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Learning Curve of Zero Fluoroscopy

  • Amee M. Bigelow
  • John M. ClarkEmail author
Chapter

Abstract

Catheter ablation of tachyarrhythmias without the use of fluoroscopy is, at present, performed only in a minority of laboratories. While the tools exist to allow fluoroless procedures in most instances, experience is lacking. While the learning curve will require time, and may slow the productivity of the lab down for a while, the benefits to both the patients and the staff are worth the investment. If one visits an experienced lab doing fluoroless procedures, they will recognize that, not only is the risk of radiation decreased, but also the comfort level of the staff is increased by the absence of lead protective gear. It is the authors’ personal observation that elimination of lead aprons has been the number one motivation to obtain staff buy-in, making them willing to endure the learning curve. This chapter reviews the experiences of multiple labs, and their approach to overcoming the hurdles of radiation elimination. Hopefully, the reader will find sufficient references to make their own learning curve as smooth as possible.

Keywords

Zero fluoroscopy Pediatric ablations Learning curve 

References

  1. 1.
    Khongphatthanayothin A, Kosar E, Nademanee K. Nonfluoroscopic three-dimensional mapping for arrhythmia ablation: tool or toy? J Cardiovasc Electrophysiol. 2000;11(3):239–43.PubMedCrossRefGoogle Scholar
  2. 2.
    Schauer DA, Linton OW. NCRP report no. 160, ionizing radiation exposure of the population of the United States, medical exposure—are we doing less with more, and is there a role for health physicists? Health Phys. 2009;97(1):1–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Limacher MC, Douglas PS, Germano G, et al. ACC expert consensus document. Radiation safety in the practice of cardiology. American College of Cardiology. J Am Coll Cardiol. 1998;31(4):892–913.PubMedCrossRefGoogle Scholar
  4. 4.
    Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111(9):1368–72.PubMedCrossRefGoogle Scholar
  5. 5.
    Goldstein JA, Balter S, Cowley M, Hodgson J, Klein LW. Interventional Committee of the Society of Cardiovascular Interventions. Occupational hazards of interventional cardiologists: prevalence of orthopedic health problems in contemporary practice. Catheter Cardiovasc Interv. 2004;63(4):407–11.PubMedCrossRefGoogle Scholar
  6. 6.
    Smilowitz NR, Balter S, Weisz G. Occupational hazards of interventional cardiology. Cardiovasc Revasc Med. 2013;14(4):223–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Klein LW, Tra Y, Garratt KN, et al. Occupational health hazards of interventional cardiologists in the current decade: results of the 2014 SCAI membership survey. Catheter Cardiovasc Interv. 2015;86(5):913–24.PubMedCrossRefGoogle Scholar
  8. 8.
    Worley SJ. Use of a real-time three-dimensional magnetic navigation system for radiofrequency ablation of accessory pathways. Pacing Clin Electrophysiol. 1998;21(8):1636–45.PubMedCrossRefGoogle Scholar
  9. 9.
    Drago F, Silvetti MS, Di Pino A, Grutter G, Bevilacqua M, Leibovich S. Exclusion of fluoroscopy during ablation treatment of right accessory pathway in children. J Cardiovasc Electrophysiol. 2002;13(8):778–82.PubMedCrossRefGoogle Scholar
  10. 10.
    Tuzcu V. A nonfluoroscopic approach for electrophysiology and catheter ablation procedures using a three-dimensional navigation system. Pacing Clin Electrophysiol. 2007;30(4):519–25.PubMedCrossRefGoogle Scholar
  11. 11.
    Smith G, Clark JM. Elimination of fluoroscopy use in a pediatric electrophysiology laboratory utilizing three-dimensional mapping. Pacing Clin Electrophysiol. 2007;30(4):510–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Clark J, Bockoven JR, Lane J, Patel CR, Smith G. Use of three-dimensional catheter guidance and trans-esophageal echocardiography to eliminate fluoroscopy in catheter ablation of left-sided accessory pathways. Pacing Clin Electrophysiol. 2008;31(3):283–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Ferguson JD, Helms A, Mangrum JM, et al. Catheter ablation of atrial fibrillation without fluoroscopy using intracardiac echocardiography and electroanatomic mapping. Circ Arrhythm Electrophysiol. 2009;2(6):611–9.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Pachon M, Arias MA, Castellanos E, Puchol A. No fluoroscopy for cavotricuspid isthmus-dependent right atrial flutter ablation. Heart Rhythm. 2009;6(3):433–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Reddy VY, Morales G, Ahmed H, et al. Catheter ablation of atrial fibrillation without the use of fluoroscopy. Heart Rhythm. 2010;7(11):1644–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Miyamoto K, Tsuchiya T, Narita S, et al. Radiofrequency catheter ablation of ventricular tachyarrhythmia under navigation using EnSite array. Circ J. 2010;74(7):1322–31.PubMedCrossRefGoogle Scholar
  17. 17.
    Von Bergen NH, Bansal S, Gingerich J, Law IH. Nonfluoroscopic and radiation-limited ablation of ventricular arrhythmias in children and young adults: a case series. Pediatr Cardiol. 2011;32(6):743–7.CrossRefGoogle Scholar
  18. 18.
    Casella M, Pelargonio G, Dello Russo A, et al. “Near-zero” fluoroscopic exposure in supraventricular arrhythmia ablation using the EnSite NavX mapping system: personal experience and review of the literature. J Interv Card Electrophysiol. 2011;31(2):109–18.PubMedCrossRefGoogle Scholar
  19. 19.
    Alvarez M, Tercedor L, Almansa I, et al. Safety and feasibility of catheter ablation for atrioventricular nodal re-entrant tachycardia without fluoroscopic guidance. Heart Rhythm. 2009;6(12):1714–20.PubMedCrossRefGoogle Scholar
  20. 20.
    Gist K, Tigges C, Smith G, Clark J. Learning curve for zero-fluoroscopy catheter ablation of AVNRT: early versus late experience. Pacing Clin Electrophysiol. 2011;34(3):264–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Giaccardi M, Chiodi L, Del Rosso A, Colella A. ‘Zero’ fluoroscopic exposure for ventricular tachycardia ablation in a patient with situs viscerum inversus totalis. Europace. 2012;14(3):449–50.PubMedCrossRefGoogle Scholar
  22. 22.
    Wan G, Shannon KM, Moore JP. Factors associated with fluoroscopy exposure during pediatric catheter ablation utilizing electroanatomical mapping. J Interv Card Electrophysiol. 2012;35(2):235–42.PubMedCrossRefGoogle Scholar
  23. 23.
    Tuzcu V. Significant reduction of fluoroscopy in pediatric catheter ablation procedures: long-term experience from a single center. Pacing Clin Electrophysiol. 2012;35(9):1067–73.PubMedCrossRefGoogle Scholar
  24. 24.
    Razminia M, Manankil MF, Eryazici PL, et al. Nonfluoroscopic catheter ablation of cardiac arrhythmias in adults: feasibility, safety, and efficacy. J Cardiovasc Electrophysiol. 2012;23(10):1078–86.PubMedCrossRefGoogle Scholar
  25. 25.
    Ergul Y, Tola HT, Kiplapinar N, Akdeniz C, Saygi M, Tuzcu V. Cryoablation of anteroseptal accessory pathways in children with limited fluoroscopy exposure. Pediatr Cardiol. 2013;34(4):802–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Gellis LA, Ceresnak SR, Gates GJ, Nappo L, Pass RH. Reducing patient radiation dosage during pediatric SVT ablations using an “ALARA” radiation reduction protocol in the modern fluoroscopic era. Pacing Clin Electrophysiol. 2013;36(6):688–94.PubMedCrossRefGoogle Scholar
  27. 27.
    Pass RH, Gates GG, Gellis LA, Nappo L, Ceresnak SR. Reducing patient radiation exposure during paediatric SVT ablations: use of CARTO(R) 3 in concert with “ALARA” principles profoundly lowers total dose. Cardiol Young. 2015;25(5):963–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Scaglione M, Ebrille E, Caponi D, et al. Single center experience of fluoroless AVNRT ablation guided by electroanatomic reconstruction in children and adolescents. Pacing Clin Electrophysiol. 2013;36(12):1460–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Macias R, Uribe I, Tercedor L, Jimenez-Jaimez J, Barrio T, Alvarez M. A zero-fluoroscopy approach to cavotricuspid isthmus catheter ablation: comparative analysis of two electroanatomical mapping systems. Pacing Clin Electrophysiol. 2014;37(8):1029–37.PubMedCrossRefGoogle Scholar
  30. 30.
    Christoph M, Wunderlich C, Moebius S, et al. Fluoroscopy integrated 3D mapping significantly reduces radiation exposure during ablation for a wide spectrum of cardiac arrhythmias. Europace. 2015;17(6):928–37.PubMedCrossRefGoogle Scholar
  31. 31.
    Scaglione M, Ebrille E, Caponi D, et al. Zero-fluoroscopy ablation of accessory pathways in children and adolescents: CARTO3 electroanatomic mapping combined with RF and cryoenergy. Pacing Clin Electrophysiol. 2015;38(6):675–81.PubMedCrossRefGoogle Scholar
  32. 32.
    Bulava A, Hanis J, Eisenberger M. Catheter ablation of atrial fibrillation using zero-fluoroscopy technique: a randomized trial. Pacing Clin Electrophysiol. 2015;38(7):797–806.PubMedCrossRefGoogle Scholar
  33. 33.
    Solimene F, Donnici G, Shopova G, et al. Trends in fluoroscopy time during radiofrequency catheter ablation of supraventricular tachycardias. Int J Cardiol. 2016;202:124–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Huo Y, Christoph M, Forkmann M, et al. Reduction of radiation exposure during atrial fibrillation ablation using a novel fluoroscopy image integrated 3-dimensional electroanatomic mapping system: a prospective, randomized, single-blind, and controlled study. Heart Rhythm. 2015;12(9):1945–55.PubMedCrossRefGoogle Scholar
  35. 35.
    Montgomery JAEC. Zero-fluoroscopy intracardiac echocardiography-guided ablation of atrial fibrillation using a single-catheter technique. J Innov Card Rhythm Manag. 2015;6:2209–15.CrossRefGoogle Scholar
  36. 36.
    Ceresnak SR, Nappo L, Janson CM, Pass RH. Tricking CARTO: cryoablation of supraventricular tachycardia in children with minimal radiation exposure using the CARTO3 system. Pacing Clin Electrophysiol. 2016;39(1):36–41.PubMedCrossRefGoogle Scholar
  37. 37.
    Raju H, Whitaker J, Taylor C, Wright M. Electroanatomic mapping and transoesophageal echocardiography for near zero fluoroscopy during complex left atrial ablation. Heart Lung Circ. 2016;25(7):652–60.PubMedCrossRefGoogle Scholar
  38. 38.
    Clark BC, Sumihara K, McCarter R, Berul CI, Moak JP. Getting to zero: impact of electroanatomical mapping on fluoroscopy use in pediatric catheter ablation. J Interv Card Electrophysiol. 2016;46(2):183–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Kuhne M, Knecht S, Muhl A, et al. Fluoroscopy-free pulmonary vein isolation in patients with atrial fibrillation and a patent foramen ovale using solely an electroanatomic mapping system. PLoS One. 2016;11(1):e0148059.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Nagaraju L, Menon D, Aziz PF. Use of 3D electroanatomical navigation (CARTO-3) to minimize or eliminate fluoroscopy use in the ablation of pediatric supraventricular tachyarrhythmias. Pacing Clin Electrophysiol. 2016;39(6):574–80.PubMedCrossRefGoogle Scholar
  41. 41.
    Cano O, Andres A, Osca J, et al. Safety and feasibility of a minimally fluoroscopic approach for ventricular tachycardia ablation in patients with structural heart disease: Influence of the ventricular tachycardia substrate. Circ Arrhythm Electrophysiol. 2016;9(2):e003706.PubMedCrossRefGoogle Scholar
  42. 42.
    Lerman BB, Markowitz SM, Liu CF, Thomas G, Ip JE, Cheung JW. Fluoroless catheter ablation of atrial fibrillation. Heart Rhythm. 2017;14(6):928–34.PubMedCrossRefGoogle Scholar
  43. 43.
    McCauley MD, Patel N, Greenberg SJ, Molina-Razavi JE, Safavi-Naeini P, Razavi M. Fluoroscopy-free atrial transseptal puncture. Eur J Arrhthymia Electrophysiol. 2016;2(2):57–61.CrossRefGoogle Scholar
  44. 44.
    Clark BC, Sumihara K, Berul CI, Moak JP. Off the pedal: fluoroless transseptal puncture in pediatric supraventricular tachycardia ablation. Pacing Clin Electrophysiol. 2017;40(11):1254–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Jan M, Zizek D, Rupar K, et al. Fluoroless catheter ablation of various right and left sided supra-ventricular tachycardias in children and adolescents. Int J Cardiovasc Imaging. 2016;32(11):1609–16.PubMedCrossRefGoogle Scholar
  46. 46.
    Fernandez-Gomez JM, Morina-Vazquez P, Morales Edel R, Venegas-Gamero J, Barba-Pichardo R, Carranza MH. Exclusion of fluoroscopy use in catheter ablation procedures: six years of experience at a single center. J Cardiovasc Electrophysiol. 2014;25(6):638–44.PubMedCrossRefGoogle Scholar
  47. 47.
    Seizer P, Bucher V, Frische C, et al. Efficacy and safety of zero-fluoroscopy ablation for supraventricular tachycardias. use of optional contact force measurement for zero-fluoroscopy ablation in a clinical routine setting. Herz. 2016;41(3):241–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Sanchez JM, Yanics MA, Wilson P, Doshi A, Kurian T, Pieper S. Fluoroless catheter ablation in adults: a single center experience. J Interv Card Electrophysiol. 2016;45(2):199–207.PubMedCrossRefGoogle Scholar
  49. 49.
    Razminia M, Willoughby MC, Demo H, et al. Fluoroless catheter ablation of cardiac arrhythmias: a 5-year experience. Pacing Clin Electrophysiol. 2017;40(4):425–33.PubMedCrossRefGoogle Scholar
  50. 50.
    Bigelow AM, Smith PC, Timberlake DT, et al. Procedural outcomes of fluoroless catheter ablation outside the traditional catheterization lab. Europace. 2017;19(8):1378–84.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of Cardiology, Department of PediatricsHeart Institute at Cincinnati Children’s Hospital Medical CenterCincinnatiUSA
  2. 2.Division of Cardiology, Department of PediatricsHeart Center at Akron Children’s HospitalAkronUSA

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