Zero-fluoroscopy radiofrequency ablation: influence of workflow design, mapping strategy, and vHPSD protocols on procedural performance
B Bocz, H Trombitas, D Torma, D Debreceni, K F Janosi, A Ferencz, P KupoAbstract
Introduction
Atrial fibrillation (AF) is the most prevalent sustained arrhythmia worldwide. Pulmonary vein isolation (PVI) is a cornerstone therapy, and recent technological innovations—including high-density mapping catheters, visualizable steerable sheaths, and high-power or very-high-power short-duration (HPSD/vHPSD) ablation protocols—have significantly reshaped procedural workflows. These advances offer the potential to reduce, or even eliminate, fluoroscopy exposure while enhancing procedural efficiency. Although workflow organization varies across electrophysiology (EP) laboratories, key procedural elements remain consistent. This study aimed to compare procedural characteristics across four distinct EP laboratory configurations to evaluate the impact of workflow optimization, catheter selection, and ablation strategy on fluoroscopy exposure and procedural performance.
Methods
In this prospective study, procedural data from 557 patients who underwent point-by-point radiofrequency PVI for symptomatic AF over a three-year period were analyzed. Four workflow configurations were evaluated, differing in mapping catheter selection, transseptal puncture (TSP) technique, fluoroscopy strategy, and ablation power settings. The conventional workflow (Con, n=185) involved double TSP, a circular mapping catheter, 35/45 W ablation, and a decapolar coronary sinus catheter. The visualizable-sheath workflow (Vis, n=43) used single TSP, a visualizable steerable sheath, a pentaspline mapping catheter, 40/45 W ablation, and omitted the coronary sinus catheter. The minimal-fluoroscopy workflow (MF, n=67) employed single TSP, a pentaspline mapping catheter, a visualizable steerable sheath, omission of the coronary sinus catheter, 40/45 W ablation, and a zero-fluoroscopy approach. The very-high-power short-duration workflow (vHPSD, n=251) used single TSP, a visualizable steerable sheath, an octaspline mapping catheter, omission of the coronary sinus catheter, a zero-fluoroscopy strategy, and 90 W ablation. Procedural parameters and complication rates were compared across all configurations.
Results
Significant differences were observed in fluoroscopy time (Con: 184.5 ± 101.2 s; Vis: 141.3 ± 56.3 s; MF: 18.8 ± 54.6 s; vHPSD: 4.5 ± 25.3 s; p<0.001), procedure time (Con: 93.9 ± 26.2 min; Vis: 77.0 ± 18.9 min; MF: 63.0 ± 16.4 min; vHPSD: 45.5 ± 16.1 min; p<0.001), and total ablation time (Con: 1436.1 ± 457.6 s; Vis: 1093.1 ± 199.0 s; MF: 1250.0 ± 292.6 s; vHPSD: 600.3 ± 298.1 s; p<0.001). Four complications occurred in the cohort, all within the conventional group.
Conclusion
Streamlined PVI workflows featuring single transseptal access, omission of the coronary sinus catheter, visualizable steerable sheaths, high-density mapping, and especially vHPSD ablation significantly improve procedural efficiency while enabling zero-fluoroscopy strategies that reduce radiation exposure to near-zero without compromising safety.