Intracardiac echocardiography guided zero-fluoroscopy workflow versus conventional fluoroscopy-guided workflow in atrial fibrillation ablation: efficiency, safety, and operator experience

Background Intracardiac echocardiography (ICE)-guided Zero-Fluoroscopy Workflow Group has been described in the literature. However, robust evidence simultaneously addressing procedural safety, efficiency, and operator experience remains limited. This study aims to systematically evaluate the procedural efficacy, intraoperative safety, and impact on operator experience of this technique. Objective To compare the ICE-guided Zero-Fluoroscopy Workflow with Conventional fluoroscopy-guided workflow in the context of radiofrequency catheter ablation for atrial fibrillation (AF), and to quantify the effect of zero-fluoroscopy mode on operator workload and comfort. Methods A retrospective study was conducted enrolling 177 patients who underwent radiofrequency catheter ablation for AF at Ningbo No. 2 Hospital between December, 2023 and June, 2026. Patients were divided into the ICE-Guided Zero-Fluoroscopy Workflow Group and the Conventional fluoroscopy-guided workflow Group. Operator subjective experience was assessed using the Visual Analogue Scale (VAS) for physical fatigue and procedural comfort immediately after each procedure. Total procedure time, TSP time, procedural success rate, and intraprocedural complications were also compared between groups. Results Operator post-procedural VAS scores for physical fatigue (1.1 ± 0.6 vs. 6.8 ± 1.9) and procedural comfort (1.3 ± 0.7 vs. 7.2 ± 1.8) were significantly lower in the ICE-Guided Zero-Fluoroscopy Workflow Group compared to the Conventional fluoroscopy-guided workflow Group (both P < 0.001). Total procedure time, TSP time, and procedural success rate showed no statistically significant differences between groups ( P > 0.05). One case of cardiac tamponade occurred in the Conventional fluoroscopy-guided workflow Group.while no intraoperative complications were observed in the ICE-guided group. Conclusion In this retrospective single-center study, an ICE-guided zero-fluoroscopy workflow for AF ablation was feasible and demonstrated similar procedural efficiency to a conventional fluoroscopy-guided workflow. The zero-fluoroscopy strategy was not associated with an observed increase in acute complications in this cohort. In addition, it was associated with substantially lower operator-reported fatigue and discomfort, likely reflecting the absence of lead apron use. These findings support further prospective evaluation of ICE-guided zero-fluoroscopy workflows as a potentially valuable strategy for balancing procedural performance and operator occupational health.