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Maximum voltage gradient technique for optimization of ablation for typical atrial flutter with zero-fluoroscopy

Karol Deutsch1, Janusz Śledź, Mariusz Mazij

  • 1ELMedica EP-Network, Kielce County Hospital Wroclaw, Wroclaw Department of Cardiology, Masovia Specialist Hospital, Radom, Poland Heart and Lung Department, Klinikum Fuerth, Fuerth, Germany Podkarpackie Center for Cardiovascular Intervention, G.V.M. Carint, Sanok Faculty of Medicine, University of Rzeszow, Rzeszow District Socialistic Hospital in Stalowa Wola, Stalowa Wola, Poland.

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Summary

Radiofrequency catheter ablation (RFCA) without fluoroscopy (NXR) is feasible and effective for cavo-tricuspid isthmus (CTI)-dependent atrial flutter (AFL). The maximum voltage-guided (MVG) technique offers optimal results, reducing procedure time and fluoroscopy exposure.

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Area of Science:

  • Cardiology
  • Electrophysiology
  • Medical Technology

Background:

  • Radiofrequency catheter ablation (RFCA) effectively treats cavo-tricuspid isthmus (CTI)-dependent atrial flutter (AFL).
  • Three-dimensional electro-anatomic systems facilitate RFCA without fluoroscopy (NXR).

Purpose of the Study:

  • To evaluate the feasibility and effectiveness of CTI RFCA using the NXR approach combined with the maximum voltage-guided (MVG) technique for AFL ablation.
  • To compare outcomes between NXR and fluoroscopy-guided (ALARA) approaches, and between MVG and pull-back (PBT) techniques.

Main Methods:

  • Prospective, multicenter ablation registry data from consecutive patients undergoing first RFCA for CTI-dependent AFL.
  • Comparison of four groups: NXR + MVG, NXR + PBT, ALARA + MVG, and ALARA + PBT.
  • Utilized 8-mm gold tip catheters and a 2-catheter femoral approach, with MVG involving mapping largest atrial signals within the CTI.

Main Results:

  • Bidirectional block in CTI achieved in 99% of all patients, with no significant difference between groups.
  • Procedure time decreased significantly in NXR groups (NXR + MVG, NXR + PBT) compared to ALARA groups.
  • Complete elimination of fluoroscopy achieved in 91-98% of NXR procedures, with significant reduction in fluoroscopy exposure.
  • Total application time decreased significantly with the MVG technique in both NXR and ALARA groups.
  • No major complications were observed across all groups.

Conclusions:

  • Complete fluoroscopy elimination is feasible, safe, and effective for RFCA of CTI in most AFL patients without cardiac implanted electronic devices.
  • The MVG technique appears optimal for RFCA of CTI-dependent AFL, though further validation of RFCA parameters with clinical follow-up is needed.