Reduction of radiation exposure in catheter ablation of atrial fibrillation: lesson learned

Over the last decades, the concern for the radiation injury hazard to the patients and the professional staff has increased in the medical community. Since there is no magnitude of radiation exposure that is known to be completely safe, the use of ionizing radiation during medical diagnostic or interventional procedures should be as low as reasonably achievable (ALARA principle). Nevertheless, in cardiovascular medicine, radiation exposure for coronary percutaneous interventions or catheter ablation of cardiac arrhythmias may be high: for ablation of a complex arrhythmia, such as atrial fibrillation, the mean dose can be > 15 mSv and in some cases > 50 mSv. In interventional electrophysiology, although fluoroscopy has been widely used since the beginning to navigate catheters in the heart and the vessels and to monitor their position, the procedure is not based on fluoroscopic imaging. Therefore, non-fluoroscopic three-dimensional systems can be used to navigate electrophysiology catheters in the heart with no or minimal use of fluoroscopy. Although zero-fluoroscopy procedures are feasible in limited series, there may be difficulties in using no fluoroscopy on a routine basis. Currently, a significant reduction in radiation exposure towards near zero-fluoroscopy procedures seems a simpler task to achieve, especially in ablation of complex arrhythmias, such as atrial fibrillation. The data reported in the literature suggest the following three considerations. First, the use of the non-fluoroscopic systems is associated with a consistent reduction in radiation exposure in multiple centers: the more sophisticated and reliable this technology is, the higher the reduction in radiation exposure. Second, the use of these systems does not automatically lead to reduction of radiation exposure, but an optimized workflow should be developed and adopted for a safe non-fluoroscopic navigation of catheters. Third, at any level of expertise, there is a specific learning curve for the operators in the non-fluoroscopic manipulation of catheters; however, the learning curve is shorter for more experienced operators compared to less experienced operators.