Intracardiac Echo Versus Fluoroscopic Guidance for Pulsed Field Ablation: Single-Center Real-Life Study.

Background: Pulsed field ablation (PFA) is a novel non-thermal modality for catheter ablation (CA) in atrial fibrillation (AF) and has been replacing traditional thermal modalities. There have been studies in the past comparing fluoroscopic (FL) versus intracardiac echocardiogram (ICE) guidance for thermal ablation modalities. However, there have not been studies that compare outcomes for PFA performed under ICE versus FL guidance. Methods: This study was designed in a longitudinal cross-sectional format. A total of 196 patients who underwent PFA for AF at Prisma Health Richland were selected for the retrospective analysis. Patients were divided into two groups: those who underwent PFA under FL guidance (103 patients) versus ICE guidance (93 patients). The recurrence of atrial arrhythmias in the six-month follow-up period was studied. Multivariate regression analysis was performed to assess the difference in the association of either modality with recurrence of atrial arrhythmias. Bayesian non-inferiority models were used to analyze the non-inferiority between the modalities. Results: A total of 31 patients (30.1%) in the fluoro group had documented atrial arrhythmias in the six months following ablation. While 23 patients (24.7%) in the ICE group had documented atrial arrhythmias in the six-month follow-up period. The recurrence of AF was noted in 22.3% (22 patients) in the fluoro group and 14% (13 patients) in the ICE group. After running the multivariate regression analysis models, PFA under fluoroscopic guidance did not differ from ICE guidance, in terms of the recurrent atrial arrhythmias in the six-month follow-up (Adjusted Odds Ratio: 0.964; 95% CI: 0.336-2.772). The fluoro and ICE groups also did not differ in terms of six-month atrial fibrillation recurrence (Adjusted Odds Ratio: 2.43; 95% CI: 0.649-9.19). Non-inferiority analysis with Bayesian model was carried out, comparing the fluoro group and the ICE group in terms of freedom from arrhythmias in the six-month follow-up, and no inferiority was proved (95% confidence interval: -0.18-0.053), with a 61.03% chance of ICE-guided PFA being superior to fluoro guidance in terms of recurrence free interval, but statistical significance was not reached. Conclusions: Mean fluoroscopic time in the FL guidance group was 15.9 min, while no radiation exposure was documented in the ICE group. CA performed under FL versus ICE guidance did not differ statistically in terms of six-month recurrence of atrial arrhythmias in general and AF in particular.