Zero-fluoroscopy transseptal puncture guided by right atrial electroanatomical mapping combined with intracardiac echocardiography: A single-center experience

Abstract

Background: Right atrial electroanatomical mapping may be combined with SoundStar 3D diagnostic ultrasound catheter (EAM-ICE) as a zero-fluoroscopy procedure for radiofrequency catheter ablation (RFCA). We aimed to evaluate the efficiency and safety of zero-fluoroscopy transseptal puncture guided by EAM-ICE and fluoroscopy combined with intracardiac echocardiography (F-ICE) in patients with paroxysmal atrial fibrillation (PAF).

Hypothesis: Zero-fluoroscopy transseptal puncture is an effective and safe procedure.

Methods: This study had a prospective design. A total of 57 patients with PAF were enrolled and assigned to two groups. Twenty-seven patients were enrolled in the EAM-ICE group, and 30 patients were enrolled in the F-ICE group.

Results: There were no statistically significant differences in baseline patient characteristics between groups. Transseptal puncture was successful in all patients (57/57, 100%). Total procedure time and duration of transseptal puncture were lower in the F-ICE group (199.4 ± 26.0 minutes vs 150.7 ± 22.1 minutes, P = 0.000; 118.4 ± 19.7 vs 70.5 ± 13.5 minutes, P = 0.000). There was no use of fluoroscopy in the EAM-ICE group (0 mGy vs 70.5 ± 13.5 mGy); the duration of fluoroscopy in the EAM-ICE group was negligible (0 minutes vs 5.4 ± 1.9 minutes). No procedural complication occurred in either group.

Conclusions: EAM-ICE guided zero-fluoroscopy transseptal puncture is an effective and safe procedure.

Keywords: catheter ablation; intracardiac echocardiography; paroxysmal atrial fibrillation; right atria electroanatomical mapping; zero fluoroscopy.

FIGURE 1

Foramen ovale mapping. A, An ablation catheter and EAM system were used to map the RA and the CS. The low‐voltage zone (foramen ovale) was marked on the anatomy (blue point). The circle formed by white points represents the foramen ovale as revealed by EAM. B, Electrography of the atrial septum was <0.3 mV (blue point). C to F. Electrography of the atrial muscle surrounding the septum. (C, electrogram of zone 1 in A; D, electrogram of zone 2 in A; E, electrogram of zone 3 in A; and F, electrogram of zone 4 in A). The magnitude of the electrogram was >0.5 mV. (yellow point, bundle of His; white point, foramen ovale area as revealed by voltage mapping; blue point, atrial septum; white point, area of low voltage identified by voltage mapping; yellow point, bundle of His; green area/circle, coronary sinus; EAM, electroanatomical mapping; RA, right atrium; CS, coronary sinus)

FIGURE 2

Intracardiac echocardiography (ICE) was performed to confirm the position of the foramen ovale. An ablation catheter and electroanatomical mapping systems (EAM) were used to map the anatomy of the foramen ovale. The position of the foramen ovale was confirmed from two readings. (pink area, foramen ovale as mapped by ICE; yellow point, bundle of His; white point, area of low voltage identified by voltage mapping; green area/circle, coronary sinus)

FIGURE 3

Transseptal puncture with electroanatomical mapping combined with diagnostic ultrasound catheter (EAM‐ICE). A, The long sheath was placed into the SVC through the guide‐wire, which was then replaced with the trans‐septal needle. The tip of the needle was inserted into the SVC (yellow circle). B and C, After withdrawal of the sheath‐dilator‐needle assembly, the tip the needle was oriented toward the atrial septum. The needle can be seen facing toward the septum in C. D, Under ICE direction, the trans‐septal needle was used to puncture the atrial septum. When the trans‐septal needle was pushed toward the atrial septum, a tenting phenomenon could be seen on ICE. E, After a rapid movement of the transseptal needle through the dilator succeeded in puncturing the atrial septum, a small bolus of physiological solution was used to confirm that the needle was inside the left atrium. The shadow created by the bolus can be seen on ICE. (yellow circle, tip of the trans‐septal needle; yellow point, bundle of His; white point, foramen ovale; blue point, low‐voltage area)