Impact of integrated 3D imaging and fluoroscopy fusion during pulsed field ablation

Three-dimensional rotational angiography (3DRA) allows real-time 3D reconstruction of the left atrium (LA) and integration in the fluoroscopy image. As such it provides anatomical guidance which can be valuable during single shot ablation procedures. There are no data estimating efficiency and effectiveness in the context of pulsed field ablation (PFA) of atrial fibrillation (AF).

We sought to investigate the impact of 3DRA on the procedural parameters in consecutive patients who underwent AF ablation with PFA technology.

All consecutive patients who underwent AF ablation with PFA at two experienced centers from November 2023 until October 2024 were eligible for this study. Operators performed pulmonary vein isolation (PVI) using device-specific instructions resulting in eight applications (four basket and 4 flower poses) for each vein. Additional lesions were done at the operator discretion. Procedural metrics were analysed according to the use of 3DRA which was used according to institutional standards.

Four hundred and four patients were included in this study. 62.9% of the population had paroxysmal AF, and 37.1% had persistent AF. 3DRA was used in 239 cases (59.2%) (Figure 1). Patients with peri-procedural 3DRA received fewer additional applications compared to patients without (applications per patients 38 [32-45] vs 40 [34-53], p =0.012). Median fluoroscopy time was 15 [10-22] min, median LA dwell time was 30 [25-37] min, and median skin-to-skin time was 41 [35-51] min. The use of 3DRA improved the procedural metrics (3DRA vs no 3DRA: 39 [34-48] min vs 45 [38-53] min for skin-to-skin time, p <0.001; 11 [9-16] min vs 20 [15-24] min for total fluoroscopy time p <0.001, and 9 [7-13] vs 20 [15-24] for fluoroscopy time during PFA) (Figure 2).

In our study, the integration of 3DRA during PVI with PFA may provide advantages in terms of procedural metrics, such as the decrease in both the total procedural time and the total fluoroscopy dose. These improvements may be a result of the anatomical information provided by the 3D model.