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Intracardiac echocardiography-guided transseptal puncture for fluoroless catheter ablation of left-sided tachycardias

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Integration of intracardiac echocardiography (ICE) and 3D electroanatomic mapping (EAM) system allows transseptal punctures (TSP) without the use of fluoroscopy. Compared with fluoroscopy, ICE provides better visualization of the anatomy relevant to TSP and early recognition of complications. The aim was to evaluate efficacy and safety of entirely ICE-guided TSPs in patients who underwent fluoroless catheter ablation of left-sided tachycardias.


Consecutive 524 adult and pediatric patients referred to our institution from July 2014 to December 2019 were analyzed. Patients with cardiac implantable electronic devices (CIEDs) were also included. All procedures were performed with ICE-guided TSP combined with 3D EAM. Adverse events following TSP and within 30 days of the procedure were analyzed.


Altogether 949 TSPs (363 double punctures, 76.5%) were performed in 586 fluoroless ablation procedures: 451 (77%) were ablation of atrial fibrillation or atypical flutter, 75 (12.8%) of left-sided accessory pathway, 33 (5.6%) of ventricular tachycardia, and 27 (4.6%) of focal atrial tachycardia. Forty-six (7.8%) procedures were performed in pediatric population and 36 procedures (6.1%) in patients with CIED. Only 2 TSPs were unsuccessful (2/949, 0.2%). Overall procedural complication rate was 1.9% (11/586 procedures). There was only 1 TSP-related pericardial tamponade (2/949, 0.2%). In CIED patients, there was 1 lead dislocation following TSP.


Entirely ICE-guided TSPs for different left-sided tachycardias can be safely and effectively performed in adult and pediatric population without the use of fluoroscopy. However, caution is advised in CIED patients due to possible lead dislocation risk.

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All data generated and analyzed during this study are included in this published article or can be provided upon request.


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Authors and Affiliations



All authors (DŽ, BA, TPK, JŠ, NK, MJ, and MJ) made substantial contribution to the design of the study, acquisition, analysis, and interpretation of data. All authors also actively participated in drafting the manuscript, its final revisions and corrections. All authors read and approved the final version of the manuscript. All authors agree to be personally accountable for their personal contributions to the manuscript.

Corresponding author

Correspondence to David Žižek.

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Conflict of interest

David Žižek received consulting/advisory board support from Medtronic and Boston Scientific. Bor Antolič and Matevž Jan received proctorship fees from Biosense Webster. All other authors have no relationships relevant to the contents of this paper to disclose.

Ethics approval and consent to participate

The study complies with the Declaration of Helsinki. The fluoroless approach to catheter ablation, including transseptal puncture, was approved by The National Medical Ethics Committee (Komisija za medicinsko etiko Republike Slovenije). All patients (or their parents in case of pediatric patients) gave written informed consent before ablation procedures were performed.

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Not applicable.

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Žižek, D., Antolič, B., Prolič Kalinšek, T. et al. Intracardiac echocardiography-guided transseptal puncture for fluoroless catheter ablation of left-sided tachycardias. J Interv Card Electrophysiol 61, 595–602 (2021).

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