Evgeny B. Kropotkin

Introduction. Pulsed field ablation (PFA) is an innovative method for the treatment of atrial fibrillation (AF). The concept of zero-fluoroscopy during ablation procedures is not new. The feasibility and safety of intracardiac echocardiography (ICE)-guided radiofrequency pulmonary vein (PV) isolation have been previously described. In this case, we aim to demonstrate a method of non-fluoro PFA without the 3D navigation mapping system. Brief description . We present the first successful experience of pulmonary vein PFA using a domestic circular catheter under ICE guidance in a patient with paroxysmal AF. Transmurality in the ablation area was confirmed by subsequent 3D electroanatomical mapping. Discussion . We have identified the following key messages: (1) ICE-guided positioning of the circular catheter is feasible and safe; (2) imaging of tight catheter contact with the pulmonary vein ostia is a mandatory aspect of the PFA procedure and ensures isolation in the target area, as confirmed by electroanatomical mapping; (3) the high safety profile of the procedure, achieved through real-time imaging, may contribute to a reduction in the risk of intraoperative complications. Conclusion . ICE-guided zero-fluoro PFA represents a new step in the treatment of AF. However, further studies are needed to evaluate the safety of the zero-fluoro approach compared to conventional fluoroscopic imaging methods during PFA in patients with AF.

Introduction. Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common paroxysmal supraventricular arrhythmia in adults, accounting for up to 60% of all supraventricular tachyarrhythmias (SVT). The first-line treatment for symptomatic recurrent AVNRT is catheter ablation (CA). Performance of CA with zero-fluoroscopy (ZF) using three-dimensional (3D) electroanatomical mapping systems is both possible and safe. Brief description. This article presents a clinical case of successful catheter ablation of right atrial supraventricular tachycardias (AVNRT and atrial tachycardia (AT) originating from the crista terminalis). All stages of the procedure were performed using CARTO 3D electroanatomical mapping (Biosense Webster Inc., USA) with a QDOT MICRO irrigated ablation mapping electrode (Biosense Webster Inc., USA) under (ZF). The first stage involved ablation of the slow pathways of the atrioventricular junction. The second stage involved ablation of a AT wave with a cycle duration (cd) of 456 ms and a right-sided activation front. We made a voltage and activation map of the right atrium, taking into account the morphology and activation pattern of the atrial component along the coronary sinus and the right atrium. Analysis of the activation map shows that the early activation zone on the SVT with a depolarisation time of 456 ms is located in the middle third of the crista terminalis. In this zone, areas of fibrotic changes in the myocardium are recorded according to the voltage map. A series of RF ablations was performed in the zone of interest, with the AT stopped at the moment of ablation, the ECG showed sustained sinus tachycardia at 92 beats per minute. Discussion. Three-dimensional electroanatomical mapping systems enable the creation of a «digital» twin of the patient’s heart, which allows for the accurate reproduction of the interrelationships between the heart’s anatomical structures. According to the findings of a number of studies and as demonstrated by our clinical case, there is no evidence to support the benefits of performing catheter ablation of right atrial SVTs under constant fluoroscopy. Conclusion. According to the findings of a number of studies and as demonstrated by our clinical case, there is no rationale for performing catheter ablation of right atrial supraventricular tachycardia under constant fluoroscopy.

Cryoballoon ablation (CBA), along with radiofrequency ablation and pulsedfield ablation, has proven to be a safe and equally effective method with a short learning curve and minimal time investment. The CBA technique for atrial fibrillation (AF) involves cryoballoon pulmonary vein occlusion, which is confirmed by the absence of contrast leakage from the target vein on fluoroscopy, followed by cryotherapy. Numerous studies have demonstrated the negative impact of fluoroscopy on the human body. This is especially relevant in centers performing a high volume of surgical procedures. This paper presents the immediate and long-term results of non-fluoroscopy CBA of AF and describes the methodology. This technique involves intravascular ultrasound-guided (IVUS) manipulations, eliminating the need for contrast agent or ionizing radiation. It also simultaneously monitors the position of tools within the heart cavities and the echo-free space. The technique is described step by step and illustrated with IVUS screenshots and explanations. Over eight years of clinical experience using non-fluoroscopy CBA of AF has demonstrated that its effectiveness and safety are comparable to the classical technique using fluoroscopy and venography. It eliminates the negative effects of ionizing radiation and radiocontrast agents, maintains the "one shot" principle, does not increase surgical time, and is reproducible.

Aim. To assess safety and effectiveness of zero fluoro catheter ablation (CA) of tachyarrhythmias in patients with antiarrhythmic device.Methods. One hundred ninety-seven patients with implanted antiarrhythmic device and indication for catheter ablation of tachyarrhythmias were included in retrospective study. In control group of patients n=63 (mean age 65.5±11.9 years) all procedures were performed under fluoroscopic guidance. In a study group, n=134 (mean age 66.1±15.6 years) all procedures were performed without the use of fluoroscopy. To reconstruct 3D anatomy we used navigation systems: magnet and impedance. In some cases we used intracardiac ultrasound. In the first group there were 65% of patients with pacemakers, 4.8% patients with implantable cardioverters-defibrillators and 30.2% of patients had cardiac resynchronization systems. In second 70.1%, 12.7% and 17.2% respectively. In control group CA was performed within 24 hours after device implantation in 13 patients (20.6%), in study group - 23 (17.2%). In the rest cohort of patients mean period between device implantation and CA was 29.26±28 months - in control group, 38.8±39 months. Antiarrhythmic device programming was performed before and right after CA.Results. Interventional catheter procedure was performed in 98.4% of patients in control group and in 98.5% of patients in study group. Radiation exposure in control group was 0.24 mZv, in study group 0 mZv. There were no conversions from zero fluoroscopy procedure to X -ray controlled due to different reasons. In control (fluoroscopy controlled) group 8 hours after CA ventricle lead dislodgement was diagnosed. Antiarrhythmic device in this patient was implanted 6 days before CA. There were no lead dislodgements or cardiac pacing disorders in study group.Conclusion. Zero fluoroscopy CA of tachyarrhythmias in patients with antiarrhythmc device is as safe and effective as standard fluoroscopy controlled procedure.

We present a case of asymptomatic coronary-atrial fistula formation after zero fluoro catheter ablation for incessant right atrial tachycardia using ABLATION INDEX module.

This article brings together the opinions of leading experts in the field of cardiac arrhythmia interventional treatment using multipolar mapping. The advantages and applicability of the PENTARAY® NAV eco mapping catheter are discussed in detail.

Purpose Our study aimed to assess the achievement of target ablation index (AI) values and their impact on first-pass pulmonary vein isolation (FPI) as well as to identify FPI predictors. Methods Atrial fibrillation (AF) ablation was performed according to the local practice, and target AIs were evaluated. The actual AI was calculated as the median value of all ablation points for the anterior and posterior left atrial (LA) walls. Results A total of 450 patients from nine centers were enrolled. Patients with first-time ablation (n = 408) were divided into the FPI and non-FPI groups. In the FPI group, a higher median target AI was reported for both the anterior and posterior LA walls than those in the non-FPI group. A higher actual AI was observed for the anterior LA wall in the FPI group. The actual AI was equal to or higher than the target AI for the posterior, anterior, and both LA walls in 54%, 47%, and 35% (n = 158) cases, respectively. Parameters such as hypertension, stroke, ablation power, actual AI value on the anterior wall, target AI values on both LA walls, AI achievement on the posterior wall, carina ablation, and operator experience were all associated with FPI in a univariate logistic regression model; only carina ablation was an independent predictor of FPI. Conclusions According to our multicenter study, FPI and a target AI were not achieved in a significant proportion of AF ablation procedures. Higher actual and target AI values were associated with FPI, but only carina ablation can independently predict FPI.

Clinical case report of zero fluoroscopy radiofrequency catheter isolation of supraventricular ectopic foci in patient after orthotopic heart transplantation is presented.

Premature ventricular contractions (PVC) is a very common type of arrhythmia. Some patients require surgical treatment. The search for the safest methods of surgical treatment is an important research task.Aim. To evaluate the efficacy and safety of catheter ablation in patients with idiopathic ventricular arrhythmias depending on the implementation of X-ray control.Material and methods. The study included 183 patients admitted to the Federal Center for Cardiovascular Surgery for elective surgery, with frequent idiopathic PVC and indications for surgical treatment of arrhythmia. In the majority of patients with idiopathic PVC, the central origin of ectopia is the right ventricular outflow tract (RVOT). The patients were divided into two groups: group 1 (n=90) — patients with idiopathic PVC after fluoroscopy-guided radiofrequency ablation (RFA); group 2 (n=93) — patients after RFA without fluoroscopy. All patients underwent electrocardiography, echocardiography, and electrophysiological testing. All patients before and after RFA underwent 24-hour Holter monitoring.Results. Among patients of group 1, the initial success of RFA was 62,2%, and in group 2 — 71% (p=0,21). Surgery complications were registered in 3,3% and 4,3% of patients of groups 1 and 2. No deaths have been reported. The duration of surgery did not depend on the use of fluoroscopy. Among patients with failed initial RFA, the effectiveness of subsequent interventions was 88,6%. The greatest efficiency of initial RFA was observed when the ectopic ventricular focus was located in RVOT The lowest efficiency of RFA was observed when the focus was located in the left ventricular papillary muscles.Conclusion. RFA in patients with idiopathic PVC without fluoroscopy does not increase the complication rate and the duration of surgery and have a comparable efficacy compared to fluoroscopy-guided RFA.