Electroanatomic mapping systems (CARTO/EnSite NavX) vs. conventional mapping for ablation procedures in a training program

  • Jorge Romero
  • Florentino Lupercio
  • David Goodman-Meza
  • Juan Carlos Ruiz
  • David F. Briceno
  • John D. Fisher
  • Jay Gross
  • Kevin Ferrick
  • Soo Kim
  • Luigi Di Biase
  • Mario J. Garcia
  • Andrew Krumerman



Three-dimensional electroanatomic mapping (EAM) systems reduce radiation exposure when radio frequency catheter ablation (RFCA) procedures are performed by well-trained senior operators. Given the steep learning curve associated with complex RFCA, trainees and their mentors must rely on multiple imaging modalities to maximize safety and success, which might increase procedure and fluoroscopy times. The objective of the present study is to determine if 3-D EAM (CARTO and ESI-NavX) improves procedural outcomes (fluoroscopy time, radio frequency time, procedure duration, complication, and success rates) during CA procedures as compared to fluoroscopically guided conventional mapping alone in an academic teaching hospital.


We analyzed a total of 1070 consecutive RFCA procedures over an 8-year period for fluoroscopic time stratified by ablation target and mapping system. Multivariate logistic regression and adjusted odds ratios were calculated for each variable.


No statistically significant differences in acute success rates were noted between conventional and 3-D mapping cases [CARTO (p = 0.68) or ESI-NavX (p = 0.20)]. Moreover, complication rates were also not significantly different between CARTO (p = 0.23) and ESI-NavX (p = 0.53) when compared to conventional mapping. Procedure, radio frequency, and fluoroscopy times were significantly longer with CARTO and ESI-NavX versus conventional mapping [fluoroscopy time: CARTO, 28.3 min; ESI, 28.5 min; and conventional, 24.3 min; p < 0.001)].


The use of 3-D EAM systems during teaching cases significantly increases radiation exposure when compared with conventional mapping. These findings suggest a need to develop alternative training strategies that enhance confidence and safety during catheter manipulation and allow for reduced fluoroscopy and procedure times during RFCA.


Radio frequency ablation Tridimensional mapping Conventional mapping Fluoroscopy time Teaching program 



Atrial fibrillation


Atrial flutter


Analysis of variance


Adjusted odds ratios


Atrial tachycardia atrioventricular nodal reentry tachycardia


Atrial tachycardia


Radio frequency catheter ablation


Ionized radiation


Wolff-Parkinson-White syndrome


Ventricular tachycardia


Compliance of ethical standards

Conflict of interest

Dr. Andrew Krumerman is consultant for Biosense Inc., Biotronik Inc., and Speak2mdbyphone.com.


  1. 1.
    Packer, D. L. (2005). Three-dimensional mapping in interventional electrophysiology: techniques and technology. Journal of Cardiovascular Electrophysiology, 16(10), 1110–1116.CrossRefPubMedGoogle Scholar
  2. 2.
    Bhakta, D., & Miller, J. M. (2008). Principles of electroanatomic mapping. Indian Pacing and Electrophysiology Journal, 8(1), 32–50.PubMedCentralPubMedGoogle Scholar
  3. 3.
    Wittkampf, F. H., Wever, E. F., Derksen, R., Wilde, A. A., Ramanna, H., Hauer, R. N., et al. (1999). LocaLisa: new technique for real-time 3-dimensional localization of regular intracardiac electrodes. Circulation, 99(10), 1312–1317.CrossRefPubMedGoogle Scholar
  4. 4.
    Sporton, S. C., Earley, M. J., Nathan, A. W., & Schilling, R. J. (2004). Electroanatomic versus fluoroscopic mapping for catheter ablation procedures: a prospective randomized study. Journal of Cardiovascular Electrophysiology, 15(3), 310–315.CrossRefPubMedGoogle Scholar
  5. 5.
    Della Bella, P., Fassini, G., Cireddu, M., Riva, S., Carbucicchio, C., Giraldi, F., et al. (2009). Image integration-guided catheter ablation of atrial fibrillation: a prospective randomized study. Journal of Cardiovascular Electrophysiology, 20(3), 258–265.CrossRefPubMedGoogle Scholar
  6. 6.
    Casella, M., Pelargonio, G., Dello Russo, A., Riva, S., Bartoletti, S., Santangeli, P., et al. (2011). “Near-zero” fluoroscopic exposure in supraventricular arrhythmia ablation using the EnSite NavX mapping system: personal experience and review of the literature. Journal of Interventional Cardiac Electrophysiology, 31(2), 109–118.CrossRefPubMedGoogle Scholar
  7. 7.
    Earley, M. J., Showkathali, R., Alzetani, M., Kistler, P. M., Gupta, D., Abrams, D. J., et al. (2006). Radiofrequency ablation of arrhythmias guided by non-fluoroscopic catheter location: a prospective randomized trial. European Heart Journal, 27(10), 1223–1229.CrossRefPubMedGoogle Scholar
  8. 8.
    Shurrab, M., Laish-Farkash, A., Lashevsky, I., Morriello, F., Singh, S. M., Schilling, R. J., et al. (2013). Three-dimensional localization versus fluoroscopically only guided ablations: a meta-analysis. Scandinavian Cardiovascular Journal, 47(4), 200–209.CrossRefPubMedGoogle Scholar
  9. 9.
    Morady, F. (1999). Radio-frequency ablation as treatment for cardiac arrhythmias. New England Journal of Medicine, 340(7), 534–544.CrossRefPubMedGoogle Scholar
  10. 10.
    Scheinman, M. M. (1995). NASPE survey on catheter ablation. Pacing and Clinical Electrophysiology, 18(8), 1474–1478.CrossRefPubMedGoogle Scholar
  11. 11.
    Katritsis, D., Efstathopoulos, E., Betsou, S., Korovesis, S., Faulkner, K., Panayiotakis, G., et al. (2000). Radiation exposure of patients and coronary arteries in the stent era: a prospective study. Catheterization and Cardiovascular Interventions, 51(3), 259–264.CrossRefPubMedGoogle Scholar
  12. 12.
    Rehani, M. M. (2007). Training of interventional cardiologists in radiation protection—the IAEA’s initiatives. International Journal of Cardiology, 114(2), 256–260.CrossRefPubMedGoogle Scholar
  13. 13.
    Bernardi, G., Padovani, R., Trianni, A., Morocutti, G., Spedicato, L., Zanuttini, D., et al. (2008). The effect of fellows’ training in invasive cardiology on radiological exposure of patients. Radiation Protection Dosimetry, 128(1), 72–76.CrossRefPubMedGoogle Scholar
  14. 14.
    Eckardt, L., & Breithardt, G. (2009). Catheter ablation of ventricular tachycardia. From indication to three-dimensional mapping technology. Herz, 34(3), 187–196.CrossRefPubMedGoogle Scholar
  15. 15.
    Coggins, D. L., Lee, R. J., Sweeney, J., Chein, W. W., Van Hare, G., Epstein, L., et al. (1994). Radiofrequency catheter ablation as a cure for idiopathic tachycardia of both left and right ventricular origin. Journal of the American College of Cardiology, 23(6), 1333–1341.CrossRefPubMedGoogle Scholar
  16. 16.
    Waldo, A. L., Henthorn, R. W., Plumb, V. J., & MacLean, W. A. (1984). Demonstration of the mechanism of transient entrainment and interruption of ventricular tachycardia with rapid atrial pacing. Journal of the American College of Cardiology, 3(2 Pt 1), 422–430.CrossRefPubMedGoogle Scholar
  17. 17.
    Gepstein, L., Hayam, G., & Ben-Haim, S. A. (1997). A novel method for nonfluoroscopic catheter-based electroanatomical mapping of the heart. In vitro and in vivo accuracy results. Circulation, 95(6), 1611–1622.CrossRefPubMedGoogle Scholar
  18. 18.
    Razminia, M., Manankil, M. F., Eryazici, P. L., Arrieta-Garcia, C., Wang, T., D’Silva, O. J., et al. (2012). Nonfluoroscopic catheter ablation of cardiac arrhythmias in adults: feasibility, safety, and efficacy. Journal of Cardiovascular Electrophysiology, 23(10), 1078–1086.CrossRefPubMedGoogle Scholar
  19. 19.
    Gellis, L. A., Ceresnak, S. R., Gates, G. J., Nappo, L., & Pass, R. H. (2013). Reducing patient radiation dosage during pediatric SVT ablations using an “ALARA” radiation reduction protocol in the modern fluoroscopic era. Pacing and Clinical Electrophysiology, 36(6), 688–694.CrossRefPubMedGoogle Scholar
  20. 20.
    Bulava, A., Hanis, J., & Eisenberger, M. (2015). Catheter ablation of atrial fibrillation using zero-fluoroscopy technique: a randomized trial. Pacing and Clinical Electrophysiology, 38(7), 797–806.CrossRefPubMedGoogle Scholar
  21. 21.
    Stellbrink, C., Siebels, J., Hebe, J., Koschyk, D., Haltern, G., Ziegert, K., et al. (1994). Potential of intracardiac ultrasonography as an adjunct for mapping and ablation. American Heart Journal, 127(4 Pt 2), 1095–1101.CrossRefPubMedGoogle Scholar
  22. 22.
    Ullah, W., Hunter, R. J., Baker, V., Dhinoja, M. B., Sporton, S., Earley, M. J., et al. (2014). Target indices for clinical ablation in atrial fibrillation: insights from contact force, electrogram, and biophysical parameter analysis. Circulation. Arrhythmia and Electrophysiology, 7(1), 63–68.CrossRefPubMedGoogle Scholar
  23. 23.
    Fisher, J. D., & Krumerman, A. K. (2011). Tamponade detection: did you look at the heart borders (redux)? Pacing and Clinical Electrophysiology, 34(1), 8.CrossRefPubMedGoogle Scholar
  24. 24.
    Ferguson, J. D., Helms, A., Mangrum, J. M., Mahapatra, S., Mason, P., Bilchick, K., et al. (2009). Catheter ablation of atrial fibrillation without fluoroscopy using intracardiac echocardiography and electroanatomic mapping. Circulation. Arrhythmia and Electrophysiology, 2(6), 611–619.PubMedCentralCrossRefPubMedGoogle Scholar
  25. 25.
    Gallagher, A. G., & Cates, C. U. (2004). Virtual reality training for the operating room and cardiac catheterisation laboratory. Lancet, 364(9444), 1538–1540.CrossRefPubMedGoogle Scholar
  26. 26.
    Di Biase, L., Paoletti Perini, A., Mohanty, P., Goldenberg, A. S., Grifoni, G., Santangeli, P., et al. (2014). Visual, tactile, and contact force feedback: which one is more important for catheter ablation? Results from an in vitro experimental study. Heart Rhythm, 11(3), 506–513.CrossRefPubMedGoogle Scholar
  27. 27.
    Nestel, D., Groom, J., Eikeland-Husebo, S., & O’Donnell, J. M. (2011). Simulation for learning and teaching procedural skills: the state of the science. Simulation in Healthcare, 6(Suppl), S10–13.CrossRefPubMedGoogle Scholar
  28. 28.
    De Ponti, R., Marazzi, R., Doni, L. A., Tamborini, C., Ghiringhelli, S., & Salerno-Uriarte, J. A. (2012). Simulator training reduces radiation exposure and improves trainees’ performance in placing electrophysiologic catheters during patient-based procedures. Heart Rhythm, 9(8), 1280–1285.CrossRefPubMedGoogle Scholar
  29. 29.
    De Ponti, R., Marazzi, R., Ghiringhelli, S., Salerno-Uriarte, J. A., Calkins, H., & Cheng, A. (2011). Superiority of simulator-based training compared with conventional training methodologies in the performance of transseptal catheterization. Journal of the American College of Cardiology, 58(4), 359–363.CrossRefPubMedGoogle Scholar
  30. 30.
    Stabile, G., Solimene, F., Calo, L., Anselmino, M., Castro, A., Pratola, C., et al. (2014). Catheter-tissue contact force for pulmonary veins isolation: a pilot multicentre study on effect on procedure and fluoroscopy time. Europace, 16(3), 335–340.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Jorge Romero
    • 1
  • Florentino Lupercio
    • 1
  • David Goodman-Meza
    • 1
  • Juan Carlos Ruiz
    • 1
  • David F. Briceno
    • 1
  • John D. Fisher
    • 1
  • Jay Gross
    • 1
  • Kevin Ferrick
    • 1
  • Soo Kim
    • 1
  • Luigi Di Biase
    • 1
  • Mario J. Garcia
    • 1
  • Andrew Krumerman
    • 1
  1. 1.Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular CareMontefiore Medical Center, Albert Einstein College of MedicineBronxUSA

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