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

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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.

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Authors and Affiliations



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.

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Correspondence to Vedran Velagic.

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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.

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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.

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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).

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