ABC | Volume 114, Nº6, June 2020

Short Editorial Zimerman The less the better Arq Bras Cardiol. 2020; 114(6):1027-1028 cost. Thirdly, inertia. Most electrophysiologists are used to traditional techniques, get good results, and are not willing to go through a new learning curve. For procedures such as atrial fibrillation ablation, these obstacles do not appear to outweigh the benefits of the technique. I believe that the doubt remains regarding low-complexity procedures, such as ablation of supraventricular tachycardia, which has been successfully performed, with very rare complications and very low doses of radiation. If the gain obtained with three-dimensional mapping and use of intracardiac echocardiography outweighs the cost and the need to place a more calibrated sheath for the echocardiogram probe, it is yet to be better defined. Ablation without fluoroscopy is a major progress and is now ready to be implemented on a large scale. But, as with every major progress in science, it is already waiting for the next step in evolution. The procedures in general are being performed This is an open-access article distributed under the terms of the Creative Commons Attribution License progressively in less invasive ways. Open surgeries are replaced by catheter and laparoscopic procedures. As for cardiac arrhythmias, ablations have been performed without the need for catheter placement, but using mapping by external electrode systems, and stereotaxis ablation, with external beam radiation (such as radiotherapy). Initially developed and described in the treatment of ventricular tachycardias, 14 the technique is now also potentially to be used in ablation of atrial fibrillation. 15 Ablation is an indispensable therapy and will remain as such as the usual treatment for tachyarrhythmia. Fluoroscopy is harmful and will be eliminated by electrophysiological procedures. This is a pressing issue and concerns the whole world. It is time to dispense with the lead apron. Here, as opposed to what is popularly said, the less the better. And if it’s zero, that’s even better. 1. Rehani MM, Ortiz-Lopez P. Radiation effects in fluoroscopically guided cardiac interventions: Keeping them under control. Int J Cardiol. 2006; 109(2):147-51. 2. Heidbuchel H, Wittkampf F, Vano E,Ernst S, Schilling RJ, 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. 3. Ross AM, Segal J, Borenstein D, Jenkins E, Cho S. Prevalence of spinal disc diseaseamong interventionalcardiologists.Am JCardiol.1997;79(1):68-70. 4. Alvarez M, Bertomeu-Gonzalez V, Arcocha M. Nonfluoroscopic Catheter Ablation. Results From a Prospective Multicenter Registry. Rev Esp Cardiol. 2017; 70(9):699-705. 5. Chen G, Wang Y, Proietti R, Wang X, Ouyang F, Ma CS, et al. Zero- fluoroscopy approach for ablation of supraventricular tachycardia using the Ensite NavX system: amulticenter experience. BMCCardiovasc Disord. 2020; 20(1):48. 6. Ferguson JD, Helms A, Mangrum J, ahapatra S, Mason P, Bilchick K, et al. Catheter ablation of atrial fibrillationwithout fluoroscopy using intracardiac echocardiography and electroanatomic mapping. Circ Arrhythm Electrophysiol. 2009 Dec; 2(6):611-9. 7. Saad EB, Slater C, Oliveira Jr LAI, Santos GV, Dias LC, Camanho LE. Ablação por cateter semuso de raios x para tratamento de fibrilação atrial e arritmias atriais. Arq Bras Cardiol. 2020; 114(6):1015-1026. 8. Sadek MM, Ramirez FD, Nery PB , Golian M, Redpath CJ, Nair GM, et al. Completely non-fluoroscopic catheter ablation of left atrial arrhythmias and ventricular tachycardia. J Cardiovasc Electrophysiol. 2019; 30(1):78-88. 9. Reddy VY, Morales G, AhmedH, Neuzil P, Dukkipati S, KimS, et al. Catheter ablation of atrial fibrillation without the use of fluoroscopy. Heart Rhythm. 2010; 7(11):1644-53. 10. 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. 11. Johnson A, Mejia-Lopez E, Bilchick K. Catheter ablation of ventricular arrhythmias without fluoroscopy using intracardiac echocardiography and electroanatomic mapping. [abstract] In: 40th Annual Heart Rhythm Scientific Sessions, May 08 November 2019. San Francisco,California. 12. Guarguagli S, Cazzoli I, Kempny A, Gatzoulius MA, Ernst S. A New Technique for Zero Fluoroscopy Atrial Fibrillation Ablation Without the Use of Intracardiac Echocardiography. JACC Clin Electrophysiol. 2018; 4(12):1647-8. 13. Weber R, Minners J, Allgeier HJ, Jadidi A, Muller-Edenborn B, Neumann FJ, et al. 3Dmapping for the identification of the fossa ovalis in left atrial ablation procedures: a pilot study of a first step towards an electroanatomic-guided transseptal puncture EP Europace. 2020; 22(5):732-8. 14. Cuculich PS, Schill MR, Kashaniand R, Mutic S, Lang A, Cooper D, et al. Noninvasive cardiac radiation for ablation of ventricular tachycardia. N Engl J Med. 2017; 377(24):2325-36. 15. Qjan P, Azpiri J, Assad J, Gonzales EM, Cordona Ibarra CE, de la Pena C, et al. Noninvasive stereotactic radioablation for the treatment of atrial fibrillation: First-in-man experience. J Arrhythmia.2020;36(1):67-74. References 1028