A completely fluoroscopy-free approach for pulmonary vein isolation including electroanatomically guided transseptal puncture without TEE, ICE or general anesthesia

Background Pulmonary vein isolation (PVI) is a cornerstone therapy for atrial fibrillation (AF). Although electroanatomical mapping systems (EAMS) are widely used, fluoroscopy remains common practice, particularly for transseptal puncture (TSP). In many centres aiming at minimizing radiation exposure, TSP is performed using guidance by transesophageal echocardiography (TEE), frequently under or general anesthesia, or intracardiac echocardiography (ICE). A completely fluoroscopy-free PVI workflow that also omits TEE and ICE, without the need for anaethesia support, has not been systematically evaluated. Methods Eighty-three consecutive patients (72% male, median age 61 years [IQR 53–69]) undergoing PVI for AF were prospectively treated using an EAMS-guided workflow. Preprocedural TEE, cardiac computed tomography or magnetic resonance imaging was performed to exclude left atrial thrombus. A three-dimensional electroanatomical map of the right atrium was created to identify and tag the fossa ovalis. The transseptal needle was visualized and advanced within the mapping system, enabling TSP without fluoroscopy or echocardiographic guidance. All procedures were performed without TEE, ICE, or general anesthesia. Wide antral circumferential ablation using conventional RF-energy oder pulsed-field ablation (PFA) was subsequently conducted. Procedural success, duration, ablation time, and complications were prospectively recorded. Results Fluoroscopy-free TSP was successfully achieved in 78 of 83 patients (94%; 95% CI 88.9–99.1%). In 5 patients (6%), limited fluoroscopy was required to complete TSP. Mean ablation time was 32.2 minutes (95% CI 29.5–34.9), and mean total procedure duration was 117.5 minutes (95% CI 111.8–123.3). Minor groin hematoma was documented in 5 patients. No major complications related to the fluoroscopy-free approach occurred. Conclusion A completely fluoroscopy-free PVI strategy, including electroanatomically guided TSP without TEE, ICE, or general anesthesia, is feasible, safe, and efficient. This approach eliminates radiation exposure while avoiding additional imaging modalities and may be performed under local anaesthesia or sedation, supporting broader implementation of entirely non-fluoroscopic AF ablation workflows in routine clinical practice.