Sub-Zero: A Review of the Current Evidence and Evolving Technologies Enabling Zero‑Fluoroscopy Procedures

Fluoroscopy has long been the cornerstone imaging modality in cardiac electrophysiology (EP), enabling real-time catheter visualization but exposing patients and healthcare providers to ionizing radiation and significant occupational hazards. With the emergence of three-dimensional electroanatomic mapping (EAM) systems and intracardiac echocardiography (ICE), zero- and near-zero fluoroscopy (ZF) approaches have become increasingly feasible across a wide spectrum of EP and structural interventions. This review synthesizes current evidence supporting ZF workflows, highlighting their efficacy, safety, and expanding clinical applicability. Contemporary data demonstrate that ZF techniques achieve procedural success, complication rates, and long-term outcomes comparable to conventional fluoroscopy-guided procedures, while substantially reducing radiation exposure and mitigating associated risks such as malignancy, cataract formation, and orthopedic injury. Advances in mapping accuracy and real-time intracardiac imaging-including 3D and 4D ICE-have enhanced anatomical visualization, procedural precision, and early detection of complications. Despite these benefits, ZF workflows introduce unique challenges, including vascular access complications, catheter-related thrombus formation, and navigation errors due to EAM system limitations. Furthermore, certain complex procedures-such as epicardial access, lead extraction, and select device implantations-continue to rely on fluoroscopic guidance. Operator experience, learning curves, and the availability of fluoroscopic "bailout" strategies remain critical considerations. Overall, the transition toward ZF approaches represents a paradigm shift in EP, emphasizing radiation safety without compromising procedural outcomes. Continued technological innovation, standardized training, and robust randomized studies are essential to further validate and optimize these techniques, ultimately advancing safer, patient-centered cardiovascular care.