Near zero fluoroscopic implantation of BIV ICD using electro-anatomical mapping

Biventricular (BIV) implantable cardioverter defibrillator (ICD) implantations are traditionally performed using fluoroscopic guidance, exposing both patients and laboratory staff to the risks of radiation. Three-dimensional (3D) electro-anatomical mapping (EAM) has been used in limited reports with modest decrease in fluoroscopy time in adjunct to standard use of contrast. The purpose of this study was to evaluate the feasibility of EAM in BIV ICD implantation with near zero use of fluoroscopy and contrast.

Retrospective analysis was performed in two patient groups (both n = 10): (1) the near zero fluoroscopy (NZF) group consisting of consecutive adult patients, in which BIV implantation was accomplished by EAM; and (2) the fluoroscopy (F) group, in which BIV implantation was additionally guided by fluoroscopy and contrast use. The same operator performed all procedures with a step-by-step approach detailed below. Complications were limited to one patient in the standard (F) group who had a pneumothorax related to difficult access with occluded collateralized subclavian vein and small hematoma with no intervention required. Another patient in the NZF group had lead revision with an extra 0.5 minutes of fluoroscopy related to microdislodgement secondary to body habitus and postural changes.

This NZF technique was feasible and effective in near elimination of contrast use, as well as in decreasing fluoroscopy exposure to as low as 0.1 minutes or near zero exposure. We also highlighted the technique in detailed step-by-step approach. It was also discovered that 3D mapping does not increase procedure time. In fact there was a tendency toward shortening the procedure time, further demonstrating the feasibility of this technique for the implantation of BIV ICD. Acute procedural success, complications, and clinical outcome were comparable in both groups.