ABC | Volume 114, Nº6, June 2020

Original Article Saad et al. Zero Fluoroscopy Catheter Ablation for Atrial Fibrillation and Supraventricular Arrhythmias Arq Bras Cardiol. 2020; 114(6):1015-1026 motivated team with a mindset change is critical in that regard. It is our perception that, after a learning curve, inmost instances, the visualization andmanipulation are indeedmore precise than that with fluoroscopy, without any blind parts. Limitations We report on a relatively small number of patients and lack a control group. Zero fluoroscopy procedures were performed by operators with a large experience in ICE and 3D mapping, and the reproducibility of our results by less experienced operators may vary due to the need for a steeper learning curve. However, we believe that these results are meaningful and represent the basis for further evaluations about the safety and efficacy of these techniques. 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 could be reached and adequately ablated without the need for backup fluoroscopy. No complications were seen. Author contributions Conception and design of the research, Acquisition of data, Analysis and interpretation of the data and Critical revision of the manuscript for intellectual content: Saad EB, Slater C, Inácio Jr. LAO, Santos GV, Dias LC, Camanho LEM; Writing of the manuscript: Saad EB, Slater C. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors. 1. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275-e444. 2. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC Jr, et al. 2019AHA/ACC/HRSFocusedUpdateofthe2014AHA/ACC/HRSGuideline for the Management of Patients With Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart RhythmSociety in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140(2):e125-e51. 3. Heidbuchel H, Wittkampf FH, Vano E, Ernst S, Schilling R, Picano E, et al. Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures. Europace. 2014;16(7):946-64. 4. Perisinakis K, Damilakis J, Theocharopoulos N, Manios E, Vardas P, Gourtsoyiannis N. Accurate assessment of patient effective radiation dose and associated detriment risk from radiofrequency catheter ablation procedures. Circulation. 2001;104(1):58-62. 5. Lickfett L, Mahesh M, Vasamreddy C, Bradley D, Jayam V, Eldadah Z, et al. Radiation exposure during catheter ablation of atrial fibrillation. Circulation. 2004;110(19):3003-10. 6. Ector J, Dragusin O, Adriaenssens B, Huybrechts W, Willems R, Ector H, et al. Obesity is a major determinant of radiation dose in patients undergoing pulmonary vein isolation for atrial fibrillation. J AmColl Cardiol. 2007;50(3):234-42. 7. Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting HH, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med. 2009;361(9):849-57. 8. Bourier F, Reents T, Ammar-Busch S, Buiatti A, Kottmaier M, Semmler V, et al. Evaluation of a new very low dose imaging protocol: feasibility and impact on X-ray dose levels in electrophysiology procedures. Europace. 2016;18(9):1406-10. 9. Duran A, Hian SK, Miller DL, Le Heron J, Padovani R, Vano E. Recommendations for occupational radiation protection in interventional cardiology. Catheter Cardiovasc Interv. 2013;82(1):29-42. 10. Lerman BB, Markowitz SM, Liu CF, Thomas G, Ip JE, Cheung JW. Fluoroless catheter ablation of atrial fibrillation. Heart Rhythm. 2017;14(6):928-34. 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. 12. Reddy VY, Morales G, Ahmed H, Neuzil P, Dukkipati S, Kim S, et al. Catheter ablation of atrial fibrillation without the use of fluoroscopy. Heart Rhythm. 2010;7(11):1644-53. 13. Macias R, Uribe I, Tercedor L, Jimenez-Jaimez J, Barrio T, Alvarez M. A zero- fluoroscopyapproachtocavotricuspid isthmuscatheterablation:comparative analysisoftwoelectroanatomicalmappingsystems.PacingClinElectrophysiol. 2014;37(8):1029-37. 14. Bulava A, Hanis J, Eisenberger M. Catheter ablation of atrial fibrillation using zero-fluoroscopy technique: a randomized trial. Pacing Clin Electrophysiol. 2015;38(7):797-806. 15. 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):425-33. 16. Yang L, Sun G, Chen X, Chen G, Yang S, Guo P, et al. Meta-analysis of zero or near-zerofluoroscopyuseduringablationofcardiacarrhythmias.AmJCardiol. 2016;118(10):1511-8. 17. Enriquez A, Saenz LC, Rosso R, Silvestry FE, Callans D, Marchlinski FE, et al. Use of intracardiac echocardiography in interventional cardiology: working withtheanatomyratherthan fighting it.Circulation.2018;137(21):2278-94. 18. Saad EB, Costa IP, Camanho LE. Use of intracardiac echocardiography in the electrophysiology laboratory. Arq Bras Cardiol. 2011;96(1):e11-7. References 1024