Comparing Low-to-Zero Fluoroscopic Navigation Systems for AVNRT Catheter Ablation: A Network Meta-Analysis.

Publisher: Futura Pub. Co. Country of Publication: United States NLM ID: 7803944 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1540-8159 (Electronic) Linking ISSN: 01478389 NLM ISO Abbreviation: Pacing Clin Electrophysiol Subsets: MEDLINE

Original Publication: Mount Kisco, N. Y. : Futura Pub. Co., c1978-

Catheter Ablation*/methods ; Tachycardia, Atrioventricular Nodal Reentry*/surgery ; Tachycardia, Atrioventricular Nodal Reentry*/diagnostic imaging; Fluoroscopy ; Humans ; Surgery, Computer-Assisted/methods ; Network Meta-Analysis

Background: Low-to-zero fluoroscopic navigation systems lower radiation exposure which improves health outcomes. Conventional x-ray fluoroscopy (CF) has long been the standard to guide to catheter location for cardiac ablation. With advancements in technology, alternative safety navigation systems have been developed. Three primary modalities commonly utilized are three-dimensional electroanatomic mapping (3D-EAM), magnetic navigation system (MNS), and intracardiac echocardiography (ICE), all of which can reduce radiation exposure during the procedure.
Objective: We aim to compare the efficacy and safety among ICE, EAM, MNS, and CF in ablation of atrioventricular nodal reentrant tachycardia (AVNRT).
Methods: This is a meta-analysis consisting of observational studies and randomized controlled trials, which evaluated the performance of navigation systems of catheter ablation in AVNRT patients. Primary endpoint was to access the AVNRT recurrence after the procedure during follow-up periods. Secondary endpoints were technical success, fluoroscopic time, fluoroscopic dose area product, radiofrequency ablation time, and adverse events. Random-effect model was applied for pooled estimated effects of included studies.
Results: A total of 21 studies (21 CF, 2 ICE, 9 EAM, 11 MNS) including 1716 patients who underwent catheter ablation for AVNRT treatment were analyzed. Of these, 16 were observational studies and 5 were randomized controlled trials.
Primary Outcome: Point estimation of AVNRT recurrence showed ICE exhibited a pooled odds ratio (ORs) of 1.06 (95% confidence interval [CI]: 0.064-17.322), MNS with ORs of 0.51 (95% CI: 0.214-1.219], and EAM with ORs of 0.394 (95% CI: 0.119-1.305) when compared to CF.
Secondary Outcomes: EAM had significant higher technical success with ORs of 2.781 (95% CI: 1.317-5.872) when compared to CF. Regarding fluoroscopy time, EAM showed the lowest time with mean differences (MD) of -10.348 min (95% CI: -13.385 to -7.3101) and P-score of 0.998. It was followed by MNS with MD of -3.712 min (95% CI: -7.128 to -0.295) and P-score of 0.586, ICE with MD of -1.150 min (95% CI: -6.963 to 4.662) with a P-score of 0.294 compared to CF, which has a P-score of 0.122. There were insignificant adverse events across the procedures.
Conclusion: AVNRT ablation navigated by low-to-zero fluoroscopic navigation systems achieves higher efficacy and comparable safety to conventional fluoroscopywhile also reducing risk of radiation exposure time.
(© 2024 Wiley Periodicals LLC.)

C. Blomström‐Lundqvist, M. M. Scheinman, E. M. Aliot, et al., “ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias–Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias) Developed in Collaboration With NASPE‐Heart Rhythm Society,” Journal of the American College of Cardiology 42, no. 8 (2003): 1493–1531.
E. M. Cronin, F. M. Bogun, P. Maury, et al., “2019 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias,” Heart Rhythm 17, no. 1 (2020): e2–e154.
M. Giaccardi, M. Anselmino, M. Del Greco, et al., “Radiation Awareness in an Italian Multispecialist Sample Assessed With a Web‐Based Survey,” Acta Cardiologica 76, no. 3 (2021): 307–311.
M. Goya, D. Frame, L. Gache, et al., “The Use of Intracardiac Echocardiography Catheters in Endocardial Ablation of Cardiac Arrhythmia: Meta‐Analysis of Efficiency, Effectiveness, and Safety Outcomes,” Journal of Cardiovascular Electrophysiology 31, no. 3 (2020): 664–673.
C. Soether, A. A. Boehmer, B. C. Dobre, B. M. Kaess, and J. R. Ehrlich, “Zero‐Fluoro Atrioventricular‐Nodal Reentrant Tachycardia Ablation,” Herzschrittmacherther Elektrophysiol 34, no. 4 (2023): 305–310.
P. Kupo, L. Saghy, G. Bencsik, et al., “Randomized Trial of Intracardiac Echocardiography‐Guided Slow Pathway Ablation,” Journal of Interventional Cardiac Electrophysiology 63, no. 3 (2022): 709–714.
C. Ma, T. Chen, Y. Chen, et al., “Understanding the Scope of Intracardiac Echocardiography in Catheter Ablation of Ventricular Arrhythmia,” Frontiers in Cardiovascular Medicine 9 (2022): 1037176.
J. Kautzner, J. Haskova, and F. Lehar, “Intracardiac Echocardiography to Guide Non‐Fluoroscopic Electrophysiology Procedures,” Cardiac Electrophysiology Clinics 13, no. 2 (2021): 399–408.
G. Mascia and M. Giaccardi, “A New Era in Zero X‐Ray Ablation,” Arrhythmia & Electrophysiology Review 9, no. 3 (2020): 121–127.
T. Reents, C. Jilek, P. Schuster, et al., “Multicenter, Randomized Comparison Between Magnetically Navigated and Manually Guided Radiofrequency Ablation of Atrioventricular Nodal Reentrant Tachycardia (the MagMa‐AVNRT‐Trial),” Clinical Research in Cardiology 106, no. 12 (2017): 947–952.
D. Tsiachris, C. K. Antoniou, I. Doundoulakis, et al., “Three‐Dimensional Electroanatomically Guided Slow Pathway Elimination is Associated With Procedural Improvements and Clinical Benefit in Atrioventricular Node Reentrant Tachycardia Patients,” Journal of Arrhythmia 38, no. 6 (2022): 1035–1041.
R. Batra, M. Nair, M. Kumar, et al., “Intracardiac Echocardiography Guided Radiofrequency Catheter Ablation of the Slow Pathway in Atrioventricular Nodal Reentrant Tachycardia,” Journal of Interventional Cardiac Electrophysiology 6, no. 1 (2002): 43–49.
M. J. Earley, R. Showkathali, M. Alzetani, et al., “Radiofrequency Ablation of Arrhythmias Guided by Non‐Fluoroscopic Catheter Location: A Prospective Randomized Trial,” European Heart Journal 27, no. 10 (2006): 1223–1229.
H. A. Kopelman, S. P. Prater, F. Tondato, N. A. Chronos, and N. S. Peters, “Slow Pathway Catheter Ablation of Atrioventricular Nodal Re‐Entrant Tachycardia Guided by Electroanatomical Mapping: A Randomized Comparison to the Conventional Approach,” Europace 5, no. 2 (2003): 171–174.
Y. X. Zhang, C. Y. Lu, Q. Xue, K. Li, W. Yan, and S. H. Zhou, “Radiofrequency Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia Guided by Magnetic Navigation System: A Prospective Randomized Comparison With Conventional Procedure,” Chinese Medical Journal 125, no. 1 (2012): 16–20.
F. Akca, B. Schwagten, D. A. Theuns, M. Takens, P. Musters, and T. Szili‐Torok, “Safety and Feasibility of Single‐Catheter Ablation Using Remote Magnetic Navigation for Treatment of Slow‐Fast Atrioventricular Nodal Reentrant Tachycardia Compared to Conventional Ablation Strategies,” Acta Cardiologica 68, no. 6 (2013): 559–567.
M. Álvarez, L. Tercedor, I. Almansa, et al., “Safety and Feasibility of Catheter Ablation for Atrioventricular Nodal Re‐Entrant Tachycardia Without Fluoroscopic Guidance,” Heart Rhythm 6, no. 12 (2009): 1714–1720.
D. R. Davis, A. S. Tang, M. H. Gollob, R. Lemery, M. S. Green, and D. H. Birnie, “Remote Magnetic Navigation‐Assisted Catheter Ablation Enhances Catheter Stability and Ablation Success With Lower Catheter Temperatures,” Pacing and Clinical Electrophysiology 31, no. 7 (2008): 893–898.
R. Kerzner, J. M. Sánchez, J. L. Osborn, et al., “Radiofrequency Ablation of Atrioventricular Nodal Reentrant Tachycardia Using a Novel Magnetic Guidance System Compared With a Conventional Approach,” Heart Rhythm 3, no. 3 (2006): 261–267.
A. M. Kim, M. Turakhia, J. Lu, et al., “Impact of Remote Magnetic Catheter Navigation on Ablation Fluoroscopy and Procedure Time,” Pacing and Clinical Electrophysiology 31, no. 11 (2008): 1399–1404.
J. Moreno, T. Archondo, R. Barrios, et al., “Ablation of Atrioventricular Nodal Reentrant Tachycardia Using Remote Magnetic Guidance (Stereotaxis) Requires Lower Temperature and Power Settings Because of Improved Local Contact,” Revista Espanola De Cardiologia 62, no. 9 (2009): 1001–1011.
A. M. E. Noten, J. A. E. Kammeraad, N. L. Ramdat Misier, et al., “Remote Magnetic Navigation Shows Superior Long‐Term Outcomes in Pediatric Atrioventricular (Nodal) Tachycardia Ablation Compared to Manual Radiofrequency and Cryoablation,” IJC Heart & Vasculature 37 (2021): 100881.
L. Parreira, R. Marinheiro, P. Carmo, et al., “Atrioventricular Node Reentrant Tachycardia: Remote Magnetic Navigation Ablation versus Manual Ablation—Impact on Operator Fluoroscopy Time,” Revista Portuguesa De Cardiologia (English Edition) 38, no. 3 (2019): 187–192.
P. Ricard, D. G. Latcu, K. Yaïci, N. Zarqane, and N. Saoudi, “Slow Pathway Radiofrequency Ablation in Patients With AVNRT: Junctional Rhythm is Less Frequent During Magnetic Navigation Ablation Than With the Conventional Technique,” Pacing and Clinical Electrophysiology 33, no. 1 (2010): 11–15.
J. See, J. L. Amora, S. Lee, et al., “Non‐Fluoroscopic Navigation Systems for Radiofrequency Catheter Ablation for Supraventricular Tachycardia Reduce Ionising Radiation Exposure,” Singapore Medical Journal 57, no. 7 (2016): 390–395.
M. Swissa, E. Birk, T. Dagan, et al., “Radiofrequency Catheter Ablation of Atrioventricular Node Reentrant Tachycardia in Children With Limited Fluoroscopy,” International Journal of Cardiology 236 (2017): 198–202.
A. S. Thornton, P. Janse, D. A. Theuns, M. F. Scholten, and L. J. Jordaens, “Magnetic Navigation in AV Nodal Re‐Entrant Tachycardia Study: Early Results of Ablation With One‐ and Three‐Magnet Catheters,” Europace 8, no. 4 (2006): 225–230.
T. Yamaguchi, T. Tsuchiya, Y. Nagamoto, et al., “Anatomical and Electrophysiological Variations of Koch's Triangle and the Impact on the Slow Pathway Ablation in Patients With Atrioventricular Nodal Reentrant Tachycardia: A Study Using 3D Mapping,” Journal of Interventional Cardiac Electrophysiology 37, no. 1 (2013): 111–120.
A. Preda, E. Bonvicini, E. Coradello, et al., “The Fluoroless Future in Electrophysiology: A State‐of‐the‐Art Review,” Diagnostics (Basel) 14, no. 2 (2024): 182.
J. W. Hirshfeld Jr, S. Balter, J. A. Brinker, et al., “ACCF/AHA/HRS/SCAI Clinical Competence Statement on Physician Knowledge to Optimize Patient Safety and Image Quality in Fluoroscopically Guided Invasive Cardiovascular Procedures: A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training,” Circulation 111, no. 4 (2005): 511–532.
D. Rodkiewicz, E. Koźluk, A. Piątkowska, A. Gąsecka, K. Krzemiński, and G. Opolski, “Efficacy and Safety of Zero‐Fluoroscopy Approach During Catheter Ablation of Accessory Pathway,” Journal of Clinical Medicine 11, no. 7 (2022): 1814.
K. Piros, P. Perge, Z. Salló, et al., “Zero Fluoroscopy Ablation for Atrioventricular Nodal Reentrant Tachycardia and Typical Atrial Flutter is Equally Safe and Effective With EnSite NavX, Carto3, and Rhythmia Mapping Systems,” Frontiers in Cardiovascular Medicine 10 (2023): 1185187.
C. S. Purtell, R. T. Kipp, and L. L. Eckhardt, “Into a Fluoroless Future: An Appraisal of Fluoroscopy‐Free Techniques in Clinical Cardiac Electrophysiology,” Current Cardiology Reports 23, no. 4 (2021): 28.
M. Houmsse and E. G. Daoud, “Radiation Exposure: A Silent Complication of Catheter Ablation Procedures,” Heart Rhythm 9, no. 5 (2012): 715–716.
E. Chu, A. P. Fitzpatrick, M. C. Chin, K. Sudhir, P. G. Yock, and M. D. Lesh, “Radiofrequency Catheter Ablation Guided by Intracardiac Echocardiography,” Circulation 89, no. 3 (1994): 1301–1305.
D. Filgueiras‐Rama, A. Estrada, J. Shachar, et al., “Remote Magnetic Navigation for Accurate, Real‐Time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures,” Journal of Visualized Experiments: JoVE no. 74 (2013): 3658.
H. L. Estner, M. Grazia Bongiorni, J. Chen, N. Dagres, A. Hernandez‐Madrid, and C. Blomström‐Lundqvist, “Use of Fluoroscopy in Clinical Electrophysiology in Europe: Results of the European Heart Rhythm Association Survey,” Europace 17, no. 7 (2015): 1149–1152.
M. Marini, D. Ravanelli, F. Guarracini, et al., “A Cost‐Effective Analysis of Systematically Using Mapping Systems During Catheter Ablation Procedures in Children and Teenagers,” Pediatric Cardiology 39, no. 8 (2018): 1581–1589.
M. Casella, A. Dello Russo, G. Pelargonio, et al., “Near zerO Fluoroscopic exPosure During Catheter ablAtion of supRavenTricular arrhYthmias: The No‐PARTY Multicentre Randomized Trial,” Europace 18, no. 10 (2016): 1565–1572.

Keywords: atrioventricular nodal reentrant tachycardia; catheter ablation; conventional fluoroscopy; electroanatomic mapping; intracardiac echocardiogram; low‐to‐zero fluoroscopic; magnetic navigation system

Date Created: 20241022 Date Completed: 20241210 Latest Revision: 20241210

20241216

10.1111/pace.15096

39437197