Kuon E, Felix SB, Weitmann K, et al. Long-Term Strategies Support Autonomy In Radiation Safety In Invasive Cardiology. J Cardiol. 2016 Jul;68(1):43-48.

We analyzed long-term radiation-reducing strategies for an experienced interventionalist from 1997 to 2012, for the target intervention of CA. Patients’ median overall DAP decreased from 33.8 Gy cm2 at baseline to 2.4 and 0.6 Gy cm2 for CA in conventional (C) and electrocardiogram-gated (E) modes – one diastolic radiographic frame per heartbeat at 77% of the RR interval.

Zhang W, Jia N, Su J, et al. The comparison between robotic and manual ablations in the treatment of atrial fibrillation: a systematic review and meta-analysis. PloS One. 2014 May 6;(5):e96331.

To examine in what aspects and to what extent robotic ablation is superior over manual ablation, we sought to design a meta-analysis to compare clinical outcomes between the two ablations in the treatment of atrial fibrillation. Pooling the results of all qualified trials found significant reductions in fluoroscopic time (minutes) (WMD; 95% CI; P: -8.9; -12.54 to -5.26; <0.0005) and dose-area product (Gy×cm2) (WMD; 95% CI; P: -1065.66; -1714.36 to -416.96; 0.001) for robotic ablation relative to manual ablation, with evident heterogeneity (P<0.0005) and a low probability of publication bias.

Zedira A, Greffier J, Brunet X, et al. Decreased Operator X-Ray Exposure By Optimized Fluoroscopy During Radiofrequency Ablation Of Common Atrial Flutter. Diagn Interv Imaging. 2018 Oct;99(10):625-632.

To evaluate operator and patient irradiation during radiofrequency ablation (RFA) of common atrial flutter (AF) using three different fluoroscopy settings. No differences in procedure time and radiation exposure were found between the three groups. In the low dose group, mean operator X-ray exposures of eye-lens (4.7 ± 2.9 [SD] μSv/h; range: 0.9–10.5 μSv/h), whole body (1.6 ± 1.2 [SD] μSv/h; range 0.5–3.6 μSv/h) and hand skin (11.1 ± 10.8 [SD] μSv/h; range 2.4–35.4 μSv/h) were significantly lower than those in the standard dose group (P < 0.001).

Zanon F, Marcantoni L, Zuin M, et al. Electrogram-only guided approach to His bundle pacing with minimal fluoroscopy: A single-center experience. J Cardiovasc Electrophysiol. 2020 Jan 24. doi: 10.1111/jce.14366. [Epub ahead of print]

His bundle pacing (HBP) is the most physiological pacing. The standard technique based on fluoroscopic approach might be challenging and fluoro consuming. Targeting the His guided exclusively by the electrical signals could enable a precise lead implant, thus reducing fluoroscopy time (FT) and X-ray dose, desirable both for patients and operators. The aim of the study is to evaluate the feasibility, efficacy, and safety both acutely and at 30 days of the electrogram (EGM)-guided HBP with minimal or no fluoroscopy.

Wannagat S, Loehr L, Lask S, et al. Implementation of a near-zero fluoroscopy approach in interventional electrophysiology: impact of operator experience. J Interv Card Electrophysiol. 2018 Apr;51(3):215-220.

Catheter ablation is performed under fluoroscopic guidance. Reduction of radiation dose for patients and staff is emphasized by current recommendations. Previous studies have shown that lower operator experience leads to increased radiation dose. On the other hand, less experienced operators may depend even more on fluoroscopic guidance. Our study aimed to evaluate feasibility and efficacy of a non-fluoroscopic approach in different training levels.

Wang Y, Chen GZ, Yao Y, et al. Ablation of idiopathic ventricular arrhythmia using zero-fluoroscopy approach with equivalent efficacy and less fatigue: A multicenter comparative study. Medicine (Baltimore). 2017 Feb;96(6): e6080.

The aim of this study was to compare the safety and efficacy of a completely ZF approach with those of the conventional F approach in the ablation of idiopathic VAs .Eligible participants were assigned to either a ZF (n = 163) or F (n = 326) approach at a ratio of 1:2. The completely ZF approach was successful in 163 (100%) patients for electrophysiological study, and in 151 patients (94.4%) for arrhythmia ablation with 9 cases having to switch to the F approach due to the need for coronary angiography. The medical staffs using the ZF approach did not wear heavy protective apparels, thus experienced significantly less fatigue compared with those using the F approach (2.1 ± 0.7 vs 3.9 ± 1.6, P < 0.05).

Walters TE, Kistler PM, Morton JB, et al. Impact Of Collimation On Radiation Exposure During Interventional Electrophysiology. Europace. 2012 Nov;14(11): 1670-1673.

Fluoroscopy remains a cornerstone imaging technique in contemporary electrophysiology practice. We evaluated the impact of collimation to the ‘minimal required field size’ on clinically significant parameters of radiation exposure. Significant reductions in radiation exposure were seen with the practice of routine maximal collimation. The largest reductions were seen during ‘simple’ ablation procedures.

Walsh KA, Galvin J, Keaney J, et al. First experience with zero-fluoroscopic ablation for supraventricular tachycardias using a novel impedance and magnetic-field-based mapping system. Clin Res Cardiol. 2018 Jul;107(7):578–585.

We aimed to test the feasibility and safety of a zero-fluoroscopic strategy using a novel integrated magnetic and impedance-based electroanatomical mapping system for radiofrequency ablation (RFA) of supraventricular tachycardias (SVTs). Group 1 comprised 14 AV-nodal re-entrant tachycardia (AVNRT), 12 typical atrial flutter, 4 accessory pathway (AP), 2 atrial tachycardia (AT), and 9 diagnostic EP studies (EPS). Group 2 comprised 16 AVNRT, 17 atrial flutter, 6 AP, 3 AT, 2 AV-nodal ablations, and 7 EPS. A complete zero-fluoroscopic approach was achieved in 94% of Group 2 patients. There was a significant reduction in fluoroscopy dose, dose area product, and time (p < 0.0001, for all), with no difference in procedure times.

Vallakati A, Reddy YM, Emert M, et al. Impact of nonfluoroscopic MediGuide™ tracking system on radiation exposure in radiofrequency ablation procedures (LESS-RADS registry)-an initial experience. J Interv Card Electrophysiol. 2013 Nov;38(2):95-100.

Radiation exposure in the electrophysiology (EP) lab is a major concern to most electrophysiologists. A new technology, MediGuide™ nonfluoroscopic catheter tracking system, has been used for the first time in the USA recently. We intended to evaluate the efficacy of this novel catheter tracking system in reducing radiation exposure.