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Objective Pulmonary vein isolation (PVI) is the cornerstone of the interventional treatment of atrial fibrillation (AF). Traditionally, during these procedures the catheters are guided by fluoroscopy, which poses a risk to the patient and staff by ionizing radiation. Our aim was to describe our experience in the implementation of an intracardiac echocardiography (ICE) guided zero fluoroscopic (ZF) ablation approach to our routine clinical practice. Methods We developed a simplified ICE guided technique to perform ablation procedures for AF, with the aid of a 3D electroanatomical mapping system. The workflow was implemented in two phases: (1) the Introductory phase, where the first 16 ZF PVIs were compared with 16 cases performed with fluoroscopy and (2) the Extension phase, where 71 consecutive patients (including repeat procedures) with ZF approach were included. Standard PVI (and redoPVI) procedures were performed, data on feasibility of the ZF approach, complications, acute and 1-year success rates were collected. Results In the Introductory phase, 94% of the procedures could be performed with complete ZF with a median procedure time of 77.5 (73.5–83) minutes. In one case fluoroscopy was used to guide the ICE catheter to the atrium. There was no difference in the complication, acute and 1-year success rates, compared with fluoroscopy guided procedures. In the Extension phase, 97% of the procedures could be completed with complete ZF. In one case fluoroscopy was used to guide the transseptal puncture and in another to position the ICE catheter. Acute success of PVI was achieved in all cases, 64.4% patients were arrhythmia free at 1-year. Acute major complications were observed in 4 cases, all of these occurred in the redo PVI group and consisted of 2 tamponades, 1 transient ischemic attack and 1 pseudoaneurysm at the puncture site. The procedures were carried out by all members of the electrophysiology unit in the Extension phase, including less experienced operators and electrophysiology fellows (3 physicians) under the supervision of the senior electrophysiologist. Consequently, procedure times became longer [90 (75–105) vs 77.5 (73.5–85) min, p = 0.014]. Conclusions According to our results, a ZF workflow of AF ablations can be successfully implemented into the routine practice of an electrophysiology laboratory, without compromising safety and effectivity.

Background Atrial fibrillation (AF) ablation has been shown to be possible using minimal or no fluoroscopic imaging for guidance. However, the techniques previously described focus on radiofrequency ablation or rely on the use of resource-heavy technology such as intra-cardiac echocardiography. We describe the first reported case in the literature of successful fluoroscopy-free AF cryoablation guided solely by transoesophageal echocardiography (TOE). Case summary A 65-year-old gentleman underwent cryoablation of paroxysmal AF using TOE guidance only with no use of fluoroscopy. Transoesophageal echocardiography was used in all stages of the procedure including guidance for transseptal puncture, ensuring balloon position in the pulmonary veins, and checking for post-procedure pericardial effusion. After 5 months of follow-up, the patient remains in sinus rhythm and has discontinued all antiarrhythmic and anticoagulant medication. Discussion This case demonstrates for the first time the feasibility of fluoroscopy-free cryoablation using only TOE for guidance.