Zero-fluoroscopy catheter ablation of atrial fibrillation using pulsed field ablation

Abstract Introduction In contemporary practices, pulsed field ablation (PFA) is becoming a method of choice for treatment of atrial fibrillation (AF). Currently, most PFA systems are made to be visualised with fluoroscopy (1). This represents a significant burden of ionising radiation to patients and operators. Different methods to eliminate fluoroscopy have been proposed, mainly based on the use of the three-dimensional electro-anatomical system and intracardiac echocardiography (ICE) (2). However, most have not been evaluated for zero-fluoroscopy procedures yet and might only be applicable to certain PFA systems. Purpose To evaluate feasibility, safety, and efficacy of zero-fluoroscopy catheter ablation with four different PFA systems. Methods In this retrospective study, we analysed 139 patients treated with zero-fluoroscopy PFA for AF from February 2023 to February 2025. Patients underwent PFA with either single shot catheters: Varipulse™, PulseSelect™ and FaraWave™ or point-by-point catheters using Centauri™ generator. Varipulse™ was visualized with CARTO™, catheters used with Centauri™ predominantly with Opal HDx™, PulseSelect™ and Farawave™ with EnsiteX™ 3D EAM. All cases were performed with ICE to perform transseptal puncture and to assess contact of the ablation catheter with the tissue. In over-the-wire systems, ICE was also utilized for guidewire visualisation. Pulmonary vein isolation was performed in all patients. Additional lesions were utilised per operator’s discretion. Results Fifteen patients underwent PFA with Varipulse™ (10.8%), 35 patients PulseSelect™ (25.2%), 31 patients with FaraWave™ (22.3%), and 58 with Centauri™ (41.7%). Baseline characteristics of patients are presented in Table 1. Mean skin-to-skin time for Varipulse™ was 82.2 ± 29.0, for PulseSelect™ 101.5 ± 23.5, for FaraWave™ 82.4 ± 18.7, and for Centauri™ 165.5 ± 42.5 minutes. First- pass pulmonary vein isolation was achieved in 80.0%, 71.4%, 87.1%, and 91.4% of Varipulse™, PulseSelect™, FaraWave™, and Galvanize™ cases, respectively. Posterior wall isolation was attempted in 0%, 11.4%, 25.8%, and 41.4% of Varipulse™, PulseSelect™, FaraWave™, and Centauri™ cases, respectively. In one patient in Varipulse™ and one patient in FaraWave™ case pulmonary vein isolation could not be achieved after additional lesions. Detailed data for each pulmonary vein and posterior wall is presented in Table 2. All in all, there were two complications (1.4%). In one patient, there was a prolonged asystole after PFA application with FaraWave™ system to the LSPV requiring a short resuscitation until sinus rhythm was established. In another patient in Centauri™ case, there was an air embolism into the right coronary artery also requiring short resuscitation. Both patients were without neurologic sequelae after the procedure. Conclusion Zero-fluoroscopy PFA with different PFA systems is feasible, safe, and effective for the treatment of AF.