How to: Streamlining Pulsed Field Ablation-Based Pulmonary Vein Isolation Using 3D Mapping Without Fluoroscopy

Background: Pulsed field ablation (PFA) is a safe and effective method for pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients. However, most first-generation PFA catheters are not integrated with 3D mapping systems, requiring fluoroscopy for guidance. The use of X-ray technologies, however, poses significant health risks to both patients and operating staff. Recently, a new variable-loop PFA catheter (VLC) with full 3D mapping integration allows for a novel fluoroscopy-free approach to PVI. In that regard, the aim was to evaluate and optimize a zero-fluoroscopy workflow for PVI using the VLC. Methods: Two workflows were described and compared: a conventional zero-fluoroscopy approach using a complete 3D left atrial map before ablation, and an optimized 'mapping-on-the-fly' approach that combines mapping and ablation into a continuous, real-time process for each pulmonary vein rather than performing them sequentially. Results: Forty-one pulmonary veins were successfully treated without fluoroscopy in 10 patients (20% female, median age 61 [IQR 55.5-66.8] years). Three patients underwent the conventional workflow, while seven received the optimized workflow. The 'mapping-on-the-fly' approach significantly reduced procedural time (median 68 vs. 144 min, p = 0.017) and left atrial dwell time (46 vs. 107 min, p = 0.016). No fluoroscopy-related complications occurred. Conclusions: PVI using the fully 3D-integrated VLC can be safely and efficiently performed without fluoroscopy. The optimized 'mapping-on-the-fly' workflow improves procedural efficiency.