Clinical Outcomes of Ablation for Persistent Atrial Fibrillation with Zero or Minimal Fluoroscopy

Recent developments in electroanatomical mapping (EAM), intracardiac echocardiography, and sheath technology have allowed for a pronounced reduction or complete elimination of fluoroscopy during catheter ablation of atrial fibrillation (AF). This real-world study evaluates the procedural efficiency, clinical effectiveness, and safety of a zero- to minimal-fluoroscopy workflow in an exclusively persistent AF (PsAF) population.

Data on consecutive PsAF catheter ablations performed with a fluoroscopy minimization workflow by three operators at a single high-volume center in the United States between January 2017 and December 2018 were collected and analyzed. All procedures were performed with EAM guidance and a contact force ablation catheter. Patients were followed for a year post-ablation for safety, arrhythmia recurrences, and reablation. Outcomes of interest included procedural efficiency measures, single-procedure success (freedom from reablation at any time or recurrence after 90-day blanking), and procedure-related complications.

The study included 406 PsAF patients (age 67.8 ± 10.1 years, 65.3% male, and CHA₂DS₂-VASc score 2.9 ± 1.5). Over 85% of ablations were performed without fluoroscopy, and ablations utilizing fluoroscopy averaged only 0.6 ± 1.5 minutes for a mean fluoroscopy time of 0.1 ± 0.6 minutes overall. Mean procedure time was 89.5 minutes, with 96.3% of the procedures including ablation beyond the pulmonary veins. Single-procedure success was 73.6% (95% confidence interval: [68.7%, 77.8%]). Eight patients (2.0%) experienced a procedure-related complication.

Minimal-fluoroscopy ablation was performed safely and without compromise to procedural efficiency or clinical effectiveness in a real-world population of PsAF patients, despite more extensive ablation than a typical paroxysmal AF population.