Routine single- versus double-transseptal center strategy and fluoroscopy exposure during point-by-point RF pulmonary vein isolation: insights from the Go for Zero Fluoroscopy registry

Background The impact of transseptal puncture (TSP) strategy on fluoroscopy exposure during pulmonary vein isolation (PVI) is usually assessed at the level of individual procedures. However, in real-world practice, TSP choice often reflects an institutional workflow rather than a purely case-specific decision. Purpose To evaluate whether a center’s routine TSP strategy is associated with radiation exposure and procedural efficiency during point-by-point radiofrequency (RF) PVI for atrial fibrillation (AF). Methods We analysed point-by-point RF PVI procedures from the prospective multicenter Go for Zero Fluoroscopy registry. Centers with at least 5 procedures were classified according to the proportion of double-TSP cases: routine single-TSP centers (≤20% double TSP), routine double-TSP centers (≥80% double TSP), and mixed centers (21–79%). The primary analysis compared procedures performed in routine single- versus routine double-TSP centers. Outcomes included fluoroscopy time, dose-area product (DAP), procedure time, and the rate of low-fluoroscopy procedures (defined as fluoroscopy time ≤5 min). A sensitivity analysis compared center-level median outcomes. Results Among 393 RF PVI procedures, 19 centers had at least 5 cases and were included in the center-strategy analysis: 6 routine single-TSP centers, 7 routine double-TSP centers, and 6 mixed centers. The primary comparison included 262 procedures performed in routine single- (n=125) and routine double-TSP centers (n=137). Compared with routine single-TSP centers, routine double-TSP centers had significantly lower fluoroscopy time (5.4 [2.86–11.0] vs 13.23 [9.0–23.25] min; p<0.001), lower DAP (470 [174–964] vs 1280 [618–2330] cGy·cm²; p<0.001), and shorter procedure time (95 [77–123] vs 140 [109–172] min; p<0.001). Low-fluoroscopy procedures (≤5 min) were markedly more frequent in routine double-TSP centers (49.6% vs 6.4%; p<0.001). However, in sensitivity analysis performed at the level of individual center medians, differences between routine single- and routine double-TSP centers were no longer statistically significant for fluoroscopy time (p=0.77), DAP (p=0.84), procedure time (p=0.13), or low-fluoroscopy rate (p=0.15). Conclusions In this multicenter RF PVI registry, centers routinely using double TSP achieved substantially lower radiation exposure and shorter procedures than centers routinely using single TSP at the procedural level. However, the attenuation of these differences in center-level sensitivity analysis suggests that the observed effect is likely driven by broader institutional workflow and procedural culture rather than puncture strategy alone. Routine double-TSP use may therefore be best interpreted as a marker of a fluoroscopy-efficient AF ablation workflow.