A Fluoroless Workflow Using Transoesophageal Echocardiography for Catheter Ablation of Atrial Fibrillation Using Pulsed Field Ablation.

Background: Catheter ablations are increasingly performed with zero or minimal fluoroscopy, enabled by ultrasound imaging and electro-anatomical mapping. Pulsed field ablation (PFA) using Farawave has been dependent on fluoroscopic assessment of catheter conformation and contact. We aimed to demonstrate the feasibility of a PFA workflow for pulmonary vein isolation (PVI) and extrapulmonary ablation.

Method: Patients with paroxysmal or persistent atrial fibrillation who underwent fluoroless PVI between August 2023 to October 2024 were included in this study. After transoesophageal echocardiography-guided transeptal puncture, the PentaRay catheter was used to acquire left atrial and pulmonary branch anatomy. The Farawave catheter and Rosen wire, clipped using alligator clips, were visualised using the CARTO 3D Electroanatomical Mapping System (https://www.jnjmedtech.com/en-US/product/carto-3-system). Arrhythmia induction and mapping were routinely performed after PVI to guide further extrapulmonary ablation.

Results: A total of 36 patients were included in this study, with a median age of 60 (52-67) years. All pulmonary veins (PVs) were antrally isolated (130/130 PVs) and 16 patients (44.4%) underwent further extrapulmonary ablations with 13 of 13 successful posterior wall isolations (100%), six of seven linear line ablations achieving bidirectional block (85.7%) and two of two successful superior vena cava isolations (100%). The median total procedure time was 77 (65-93) minutes, left atrial dwelling time of 54 (46-74) minutes, with ablation time of 24 (20-29) minutes.

Conclusions: A fluoroless PFA workflow is feasible and rapid in achieving successful PVI and extrapulmonary ablation to treat atrial fibrillation and induced organised atrial tachyarrhythmias.