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Fluoroless Ablation of VT in Structural Heart Disease
Quick Takes
- This multicenter experience shows that a fluoroless approach is feasible and safe in patients with structural heart disease undergoing endocardial VT ablation.
- Future efforts should include developing strategies to safely perform epicardial access without the use of fluoroscopy and to facilitate ablation near the coronary arteries without relying on angiography.
Study Questions:
What is the feasibility and safety of ventricular tachycardia (VT) ablation in patients with structural heart disease using a zero-fluoroscopy approach?
Methods:
This was a multicenter study of consecutive patients with ischemic and nonischemic cardiomyopathy undergoing fluoroless VT ablation. Patients requiring epicardial access or coronary angiography were excluded.
Results:
A total of 198 patients were included. Most patients (95%) underwent left ventricular (LV) mapping and/or ablation, which was conducted via transseptal route in 55%, via retrograde aortic route in 43%, and using a combined approach in 2% of patients. Two-thirds of patients had a cardiac device, including a biventricular device in 15%, two patients had an LV assist device, and one patient had a mechanical aortic valve prosthesis. The mean total procedural time was 211 ± 70 minutes, and the total radiofrequency time was 30 ± 22 minutes. Procedural-related complications occurred in six patients (3%). Over a mean follow-up of 22 months, the freedom from VT recurrence was 80% and 7.6% of patients underwent a repeat ablation.
Conclusions:
The authors conclude that fluoroless ablation of VT in structural heart disease is feasible and safe when epicardial mapping/ablation is not required.
Perspective:
Minimally fluoroscopic or fluoroless ablation procedures minimize the risks of ionizing radiation for patients and staff. This is of especially great importance to pediatric patients, who are more sensitive to the detrimental effects of radiation, and patients with congenital heart disease, who are exposed throughout their lifetime to multiple diagnostic and therapeutic procedures requiring radiation. Nonetheless, all patients may benefit from minimizing or eliminating ionizing radiation.
The authors of this report show that the procedures can be safely performed without fluoroscopy in patients with structural heart disease and VT. The authors used ultrasound guidance to visualize the vasculature for access and intracardiac echocardiography to enhance mapping and ablation of the ventricular arrhythmia substrate. Procedure-related complications were low and occurred in 3% of the cohort. There were no lead dislodgments despite two-thirds of the patients having a cardiac implantable electronic device and 15% having biventricular devices.
Fluoroless mapping and ablation has been made possible by many advances in the electroanatomic mapping technology, image integration, the use of phased-array intracardiac echocardiography, and force sensing catheter design. Future efforts should include developing strategies to safely perform epicardial access without the use of fluoroscopy and to facilitate ablation near the coronary arteries without relying on angiography.
Clinical Topics: Arrhythmias and Clinical EP, SCD/Ventricular Arrhythmias
Keywords: Ablation, Tachycardia, Ventricular
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