Co-Author(s):
Gustavo Morales, MD
Tina Hunter, PhD
Paul Zei, MD
Joshua Silverstein, MD
Carolyn Whitmire, MBA
Allyson Varley, PhD, MPH
Anil Rajendra, MD
Grandview Medical Center
Grandview Medical Center Alabama Cardiovascular Group 3686 Grandview Parkway, Suite 720 Birmingham, AL
Introduction | Objectives: With advances in 3-dimensional (3D) electroanatomical mapping (EAM), fluoroscopy utilization and procedure time during paroxysmal atrial fibrillation (PAF) ablation have declined substantially. Recently, a new sheath became available that can be visualized with 3D EAM. This may further simplify ablation workflow and reduce fluoroscopy exposure. The objectives of this study were to evaluate early user experience incorporating the new EAM visualizable sheath into PAF ablations and to compare outcomes to procedures performed without the sheath.
Methods: Consecutive de novo PAF procedures using a porous tip contact force catheter at a high-volume site between January 2018 and May 2019 were included. Procedures using the new EAM visualizable sheath were compared to those performed without it. All ablations employed a standardized low-fluoroscopy workflow. Pulmonary vein isolation was performed with wide-area circumferential ablation, contact force was held between 10-20 grams, the catheter moved every 10-20 seconds, and radiofrequency (RF) energy set at 40-45 watts throughout the atrium.  Due to asynchronous adoption of the sheath by operators of varying experience, analysis of outcomes employed stabilized inverse probability of treatment weights to balance cohorts by operator, age, sex, and CHA2DS2-VASc score.
Results: Cohorts were similar at baseline (Table). Complications were few across cohorts with no death or stroke.  The EAM visualizable sheath cohort reported 7 complications: arteriovenous fistula (1), cardiac tamponade/pericardial effusion (2), hematoma (1), pseudoaneurysm (1), pericarditis (2) versus the without EAM visualizable sheath cohort reported 2 complications, cardiac tamponade/pericardial effusion and pseudoaneurysm. Use of the EAM visualizable sheath was associated with significant reduction in RF time and increase in ablations performed without fluoroscopy (Table). There were fewer reablations at 12 months in the EAM visualizable sheath cohort, but the difference was not statistically significant due to low number of events (Table).
Conclusions: A 3D EAM visualizable sheath safely reduced RF time and facilitated procedures performed without fluoroscopy, with no impact on clinical outcomes.