Step-by-Step: How to Perform Pulsed Field Ablation of Atrial Fibrillation Guided Exclusively by Intracardiac Echocardiography Using a Pentaspline Catheter.

Pulsed-field ablation (PFA) is an emerging technique for pulmonary vein isolation in atrial fibrillation. However, its implementation is commonly guided by fluoroscopy with or without 3D electroanatomic mapping, increasing either radiation exposure or procedural cost. We describe a practical, step-by-step workflow for performing completely fluoroless pulmonary vein isolation using a pentaspline PFA ablation catheter guided exclusively by intracardiac echocardiography (ICE). All procedural stages-including transseptal access, intracardiac navigation, catheter deployment, energy delivery, and acute assessment of electrical isolation-are performed under continuous ICE visualization. Although this workflow is designed for pulmonary vein isolation, selected examples of extra-pulmonary vein ablation guided by ICE are included to illustrate catheter manipulation and energy delivery. This ICE-only approach suggests that fluoroless PFA is achievable using continuous ICE guidance while avoiding radiation exposure. In centers where the combined use of ICE and 3D mapping systems may be limited, this workflow may also represent a practical alternative for the treatment of atrial fibrillation.