Left Atrial Intracardiac Echocardiography to Assist Zero Fluoroscopy Pulse Field Atrial Fibrillation Ablation—A Beginner's Guide

Background: Pulsed-field ablation (PFA) has emerged as a novel energy source for the management of atrial fibrillation (AF), offering improved tissue selectivity and a better safety profile. Although fluoroscopy has traditionally guided catheter positioning, the integration of intracardiac echocardiography (ICE), particularly from a left atrial (LA) vantage point, presents an opportunity for real-time visualization and enhanced procedural precision. In this paper, we describe a workflow for LA-ICE-guided PFA, without using fluoroscopy, and present preliminary data from our centre. Methods: All patients who underwent PFA for AF since December 2024 were screened, and those who underwent LA-ICE-guided ablation were included in the study. After patients provided informed consent, procedures were performed under general anesthesia with muscle relaxants to minimize stimulation of extracardiac muscles. Results: LA-ICE-guided PFA was performed in 100 consecutive patients with paroxysmal (73%) and persistent (27%) AF at a single centre. Zero-fluoroscopy (ZF) ablation was successfully performed in 28 patients, without any major complications. The challenges encountered during ZF ablation included enlarged atria, thick interatrial septum, venous tortuosity, aortic root aneurysm, and pacemaker leads. Visualizing the FlexCath sheath while crossing the interatrial septum and confirming its position in the left atrium immediately after crossing does require some effort, especially in a dilated left atrium. Conclusions: LA-ICE facilitates ZF-PFA for AF by offering superior visualization of the LA anatomy, continuous monitoring of catheter orientation, precise catheter positioning, and maintenance of catheter-tissue contact.