Into a Fluoroless Future: an Appraisal of Fluoroscopy-Free Techniques in Clinical Cardiac Electrophysiology

Abstract

Purpose of review: There are risks to both patients and electrophysiology providers from radiation exposure from fluoroscopic imaging, and there is increased interest in fluoroscopic reduction. We review the imaging tools, their applications, and current uses to eliminate fluoroscopy.

Recent findings: Multiple recent studies provide supporting evidence for the transition to fluoroscopy-free techniques for both ablations and device implantation. The most frequently used alternative imaging approaches include intracardiac echocardiography, cardiac MRI guidance, and 3D electroanatomic mapping systems. Electroanatomic mapping and intracardiac echocardiography originally used to augment fluoroscopy imaging are now replacing the older imaging technique. The data supports that the future of electrophysiology can be fluoroscopy-free or very low fluoroscopy for the vast majority of cases. As provider and institution experience grows with these techniques, many EP labs may choose to completely forego the use of fluoroscopy. Trainees will benefit from early experience with these techniques.

Keywords: Diagnostic techniques and procedures; Electroanatomic mapping; Electrophysiology; Fluoroscopy.

Fig. 1

Representative 3D EAM image from an FF ablation for AV nodal reentry tachycardia. The right anterior oblique (a) and left anterior oblique (b) show right atrial (tan), coronary sinus (purple), and inferior vena cava (fuchsia) reconstruction and respective diagnostic catheters (right atrial in light blue, right ventricle in periwinkle, coronary sinus in green, and His bundle in yellow). The cryoablation catheter is shown in red, with ablation lesions marked by circles (from: Kipp RT, et al. J Innov Cardiac Rhythm Manage. 2018;9(9):3305–3311, by permission of MediaSphere Medical, LLC) [•]

Fig. 2

Representative intracardiac echocardiography (ICE) image from ablation of ventricular tachycardia. The black arrows indicate the anterolateral papillary muscle. The white arrows indicate the mitral valve. The black arrowheads indicate the ablation catheter (image courtesy of Ryan Kipp, MD)