Use of intracardiac echocardiography and three-dimensional mapping during catheter ablation for atrial fibrillation is associated with reduced complications: a retrospective analysis of United States Medicare Fee-For-Service Database

Aim: This retrospective cohort study assessed differences in procedure-related complications and death among old patients with atrial fibrillation (AF) undergoing catheter ablation (CA) procedure with versus without use of intracardiac echocardiography (ICE) and advanced three-dimensional (3D) electroanatomical mapping. Materials & methods: Using the Medicare Database, a retrospective cohort of AF patients ≥65 years of age who underwent CA procedure were identified, and categorized into two cohorts: CA without ICE/3D mapping versus CA with ICE/3D mapping. Outcomes including a composite of complications (any), cardiac perforation, esophageal fistula and death, respectively, in the 30-day period post-CA were assessed. Inverse probability of treatment weighting method was used for covariate balancing. Cox regression models were performed to evaluate outcomes. Results: There were 35,490 patients in CA without ICE/3D mapping cohort and 170,762 in the CA with ICE/3D mapping cohort. Cox regression model revealed that patients who underwent CA without ICE/3D mapping use were ∼3.5-times more likely to have 30-day any complication versus those who had CA with ICE/3D mapping (7.3% vs 2.2%, log-rank test p < 0.001; hazard ratio: 3.507; 95% CI: 3.307–3.720, p < 0.001). The incidence of cardiac perforation (2.5% vs 0.1%, log-rank test p < 0.001), atrio-esophageal fistula (0.03% vs 0.01%, log-rank test p = 0.03) and death (1.6% vs 0.2%, log-rank test p < 0.001) were significantly higher among patients without ICE/3D mapping versus those who had CA with ICE/3D mapping. Conclusion: The absence of ICE and 3D mapping during CA procedures was associated with significantly increased risk of complications and death among Medicare eligible patients with AF.