Zero‐fluoroscopy cryothermal ablation of atrioventricular nodal re‐entry tachycardia guided by endovascular and endocardial catheter visualization using intracardiac echocardiography (Ice&ICE Trial)

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Catheter ablation is the therapy of choice in patients with symptomatic atrioventricular‐nodal‐re‐entry‐tachycardia (AVNRT).1 The two accepted and widely available ablation techniques are radiofrequency (RFA) and cryothermal ablation (CA). For the latter, several advantages over RFA have been demonstrated, such as the possibility of anticipating the ablation result (regarding effectiveness and safety) at potential substrates using cryo‐mapping (CM; freezing at –30°C for maximal 60 seconds, which generates only temporary electrophysiologic effects) and a significant reduction in fluoroscopic time (FT) as well as radiation dose (RD) due to cryoadhesion (freezing of the catheter tip on the targeted substrate, which prevents catheter dislocation and renders unnecessary the continuous fluoroscopic evaluation of the catheter during CM or CA),2 though at the expense of higher recurrence rates.3
The navigation of the diagnostic and ablation catheters has been traditionally performed by fluoroscopic guidance. Because of the stochastic and deterministic deleterious effects of the ionizing radiation, complications can occur for both patients and laboratory staff with any exposure to fluoroscopy with a cumulative effect regarding FT and RD.5 Since the AVNRT is not usually a life‐threatening arrhythmia (often affecting children or young adults without structural heart disease) it is very important to maximally reduce or ideally avoid radiation exposure during the electrophysiology study (EPS) according to the ALARA (= as low as reasonably achievable) principle.7
A zero‐fluoroscopy EPS using three‐dimensional (3‐D) electroanatomic mapping systems (3‐D EAM) is achievable for treatment of most arrhythmias, including AVNRT,8 but these navigation tools are related to higher costs and procedure times as compared to fluoroscopy guidance.5
The use of intracardiac echocardiography (ICE) for visualization of anatomical slow pathway locations to facilitate AVNRT ablation has rarely been reported.13 In these studies ICE has only been used as an add‐on tool to fluoroscopy guidance or 3‐D EAM navigation with controversial results regarding reduction of FT, RD, or procedure time in these patients.
We aimed to investigate, in a prospective pilot study, the feasibility and safety of using ICE as the sole means of imaging during EPS and CA of the slow pathway in patients with symptomatic AVNRT.
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