacing Clin Electrophysiol. 2015;38(6):675–81. The first manuscript demonstrating the usefulness of CARTO 3 to eliminate fluoroscopy in multiple tachycardia mechanisms.PubMedCrossRefGoogle Scholar
- 21.Kühne M, Knecht S, Mühl A, Reichlin T, Pavlović N, Kessel-Schaefer A, et al. Fluoroscopy-free pulmonary vein isolation in patients with atrial fibrillation and a patent foramen ovale using solely an electroanatomic mapping system. Talkachova A, editor. PLoS One. 2016;11(1):e0148059. PubMedPubMedCentralCrossRefGoogle Scholar
- 22.Marini M, Del Greco M, Ravanelli D, Cima A, Coser A, Porcedda G, et al. The benefit of a general, systematic use of mapping systems during electrophysiological procedures in children and teenagers: the experience of an adult EP laboratory. Pediatr Cardiol. 2016;37(4):802–9.PubMedCrossRefGoogle Scholar
- 23.•• Razminia M, Willoughby MC, Demo H, Keshmiri H, Wang T, D’Silva OJ, et al. Fluoroless catheter ablation of cardiac arrhythmias: a 5-year experience. Pacing Clin Electrophysiol. 2017;40(4):425–433. This study demonstrates the extent to which fluoroscopy can be minimized when the tools are used to their potential.PubMedCrossRefGoogle Scholar
- 24.Koca S. Electroanatomic mapping guided pediatric catheter ablation with limited/zero fluoroscopy. Anatol J Cardiol [Internet]. 2018 [cited 2018 Oct 1]; Available from: http://www.anakarder.com/jvi.aspx?pdir=anatoljcardiol&plng=eng&un=AJC-72687.
- 36.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.PubMedCrossRefPubMedCentralGoogle Scholar
- 38.Elmaraezy A, Ebraheem Morra M, Tarek Mohammed A, Al-Habaa A, Elgebaly A, Abdelmotaleb Ghazy A, et al. Risk of cataract among interventional cardiologists and catheterization lab staff: a systematic review and meta-analysis: risk of cataract among in IC’s. Catheter Cardiovasc Interv. 2017;90(1):1–9.PubMedCrossRefPubMedCentralGoogle Scholar
- 42.Goldstein JA, Balter S, Cowley M, Hodgson J, Klein LW. On behalf of the Interventional Committee of the Society of Cardiovascular Interventions. Occupational hazards of interventional cardiologists: prevalence of orthopedic health problems in contemporary practice. Catheter Cardiovasc Interv. 2004;63(4):407–11.PubMedCrossRefPubMedCentralGoogle Scholar
- 54.Stec S, Krynski T, Baran J, Kulakowski P. “Rescue” ablation of electrical storm in arrhythmogenic right ventricular cardiomyopathy in pregnancy. BMC Cardiovasc Disord [Internet]. 2013 Dec [cited 2018 Oct 1];13(1). Available from: http://bmccardiovascdisord.biomedcentral.com/articles/10.1186/1471-2261-13-58.
- 55.Szumowski L, Szufladowicz E, Orczykowski M, Bodalski R, Derejko P, Przybylski A, et al. Ablation of severe drug-resistant tachyarrhythmia during pregnancy. J Cardiovasc Electrophysiol. 2010;21(8):877–82.Google Scholar
- 63.•• Dubin AM, Jorgensen NW, Radbill AE, Bradley DJ, Silva JN, Tsao S, et al. What have we learned in the last 20 years? A comparison of a modern era pediatric and congenital catheter ablation registry to previous pediatric ablation registries. Heart Rhythm. 2019;16(1):57–63. This is a multi-centered study, showing that the procedure has broad application.PubMedCrossRefGoogle Scholar
- 66.•• Philip Saul J, Kanter RJ, Writing Committee, Abrams D, Asirvatham S, Bar-Cohen Y, et al. PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease: developed in partnership with the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American Academy of Pediatrics (AAP), the American Heart Association (AHA), and the Association for European Pediatric and Congenital Cardiology (AEPC). Heart Rhythm. 2016;13(6):e251–89. This article demonstrates the acceptance that the approach has obtained in the pediatric field, being now considered standard of care.PubMedCrossRefGoogle Scholar
- 67.•• Razminia M, Zei P. Fluoroscopy reduction techniques for catheter ablation of cardiac arrhythmias. Cardiotext. 2019. The book is significant because it is a more in-depth review of fluoroless procedures and it is the first book published on the topic.Google Scholar