Near-Zero-Fluoroscopy Ablation of Atrial Fibrillation Without ICE or Non-Fluoroscopic Tracking Systems: Findings From the SHORT LOOK Registry.

BACKGROUND

Catheter ablation is the key element of rhythm control in atrial fibrillation (AF), yet its reliance on fluoroscopy exposes patients and operators to radiation. A fluoroscopy-free procedure is possible using intracardiac echocardiography (ICE), but due to high cost, the learning curve, and added procedural steps, ICE is rarely used in Europe. Similarly, non-fluoroscopic tracking systems (NCTS) like MediGuide for near-zero fluoroscopy ablation have fallen out of favor. The SHORT LOOK study evaluates the efficiency and safety of a streamlined near-zero fluoroscopy workflow for first-time pulmonary vein isolation (PVI) based solely on advanced 3D mapping and an ultra-low-dose fluoroscopy protocol. The aim was to determine whether near-zero fluoroscopy ablation can be achieved using conventional techniques, enabling broader adoption in modern electrophysiology labs.

METHODS

The SHORT LOOK registry is a single-center, investigator-initiated prospective standard-of-care study enrolling consecutive patients undergoing first-time PVI for AF. A total of 450 patients were included in the final analysis. The workflow used a 3D mapping system (CARTO3, J&J MedTec) with an ultra-low-dose fluoroscopy protocol, without adjunctive technologies. Baseline assessments included medical history, physical examination, labs, ECG, EQ-VAS, and echocardiography. The primary efficacy endpoint was median fluoroscopy time; the primary safety endpoint was a composite of procedure-related death or cardiovascular, neurological, or vascular events. Secondary endpoints included 1-year freedom from atrial arrhythmia > 30 s, skin-to-skin time, fluoroscopy dose, and proportion of procedures with fluoroscopy < 1 min. Patients were followed up for 1 year.

RESULTS

The SHORT LOOK cohort (n = 450) achieved a median procedural time of 57 min, with median fluoroscopy time of 26 s and dose of 9.1 µGy*m². The complication rate was < 1% and no major adverse events occurred. Follow-up revealed that for paroxysmal atrial fibrillation, 86.1% were AT/AF-free at 3 months, decreasing to 82.6% at 12 months, while for persistent atrial fibrillation, the rates were 77.3% and 71.7%, respectively, confirming sustained rhythm control. EQ-VAS analyses revealed a significant improvement in health-related quality of life from baseline (p < 0.05). Compared to a historical NCTS group, our workflow leads to similarly low fluoroscopy times and radiation doses.

CONCLUSION

The streamlined workflow for initial atrial fibrillation ablation, which nearly eliminates fluoroscopy, demonstrates a significant reduction in both fluoroscopy time and radiation dose. This approach is feasible in any electrophysiology laboratory and offers a practical method for performing rapid, safe, and effective AF ablations while maintaining minimal radiation exposure-all without the need for additional adjunctive technologies.