Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.     

Pulmonary vein isolation by high intensity focused ultrasound

Pulmonary vein isolation (PVI) using radiofrequency current (RFC) ablation is a potentially curative treatment option for patients with atrial fibrillation (AF). The shortcomings of the RFC technology (technically challenging, long procedure times, complications) steadily kindle the interest in new energy sources and catheter designs. High intensity focused ultrasound (HIFU) has the ability to precisely focus ultrasound waves in a defined area with a high energy density. HIFU balloon catheters (BC) positioned at the PV ostia appear to be an ideal tool to transmit the ablation energy in a circumferential manner to the PV ostia and may therefore bear substantial advantage over conventional ablation catheters in PVI procedures. In clinical trials the HIFU BC has shown promising success rates similar to RFC catheter ablation for PVI in patients with AF. However, procedure times are still long and serious complications have been observed. Therefore, it may be a valuable alternative to the conventional techniques in selected patients but further clinical trials have to be initiated.     

Three-dimensional electroanatomical mapping for non-pulmonary vein foci in a patient with complete situs inversus and dextrocardia

In patients with atrial fibrillation (AF) having congenital anatomical abnormalities, such as complete situs inversus and dextrocardia, pulmonary vein isolation (PVI) ablation can be performed safety using a three-dimensional electroanatomical mapping system. However, it is not clear whether a three-dimensional electroanatomical mapping system can be used to detect non-PV ectopic beats initiating AF in patients with complete situs inversus and dextrocardia. Here, we report a 21-year-old man with complete situs inversus and dextrocardia, who showed AF caused by non-PV ectopic beats. We successfully detected the origin of the triggered activity from the non-PV foci using three-dimensional electroanatomical mapping.     

Three-dimensional computed tomography overlay for pulmonary vein antrum isolation: Follow-up and clinical outcomes

Background

To facilitate the creation of circumferential lines in pulmonary vein (PV) antrum isolation, three-dimensional (3D) navigation systems are used widely. Alternatively, 3D reconstructions of the left atrium (LA) can be superimposed directly on fluoroscopy to guide ablation catheters and to mark ablation sites.

Methods

In 71 atrial fibrillation patients circumferential PV ablation was performed. 3D reconstructions of the LA were derived from contrast cardiac-computed tomography and circumferential PV isolation was performed. In subsequent ablation procedures, veins were re-isolated, and defragmentation or linear lesions were performed if necessary.

Results

Adequate 3D reconstructions were formed and registered to fluoroscopy in all patients. All veins, except 2 in one single patient, could be isolated, resulting in freedom of AF in 45 patients (63?%). In 19 patients a second procedure was performed, in which 2.7?±?1.1 PV per patient were re-isolated; in 3 patients a third procedure was performed. After follow-up of 15?±?8?months, 51 (91?%) of patients with paroxysmal and 10 (67?%) with persistent AF were free of AF.

Conclusions

The results of 3D overlay for circumferential PV isolation are good, although the reconduction rate and need for subsequent ablations remains high, and the outcomes of this technique appear to be equivalent to other mapping techniques.     

肺静脉口弧形指数与房颤消融术后复发的关系

目的:探讨肺静脉口弧形指数与心房颤动(房颤)导管消融术后复发的关系。方法:选取2008年2月至2011年3月在我院接受导管消融术的房颤患者120例,所有患者于术前3日内利用多排CT行左心房及肺静脉造影,并进行图像的三维重建。测量每条肺静脉前后径及上下径,并计算弧形指数(肺静脉前后径/肺静脉上下径)以描述肺静脉口形态。行射频消融治疗的房颤病人全部达消融终点,术后随访超过3个月,根据患者房性快速性心律失常(房颤、房扑或房速)的发生情况,将其分为治愈组和复发组,进行统计分析。结果:由弧形指数分析,四支肺静脉开口形态存在统计学差异(P0.05);房颤消融术后,53例病人复发。房颤消融术后复发患者的LIPV弧形指数与治愈者不同,差异有显著性(P0.05);两组患者的左上肺静脉(Left Superior Pulmonary Vein,LSPV),右上肺静脉(Right Superior Pulmonary Vein,RSPV),右肺下静脉(Right Inferior Pulmonary Vein,RIPV),的弧形指数比较差异不明显(P0.05)。结论:左下肺静脉形态的不一致性与房颤导管消融术复发有关。     

Characterization of pulmonary vein reconnection post Cryoballoon ablation

BackgroundThe Arctic Front Cryoballoon System is a technology in which substrate alterations in patients with atrial fibrillation (AF) recurrence have not been well characterized. In this study, we evaluated sites of pulmonary vein (PV) reconnections and the accuracy of the Achieve? circular mapping catheter in detecting these reconnections after cryoablation.MethodsThis study included 15 patients undergoing redo AF ablation after a prior single cryoablation procedure. PV reconnection sites were determined by measuring PV signals and high output pacing from 4 vectors of the Achieve catheter. The results were compared with a roving mapping catheter guided by rotational intracardiac echocardiography (ICE) in the left atrium.ResultsAll patients had PV reconnections (2.1 ± 0.8 veins/patient). The left superior PV was most commonly reconnected (n = 11), whereas the right inferior PV was least likely (n = 3). Both carinas (left: n = 11; right: n = 7) and left atrial appendage ridge (n = 11) were also frequently reconnected. Mapping with the Achieve catheter showed a positive predictive value (PPV) 100% and negative predictive value (NPV) 96% when compared with ICE guided mapping. In 2 patients, right superior PV reconnection was not identified by the Achieve.ConclusionDuring redo AF ablation after index cryoablation, multiple PVs are usually reconnected, with both carinas and left atrial appendage ridge being common sites of reconnection. The Achieve mapping catheter was able to identify reconnection with high positive and negative predictive values.     

Technique of pulmonary vein isolation by catheter ablation

In selected patients with atrial fibrillation, the fibrillation episodes may be initiated by single or short bursts of ectopy often originating from one or more pulmonary veins (PVs). Therefore, electrical isolation of these veins by catheter ablation is currently being explored as a treatment modality for patients with paroxysmal and even more permanent types of atrial fibrillation. At present, two different techniques are used: 1) selective ablation of electrical connections between left atrium and myocardial sleeves inside the PVs; and 2) contiguous encircling lesions around and outside the PV ostia. With both techniques, moderate to high success rates have been reported with a limited follow-up duration. Both types of procedure are very complex and require a highly skilful team. With the variable anatomy of the PVs, non-invasively acquired angiographic images may serve as a roadmap for catheter manipulation. Modern three-dimensional catheter navigation techniques can be applied to facilitate accurate catheter positioning with limited fluoroscopic exposure. Experimental and clinical research is needed to define patient selection criteria.     

Effective contact and outcome after pulmonary vein isolation in novel circular multi-electrode atrial fibrillation ablation

Introduction

Pulmonary vein (PV) reconnection is frequently the cause of recurrence of atrial fibrillation (AF) after ablation. The second-generation gold multi-electrode ablation (Gold-MEA) catheter has a new design possibly resulting in improved lesion formation compared with its predecessor. We aimed to determine the association between effective radiofrequency applications with the Gold-MEA catheter and outcome after AF ablation.

Methods

50 consecutive patients with paroxysmal AF underwent Gold-MEA (PVAC GOLD^TM, Medtronic Inc.) ablation. The Gold-MEA catheter was navigated to the PV ostium by fluoroscopy. Duty-cycled radiofrequency ablations were performed at all PV ostia. Lesions were considered transmural when electrode temperature was >50 °C and power >3 W for >30 seconds. After the ablation procedure, patients visited the outpatient clinic at 3?month intervals including 24-hour Holter ECGs.

Results

Mean age was 56 years. All PVs were acutely isolated with the Gold-MEA catheter. Procedure time was 111 ± 22 minutes, ablation time was 24 ± 6.7 minutes and fluoroscopy time was 20 ± 8.1 minutes. No procedure-related complications were observed. One year after ablation, 60?% of patients were still free of arrhythmia recurrences after a single PV isolation attempt. The number of transmural lesions was associated with arrhythmia-free survival: 25.0?% in <72 transmural lesions, 64.3?% in 72–108 transmural lesions and 71.4?% in >108 transmural lesions (p = 0.029).

Conclusion

PV isolation can be performed successfully with the Gold-MEA catheter, with a favourable safety profile. Transmurality of lesions was associated with ablation success and may improve AF ablation success.

     

Pulmonary vein reconnection following cryo-ablation: Mind the “Gap” in the carinae and the left atrial appendage ridge

Pulmonary vein (PV) isolation (PVI) remains cornerstone to ablation of atrial fibrillation (AF). For effective and durable PVI and thus fewer AF recurrences, lesion gaps in transmurality and contiguity responsible for PV reconnection (PVR) could only be addressed when one is cognizant of the potential location and sites where these lesion characteristics may be more prevalent and responsible for PVR. In the case of RF ablation, newer technologies incorporating contact force, time and power with automated monitoring of lesion formation, paying attention to difficult areas (carinae, left superior PV-LAA ridge, right inferior PV) and measuring inter-lesion distance may provide the tools to reduce PVR. On the other hand, the improved thermodynamic characteristics of the latest generation of cryoballloons and operator dexterity to achieve better PV occlusion, may be crucial determinants towards the direction of reduced PVR. Whether newer visualization tools, more vigilant testing during the index ablation procedure in these particular regions, prolonging or adding cryothermic applications, waiting longer to test for entrance and exit block, and/or use of provocative drug testing (isoproterenol/adenosine challenge) might help prevent future PVRs awaits further studies.     

Association of the left common ostium with clinical outcome after pulmonary vein isolation in atrial fibrillation

IntroductionElectrical pulmonary vein isolation (PVI) is used for the invasive treatment of atrial fibrillation (AF). However, despite the procedure’s technical evolution, the rate of AF recurrence due to electrical reconnection of the PVs is high. The aims of this study was to assess the influence of left common pulmonary venous ostium (LCO) on clinical outcomes following PVI.MethodsRetrospective cohort of 254 patients who underwent the first procedure of PVI from the years 2013–2018 was assessed. Patients with persistent AF of long duration and extra-pulmonary focus associated with triggers for arrhythmia were excluded. Patients were stratified into two groups according to the presence of a LCO and received follow up for atrial tachyarrhythmia-free survival. The mean follow-up period was 28 ± 1.73 months.ResultsThe majority were men (68.5%), with a mean age of 54 ± 12 years. With respect to the atrial anatomy, LCO occurred in 23.6% of cases after pulmonary venous angiotomography. The arrhythmia-free survival rate was 79.5% in the follow-up period. The Cox regression model was utilized and the adjusted hazard ratio for LCO was 0.36 (95% CI 0.15–0.87; p = 0.02) in terms of age, body mass index, left atrium diameter, bi-directional blocking of the cavotricuspid isthmus, persistent AF, left ventricular ejection fraction adjusted model.ConclusionAnatomic abnormality with the presence of the LCO is present in a quarter of patients undergoing AF ablation, which is associated with a lower rate of arrhythmia recurrence in our population.     

Cryoballoon Ablation for Paroxysmal Atrial Fibrillation in Septuagenarians: a Prospective Study

Aims

To evaluate the effects of pulmonary vein isolation (PVI) in terms of feasibility, safety and success rate on a midterm follow-up period in septuagenarians undergoing ablation with the Arctic Front Cryoballoon for atrial fibrillation (AF).

Methods and Results

We prospectively enrolled 21 patients aged 70 years or older (14 male; age 73 ± 2.5 years) elected to circumferential PVI with the 28mm cryoballoon for symptomatic drug resistant paroxysmal AF. A total number of 82 pulmonary veins (PV) were evidenced. Successful isolation could be obtained in all 82 (100%) PV ostia at the end of procedure. No major complication occurred during procedure. At a mean follow-up of 11.5 ± 4.7 months following ablation, 62% of patients did not present recurrence of atrial arrhythmias.

Conclusion

Cryoballoon ablation may be feasible and safe in older patients. Moreover a large proportion of the latter did not present AF recurrence during follow-up.     

Therapeutic options for patients with advanced atrial fibrillation: from lifestyle and medication to catheter and surgical ablation

Atrial fibrillation (AF) is part of a vicious cycle that includes multiple cardiovascular risk factors and comorbidity which can promote atrial remodelling and AF progression. Most AF-related risk factors—hypertension, diabetes, sleep apnoea, obesity and sedentary lifestyle—are in essence modifiable which may prevent AF development. Treatment of associated cardiovascular conditions may prevent both symptoms and future cardiovascular events. For advanced forms of symptomatic AF refractory to lifestyle management and optimal medication, invasive ablation therapies have become a cornerstone. Although electrical trigger isolation from the pulmonary veins is reasonably effective and safe, more potent energy sources including high output-short duration radiofrequency, ultra-low cryo-energy, and electroporation, as well as more sophisticated arrays, balloons, and lattice-tipped catheter tools, are on their way to eliminate existing pitfalls and simplify the procedure. Electroanatomical navigation and mapping systems are becoming available to provide real-time information on ablation lesion quality and the critical pathways of AF in the individual patient to guide more extensive ablation strategies that may enhance long-term outcome for freedom of advanced AF. Surgical techniques, either stand-alone or concomitant to structural cardiac repair, hybrid, or convergent, with novel less invasive access options are developing and can be helpful in situations unsuitable for catheter ablation.

     

Pulmonary vein isolation using new technologies to improve ablation lesion formation: Initial results comparing enhanced catheter tip irrigation (Surround Flow?) with contact force measurement (Smarttouch?)

Introduction

Pulmonary vein reconnection after pulmonary vein isolation (PVI) is a significant problem in the treatment of paroxysmal atrial fibrillation (AF). We report about patients who underwent contact force (CF) guided PVI using CF catheter and compared them to patients with PVI using an ablation catheter with enhanced tip irrigation.

Methods

A total of 59 patients were included in the analysis. In 30 patients circumferential PVI was performed using the Thermocool Smarttouch^® ablation catheter (ST) whereas in 29 patients circumferential PVI using the Thermocool Surround Flow SF^® ablation catheter (SF) was performed. Patients were compared in regard to procedure time, fluoroscopy time/dose as well as RF-application duration and completeness of PVI. Adverse events (pericardial effusion, PV stenosis, stroke, death) were evaluated. The presence of sinus rhythm off antiarrhythmic medication was assessed during 6 months follow-up using multiple 7 day Holter-ECGs.

Results

In both groups, all PVs were isolated without serious adverse events. Procedure time was 2.15 ± 0.5 h (ST) vs. 2.37 ± 1.13 h (SF) (p = 0.19). Duration of RF-applications was 46.6 ± 18 min (ST) and 49.8 ± 19 min (SF) (p = 0.52). Fluoroscopy time was 25.2 ± 13 min (ST) vs. 29 ± 18 min (SF), fluoroscopy dose 2675.6 ± 1658 versus 3038.3 ± 1997 cGym² (p = 0.36 and 0.46 respectively). Sinus rhythm off antiarrhythmic medication validated with 7 day Holter ECGs was present in both groups in 72% of patients after 6 months of follow up.

Conclusion

PVI using the new contact force catheter is safe and effective in patients with paroxysmal AF.     

Anatomical Characteristics of Pulmonary Veins for the Prediction of Postoperative Recurrence after Radiofrequency Catheter Ablation of Atrial Fibrillation

Background

The relationship between focal pulmonary vein potential and atrial fibrillation (AF) has been confirmed. Pulmonary vein (PV) isolation and circumferential pulmonary vein ablation have been the most commonly used procedures of radiofrequency ablation. However, few studies have investigated the relationship between anatomical characteristics of PV and AF recurrences after radiofrequency ablation.

Methodology

For 267 AF patients treated by radiofrequency catheter ablation, the anatomic structure characteristics of pulmonary veins were assessed by multi-slice spiral computed tomography while the values of left atrial diameter (LAD) were measured with transesophageal ultrasonic cardiogram. After radiofrequency catheter ablation, postoperative recurrence was evaluated during a 10-month term follow-up.

Principal Findings

During follow-up, postoperative recurrence occurred in 44 patients. The mean diameters of LAD, left superior PV, right superior PV, all left PV, and all superior PV were significantly larger in patients with postoperative recurrence (Recurrence vs. Non-recurrence group; 43.9 ± 6.4 mm vs. 40.7 ± 5.6 mm; 18.4 ± 2.1 mm vs. 17.1 ± 3.1 mm; 18.2 ± 2.8 mm vs. 17.2 mm ± 3.9 mm; 16.4 ± 1.5 mm vs. 15.6 ± 2.5 mm; 18.3 ± 2.1 mm vs. 17.1 ± 3.0 mm; respectively; all P < 0.05). Multivariable survival analysis showed that the type and the course of AF, LAD, and the diameters of all superior PV were the independent risk factors for the postoperative recurrence after radiofrequency catheter ablation.

Conclusions

The enlargements of all superior PV and LAD, long course of diseases, and persistent AF were the independent risk factors for the postoperative recurrence after radiofrequency catheter ablation.     

Usefulness of Contrast Intracardiac Echocardiography in Performing Pulmonary Vein Balloon Occlusion during Cryo-ablation for Atrial Fibrillation

BackgroundCryoballoon ablation (CBA) has been proven to be very effective for pulmonary vein (PV) isolation (PVI) if complete occlusion is achieved and conventionally assessed by angiographic injection of contrast within PV lumen. The aim of our study was to assess the usefulness of saline contrast intracardiac echocardiography in guiding CBA with respect to PV angiography.MethodsThirty consecutive patients with paroxysmal atrial fibrillation were randomly assigned fluoroscopy plus color-flow Doppler (n = 15; group 1: an iodinated medium as both angiographic and echographic contrast) or contrast intracardiac echocardiography plus color-flow Doppler (n = 15; group 2: saline contrast) for guidance of CBA.ResultsWe evaluated 338 occlusions of 107 PVs. The intracardiac echocontrastography-guided assessment of occlusion, defined as loss of echocontrastographic back-flow to the left atrium after saline injection regardless of the visualization of PV antrum, showed a high level of agreement with the angiographic diagnosis of occlusion. PVI rate was similar in both groups and effectively guided by intracardiac echocontrastography (PVI using ≤ 2 double cryofreezes: 89% of PVs in group 1 vs. 91% in group 2; p=n.s.). Group 2 patients had significantly shorter procedure (127 ± 16 vs. 152 ± 19 minutes; p<0.05) and fluoroscopy times (30 ± 12 vs. 43 ± 9 minutes, p<0.05) and used a lower iodinated contrast (88 ± 26 vs. 190 ± 47 mL, p<0.05).ConclusionsPV occlusion and PVI during cryoablation can be effectively predicted by intracardiac saline echocontrastography. This technique reduces procedural time, radiological exposure and iodinated contrast use.     

Feasibility of remote magnetic navigation for epicardial ablation

Percutaneous epicardial mapping and ablation is an emerging method to treat ventricular tachycardias (VT), premature ventricular complexes (PVC), and accessory pathways. The use of a remote magnetic navigation system (MNS) could enhance precision and maintain safety. This multiple case history demonstrates the feasibility and safety of the MNS-guided epicardial approach in mapping and ablation of ischaemic VT, outflow tract PVCs, and a left-sided accessory pathway. All patients had previously undergone endocardial mapping for the same arrhythmia. MNS could present an advantage from more precise navigation for mapping and maintaining catheter stability during energy application.     

Safety and feasibility of atrial fibrillation ablation using Amigo® system versus manual approach: A pilot study

Background

The Amigo^® Remote Catheter System is a relatively new robotic system for catheter navigation. This study compared feasibility and safety using Amigo (RCM) versus manual catheter manipulation (MCM) to treat paroxysmal atrial fibrillation (PAF). Contact force (CF) and force-time integral (FTI) values obtained during pulmonary vein isolation (PVI) ablation were compared.

Adenosine testing after cryoballoon pulmonary vein isolation improves long-term clinical outcome

Background

Adenosine infusion after pulmonary vein isolation (PVI) with radiofrequency energy reveals dormant muscular sleeves and predicts atrial fibrillation (AF) recurrence. The aim of our study was to determine whether adenosine could reveal dormant PV sleeves after cryoballoon isolation and study its effect on long-term recurrence of AF.

Methods

Patients with paroxysmal AF underwent cryoballoon PVI. After PVI, adenosine 25 mg was infused to test for dormant muscular sleeves in each vein. If reconnection under adenosine was shown, further cryoballoon ablation was performed until no more reconnection occurred. Follow-up was performed with ECG, 24-h Holter recording, and a symptom questionnaire at three monthly intervals. Transtelephonic Holter monitoring was performed for 1 month before and 3 months after PVI. Patients who underwent cryoballoon PVI without adenosine administration were used as controls for comparison.

Results

In the study group (n = 34, 24 males), adenosine revealed dormant sleeves in 9/132 (8 %) veins, and 7/34 (21 %) patients. All but one vein was further treated until the dormant sleeves were isolated. During a mean follow-up of 520 ± 147 days, 23/34 (68 %) patients were free of AF without antiarrhythmic drugs (AADs). In the control group (n = 65, 46 males), 29/65 (46 %) were free of AF without AADs. There were significantly less AF recurrences in the study group (p = 0.04).

Conclusions

Adenosine administration after cryoballoon PVI reveals dormant muscular sleeves in 21 % of patients. Clinical follow-up shows that adenosine testing is effective in reducing AF recurrence after cryoballoon ablation.     

The usefulness of ventricular pacing during atrial fibrillation ablation in a persistent left superior vena cava: A case report

A 69-year-old woman with palpitations was referred to our hospital for a second session of atrial fibrillation (AF) catheter ablation. She had a history of AF ablation including pulmonary vein (PV) isolation and persistent left superior vena cava (PLSVC) isolation. Electrophysiologic studies showed the veno-atrial connections that had recovered. After PV isolation was performed, AF was induced by atrial premature contraction (APC) from the PLSVC, and AF storm occurred. During PLSVC isolation, AF was not induced by APC from the PLSVC. PLSVC isolation continued during sinus rhythm. The elimination of the PLSVC potential was difficult to confirm because of the far-field potential of the left ventricle. Then, we performed right ventricular pacing. The remaining PLSVC potential was identified. After that, the PLSVC isolation was successful during right ventricular pacing. Complications were not observed. The patient had no recurrence of AF thereafter.     

Fluoroscopy-Free Pulmonary Vein Isolation in Patients with Atrial Fibrillation and a Patent Foramen Ovale Using Solely an Electroanatomic Mapping System

Introduction

The advent of electroanatomical mapping (EAM) systems for pulmonary vein isolation (PVI) has dramatically decreased radiation exposure. However, the need for some fluoroscopy remains for obtaining left atrial (LA) access. The aim was to test the feasibility of fluoroscopy-free PVI in patients with atrial fibrillation (AF) and a patent foramen ovale (PFO) guided solely by an EAM system.

Methods

Consecutive patients with AF undergoing PVI and documented PFO were studied. An EAM-guided approach without fluoroscopy and ultrasound was used. After completing the map of the right atrium, the superior vena cava and the coronary sinus, a catheter pull-down to the PFO was performed allowing LA access. The map of the LA and subsequent PVI was also performed without fluoroscopy.

Results

30 patients [age 61±12 years, 73% male, ejection fraction 0.64 (0.53–0.65), LA size in parasternal long axis 38±7 mm] undergoing PVI were included. The time required for right atrial mapping including transseptal crossing was 9±4 minutes. Total procedure time was 127±37 minutes. Fluoroscopy-free PVI was feasible in 26/30 (87%) patients. In four patients, fluoroscopy was needed to access (n = 3) or to re-access (n = 1) the LA. In these four patients, total fluoroscopy time was 5±3 min and the DAP was 14.9±13.4 Gy*cm². Single-procedure success rate was 80% (24/30) after a median follow-up of 12 months.

Conclusion

In patients with a documented PFO, completely fluoroscopy-free PVI is feasible in the vast majority of cases.