As a cardiac electrophysiologist, I have been working on reducing fluoro time since my EP fellowship. Thanks to the support of my attending physicians, EP lab staff members, and support staff members, I am now doing zero fluoro ablation for most of my supraventricular tachycardia cases. Although I do not consider myself a master of this approach, I have been working on a fluoro reduction technique for some time, and can provide some helpful tips. I hope this article will help you move toward a zero fluoro ablation approach.
There are several techniques and tips for reducing fluoroscopy. Included here are 10 tips for performing fluoroless ablation.
#1: Know the basics
Catheter ablation is a standard therapeutic modality for arrhythmias. The basic concept of fluoroless ablation is the same as conventional catheter ablation: doing an EP study, making a diagnosis, and then proceeding with catheter ablation. The only difference is whether or not to use fluoroscopy. Therefore, having an understanding of cardiac electrophysiology, including of the anatomy of the heart and maneuvers for diagnosing tachycardia, is the basic necessity for performing zero fluoro ablation.
#2: Be comfortable using a 3D mapping system to create a geometric model
Once vascular access is obtained in the femoral vein, catheters can be advanced through the inferior vena cava (IVC). Creating a geometric model from the groin to the heart with a diagnostic EP catheter (such as a Josephson or CRD catheter) will obviate the need for fluoroscopy to advance catheters to the heart (Figure 1). You can then advance the other catheters through this without fluoroscopy. (Figure 2)
#3: Do not push catheters
When making a geometric model of the heart, do not push too hard when manipulating catheters. If resistance is felt, withdraw the catheter and redirect it to the place of interest. Forceful movement is not permitted inside the heart. Remember that the heart wall may be thin in the atrium, and damaging the structure could result in cardiac perforation. Therefore, if there is resistance, do not push — change directions!
#4: Remember that ICE is your friend, not your enemy
ICE is extremely important for fluoroless ablation, and can help the operator determine the optimal site for transseptal puncture. ICE can be useful for cavotricuspid isthmus (CTI) ablation for atrial flutter, and can also be utilized to evaluate the ostium of the coronary arteries at the time of left ventricular outflow tract tachycardia (LVOT-VT) ablation. Real-time location and movement of catheters can be visualized with ICE. It is also very helpful for complex ablations, as it can be readily available to evaluate for pericardial effusion at the time of emergency (e.g., hypotension and cardiac tamponade). Therefore, become comfortable manipulating the ICE catheter.
#5: You do not have to achieve zero fluoroscopy on the first day
It’s not important to achieve zero fluoroscopy on day 1. Start by simply reducing fluoroscopy time during “non-essential” moments. For example, in the instances when fluoroscopy would typically be used, determine if there is another modality (such as 3D mapping or ICE) that can replace your use of fluoro. Another recommendation when using fluoroscopy is to choose a lower frame rate (7.5 or 3.75 frames per second), which will decrease radiation exposure. Reducing fluoroscopy time will benefit your patients and personnel in the EP lab. Remember that safety is the number one priority. Utilize the ALARA (as low as reasonably achievable) principle and wear appropriate radiation personal protective equipment.
#6: Review your workflow to find where fluoroscopy time can be reduced
Reviewing your workflow is essential for improving procedural safety and efficiency. When reviewing fluoro time, question whether fluoroscopy was needed or helpful in those cases. If not, try to use less fluoroscopy the next time you do the same process. Small steps to reduce fluoroscopy will result in an overall change in workflow.
#7: Monitor your progress
Once workflow has been reviewed and change has been implemented, follow up on your progress. Keep a log of all fluoroscopic times to view trends and progress over time. Knowing these outcomes can help you prepare options for improving your procedures with a Plan-Do-Check-Act (PDCA) cycle.
#8: Repetition is key
Once you are comfortable performing zero fluoro ablation, it will no longer be necessary to wear lead, which will reduce orthopedic risk associated with EP procedures. Continuous improvement is crucial for long-term success.
#9: Use available resources
I have attended workshops on ICE as well as participated in observerships to learn fluoroless ablation, and these opportunities were very helpful in learning how to reduce fluoroscopy time and improve procedural workflow. There is also a lot of information in the literature on the zero fluoro ablation approach; various examples can be found in journals and textbooks.1-6 Information can be found on Twitter as well; follow some of the electrophysiologists who have pioneered this technique, including @MRazminia, @paulzei, @josoriomd, and @BrettGidney.
#10: Seeing is believing
When I first saw zero fluoro ablation being used for atrial fibrillation several years ago, it was an eye-opening experience. With the advancement of technologies such as 3D mapping, ICE, and contact force sensing technology, fluoroless ablation is becoming safer and more feasible. There are some hurdles to overcome before successfully achieving fluoroless ablation. However, once you make the decision to proceed with a zero fluoro ablation technique, 90% of the mission is complete! Good luck!
Acknowledgements. I want to thank Dr. Jane Crosson, a pediatric cardiac electrophysiologist at Johns Hopkins Children’s Center, for her encouragement and support with fluoroless ablation during my EP fellowship. I’d also like to thank Debbie Tankersley and Robert Russell for their support with intracardiac echocardiography during cases.
Find Dr. Suzuki on Twitter at @takekisuzuki
Disclosure: The author has no conflicts of interest to report regarding the content herein.
- Razminia M, Willoughby MC, Demo H, et al. Fluoroless catheter ablation of cardiac arrhythmias: a 5-year experience. Pacing Clin Electrophysiol. 2017;40:425-433.
- Lerman BB, Markowitz SM, Liu CF, Thomas G, Ip JE, Cheung JW. Fluoroless catheter ablation of atrial fibrillation. Heart Rhythm. 2017;14:928-934.
- Enriquez A, Saenz LC, Rosso R, et al. Use of intracardiac echocardiography in interventional cardiology: working with the anatomy rather than fighting it. Circulation. 2018;137:2278-2294.
- Razminia M, Zei PC. Fluoroscopy Reduction Techniques for Catheter Ablation of Cardiac Arrhythmias. Minneapolis, MN: Cardiotext Publishing; 2019.
- Dell’Orfano J. Unleaded ablations: starting a zero-fluoro ablation program. EP Lab Digest. 2019;19(1):28-30.
- Percell RL. The SANS FLUORO approach to ablation. EP Lab Digest. 2019;19(3):33-35.