ABC | Volume 114, Nº6, June 2020

Original Article Catheter Ablation for Treatment of Atrial Fibrillation and Supraventricular Arrhythmias Without Fluoroscopy Use: Acute Efficacy and Safety Eduardo B. Saad, 1 C harles Slater, 1 Luiz Antonio Oliveira Inácio Jr., 1 Gustavo Vignoli dos Santos, 1 Lucas Carvalho Dias, 1 Luiz Eduardo Montenegro Camanho 1 Hospital Pró-Cardíaco - Serviço de Arritmias e Estimulação Cardíaca Artificial, 1 Rio de Janeiro, RJ - Brazil Mailing Addresss: Eduardo B. Saad • Hospital Pró-Cardíaco - Serviço de Arritmias e Estimulação Cardíaca Artificial - Rua General Polidoro, 192. CEP 22280-003, Botafogo, RJ – Brazil E-mail: eduardobsaad@hotmail.com Manuscript received February 05, 2020, revised manuscript March 30, 2020, accepted April 08, 2020 DOI: https://doi.org/10.36660/abc.20200096 Abstract Background: The use of ionizing radiation in medical procedures is associated with significant health risks for patients and the health care team. Objectives: Evaluate the safety and acute efficacy of ablation for atrial fibrillation (AF) and supraventricular arrhythmias (SVTs) using an exclusively non-fluoroscopic approach guided by intracardiac echo (ICE) and 3D-mapping.  Methods: 95 pts (mean age 60 ± 18 years, 61% male) scheduled for AF Ablation (69 pts, 45 paroxysmal AF and 24 persistent AF) or non-AF SVT (26 pts – 14 AV node reentry, 6 WPW, 5 right atrial (RA) flutters, 1 atrial tachycardia) underwent zero fluoro procedures. Nine patients (9.5%) had permanent pacemakers or defibrillator resynchronization (CRT-D) devices. Both CARTO (65%) and NAVx (35%) mapping systems were used, as well as Acunav and ViewFlex ICE catheters. Results: Pulmonary vein isolation (PVI), as well as all other targets that needed ablation in both atria were reached and adequately visualized. No pericardial effusions, thrombotic complications or other difficulties were seen in these series. Difficult transseptal puncture (19 patients - 20%) was managed without fluoroscopy in all cases. No backup fluoroscopy was used, and no lead apparel was needed. Pacemaker interrogations after the procedure did not show any lead damage, dislocation, or threshold changes. Conclusions: A radiation-free (fluoroless) catheter ablation strategy for AF and other atrial arrhythmias is acutely safe and effective when guided by adequate ICE and 3D-mapping utilization. Multiple different bi-atrial sites were reached and adequately ablated without the need for backup fluoroscopy. No complications were seen. (Arq Bras Cardiol. 2020; 114(6):1015-1026) Keywords: Arrhythmias, Cardiac; Atrial, Fibrillation; Catheter Ablation; Fluoroscopy; radiation; Efficacy; Safety. radiation use to the minimum needed to meet the objective. 3 In recent years, several efforts have succeeded in reducing radiation exposure during catheter ablation procedures, including a reduction in fluoroscopy times and doses, 8,9 better shielding, and especially regarding other non-fluoroscopic imaging modalities – namely 3D electroanatomical systems (EA) and intracardiac echocardiography (ICE). Those fluoroscopy reduction tools have been increasingly used in the electrophysiology (EP) lab over the years, so that it became possible to guide the entire ablation procedure and thus avoid the use of X-ray 10 entirely. First reported about 10 years ago, 11-13 those Zero-Fluoro techniques are gaining popularity in the EP community, as they are as safe and as effective as the ones guided by fluoroscopy. 14-16 Objectives The purpose of this study was to demonstrate the feasibility and safety of catheter ablation of atrial fibrillation, atrial flutter, and supraventricular tachycardias without the use of fluoroscopy, using exclusively electroanatomic mapping and intracardiac echocardiography in a series of 95 consecutive patients in a single center. Introduction Catheter ablation is currently the most effective treatment for atrial fibrillation AF, 1,2 Atrial flutter, and supraventricular tachycardias (SVTs). It is widely performed in various centers around the world, giving the increasing prevalence of AF in the population and the modest response to anti-arrhythmic medications. As with most percutaneous cardiac procedures, fluoroscopy has been a primary imaging modality to manipulate catheters in the vascular space and cardiac chambers. However, ionizing radiation has multiple potential deleterious effects for both patients and the healthcare team. 3-6 These effects are cumulative, and all of us are continuously exposed nowadays due to high usage in diagnostic and therapeutic imaging modalities. 7 In that regard, the ALARA ( A s L ow A s R easonably A chievable) principle has been proposed to minimize 1015