Cutting down time and radiation in atrial fibrillation ablation: lessons from four workflow setups

Pulmonary vein isolation (PVI) for atrial fibrillation (AF) is a complex and evolving procedure. While the anatomical target remains consistent, recent advances such as high-density mapping catheters, visualizable steerable sheaths, and high-power or very-high-power short-duration (HPSD) ablation protocols may improve procedural efficiency and reduce radiation exposure. We aimed to compare procedural outcomes across four different electrophysiology (EP) laboratory setups to assess the impact of workflow optimization on procedural time, fluoroscopy exposure, and left atrial dwelling time.

This retrospective study enrolled patients with symptomatic AF who underwent point-by-point radiofrequency (RF) PVI in our electrophysiology lab over the past two years. Four PVI setups were analyzed, each incorporating different catheter types, transseptal puncture techniques, and power settings:

35/45W AI: Decapolar catheter, double transseptal puncture (TSP), circular mapping catheter, and ablation with 35/45 W, guided by an ablation index (AI).

40/45W AI: Single TSP, visualizable steerable sheath, pentaspline mapping catheter, and ablation with 40/45 W, guided by AI.

40/45W AI-ZF: Single TSP, visualizable steerable sheath, pentaspline mapping catheter, ablation with 40/45 W, guided by AI, with a zero-fluoroscopy approach.

90W ZF: Single TSP, visualizable steerable sheath, octaspline mapping catheter, and 90 W ablation, also using a zero-fluoroscopy approach.

Procedural data and outcomes were analyzed across the groups.

A total of 248 patients were included (35/45W AI: n=84; 40/45W AI: n=50; 40/45W AI-ZF: n=49; 90W ZF: n=65). Significant differences were observed in procedure time [median (IQR) 103 (80, 120) min for 35/45W AI vs. 72.5 (65, 86) min for 40/45W AI vs. 58 (52, 65) min for 40/45W AI-ZF vs. 38 (32, 43) min for 90W ZF, p<0.001], fluoroscopy time [192 (145.5, 250.5) s vs. 131.5 (100, 159) s vs. 0 (0, 0) s vs. 0 (0, 0) s, p<0.001], and left atrial dwelling time [60 (45, 79.2) min vs. 41.5 (36, 52) min vs. 40 (35, 46) min vs. 25 (21, 30) min, p<0.001]. Two minor vascular complications occurred, one each in the 35/45W and 90W ZF groups. Results are shown in Figures 1-3.

HPSD protocols, omitting the decapolar catheter, single transseptal access, and high-density mapping catheters significantly reduced procedural, left atrial dwelling, and fluoroscopy times. Zero-fluoroscopy setups effectively eliminated radiation without compromising efficiency or safety. These findings highlight optimized PVI workflows' potential to enhance efficiency and minimize radiation exposure in AF ablation.