Author + information
- Received August 2, 2018
- Revision received August 15, 2018
- Accepted August 17, 2018
- Published online December 17, 2018.
- Silvia Guarguagli, MDa,b,
- Ilaria Cazzoli, MDa,
- Aleksander Kempny, MD, PhDa,
- Michael A. Gatzoulis, MD, PhDa and
- Sabine Ernst, MD, PhDa,∗ ()
- aDepartment of Cardiology, Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, United Kingdom
- bDivision of Cardiology, School of Cardiovascular Disease, University of Pavia, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
- ↵∗Address for correspondence:
Dr. Sabine Ernst, Department of Cardiology, National Heart and Lung Institute, Imperial College, Royal Brompton and Harefield Hospital, Sydney Street, London SW3 6NP, United Kingdom.
According to the “as low as reasonably achievable” principle (1,2), physicians should explore ways to reduce radiation exposure during invasive procedures. While using a radiofrequency (RF) needle (Baylis Medical, Montreal, Canada) (3) in challenging transseptal punctures (TSPs), we developed a new technique that allows a zero fluoroscopy approach for TSP as an alternative to more expensive tools (e.g., intracardiac echocardiogram).
A 47-year-old man, with a known persistent left superior caval vein (LSCV), was urgently admitted for ablation of poorly controlled atrial fibrillation. He had 2 previous right atrial flutter ablations. As per institutional standard, this procedure was performed under general anesthesia and after exclusion of intracardiac thrombus by transesophageal echocardiography. A 3-dimensional fast anatomic map (FAM) of the right atrium and the coronary sinus was acquired using a bidirectional map catheter (CARTO, Biosense Webster, Irvine, California) and merged with a pre-acquired cardiac magnetic resonance scan. This created a matrix (Figure 1A, Online Video 1) that allowed advanced catheter localization (ACL) of 2 decapolar catheters in the CS and at the His position on the electroanatomic mapping system (4). The RF needle was then “faked” as a bipolar catheter and advanced in the superior caval vein (yellow circle, Figure 1B). Double TPSs were performed with active RF (pulsed mode, monopolar power for 600 ms) using direct visualization by ACL (Figure 1C and 1D). Both right and left anterior oblique projections were checked before the RF energy delivery, and we closely observed the intracardiac pressure tracing from the needle-tip side holes. Subsequently, FAMs of the left atrium and the pulmonary veins (PVs) were acquired, followed by ipsilateral PV isolation plus complex fractionated atrial electrograms ablation in both atria and in the LSCV. The total procedural duration was 146 min, and no fluoroscopy was used during the entire procedure.
Dr. Ernst is a consultant to Baylis Medical and Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received August 2, 2018.
- Revision received August 15, 2018.
- Accepted August 17, 2018.
- 2018 American College of Cardiology Foundation
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