Letter to the Editor: AF Catheter Ablation Without Fluoroscopy and Protective Lead

Dear Editor,

The approach featured in the recent EP Lab Digest article¹ on fluoroless pulmonary vein isolation using three-dimensional mapping and intracardiac echocardiography (ICE) was very helpful. The author is successfully advancing catheters into the heart, followed by performing a transseptal puncture and left atrial ablation for the interventional management of atrial fibrillation (AF) utilizing the CARTO 3 mapping system (Biosense Webster) and ICE without using fluoroscopy. In the description, the author depicted employing a few seconds of fluoroscopic imaging to verify the location of the esophageal temperature probe. This maneuver required less than 30 seconds of fluoroscopy. We are not opposed to such an approach because inappropriate probe location would pose risk, which can be easily mitigated with minimal use of fluoroscopy. However, we also recognize the benefit afforded to the team and patient of not “putting on lead” and performing a leadless and flouroless procedure.^2,3

In our own practice, we have used the CARTO VIZIGO sheath (Biosense Webster) for our AF ablations. This sheath can be visualized using the CARTO 3 system, and thus, has further reduced our dependence on fluoroscopy. We have also been studying the safety and feasibility of positioning a temperature probe into the esophagus at an appropriate location to correctly measure esophageal temperatures while ablating at the posterior left atrium, with direct visualization of the esophagus and temperature probe using only ICE. Accurate placement is confirmed with fluoroscopy after everyone but 2 team members step out of the room; the temperature probe has been positioned properly in all but one instance. Our goal is to determine if the temperature probe can be correctly placed using only ICE visualization and without fluoroscopy. Our findings suggest that the esophageal probe can be placed safely without fluoroscopy; however, these results still need to be further confirmed and validated in our laboratory. A detailed description of our procedure and outcomes will be provided in part II of our upcoming EP Lab Digest article on minimizing fluoroscopy during EP procedures. Once we have confirmed our results, and after further review by our institution’s peer review and safety committees, we plan to employ this approach and perform our AF ablations possibly without out any reliance on fluoroscopy. 

Thank you,

Shannon Gleason, DNP, FNP-C, APRN; Hillary Strahan, MSN, RN; Sandeep Sagar, MD, PhD

Clinical Cardiac Electrophysiology Program, Owensboro Health Regional Hospital, Owensboro, Kentucky

Disclosures: The authors have no conflicts of interest to report regarding the content herein.   

Response to Letter to the Editor:

Dear Editor,

This is in response to the “Letter to the Editor: AF Catheter Ablation Without Fluoroscopy and Protective Lead.” I would like to thank the authors for their excellent comments. Yes, we use fluoroscopy for checking placement of the esophageal temperature probe. While the probe is being placed, only 2 staff members stay in the room to check the placement of the probe. At our center, we use the multi-sensor S-CATH Esophageal Temperature Probe (CIRCA Scientific, Inc.). We have recently tried incorporating Dr. Mansour Razminia’s approach of placing the esophageal probe using the right inferior pulmonary vein (RIPV) on ICE as the landmark. We continue to advance the esophageal probe beyond the RIPV until at least 6 sensors pass beyond it. We have also started using CARTO VIZIGO sheaths (Biosense Webster). We agree with the authors’ comments that we should try to use any strategy that helps with safe fluoroscopy reduction. However, we also believe that operators should use fluoroscopy whenever they need it, as the aim is the reduction in the use of fluoroscopy while maintaining the safety of the procedure. I look forward to their article being published in EP Lab Digest, and would also like to thank EPLD for providing us with the opportunity to share and learn from other articles on fluoroscopy reduction. 

Thank you,

Khalil Kanjwal, MD, FACC, FHRS, CCDS, CEPS (P)

Clinical Associate Professor of Medicine, Michigan State University; Director of Electrophysiology,

McLaren Greater Lansing Hospital, Lansing, Michigan

Disclosures: Dr. Kanjwal has no conflicts of interest to report regarding the content herein. Outside the submitted work, he is a consultant for Biosense Webster and Abbott.

1. Kanjwal K. Catheter ablation for atrial fibrillation using zero fluoroscopy approach at McLaren Greater Lansing Hospital. EP Lab Digest. 2021;21(1):36-38.
2. Goldstein JA, Balter S, Cowley M, et al. Occupational hazards of interventional cardiologists: prevalence of orthopedic health problems in contemporary practice. Catheter Cardiovasc Interv. 2004;63:407-411.
3. Picano E, Piccaluga E, Padovani R, et al. Risks related to fluoroscopy radiation associated with electrophysiology procedures. J Atr Fibrillation. 2014;7(2):1044.