How to perform fluoroscopy-free PFA ablation procedures 

"It is remarkable what pulsed field has done in the atrial fibrillation world, it is truly a paradigm shift," Nair explained. "In Europe, PFA was very fluoroscopy-driven, which felt like a step back for me. But we've developed a workflow that allows physicians to continue using a no-fluoroscopy, no-lead approach for PFA."

Nair's techniques are especially relevant now with two commercial PFA systems available in the U.S., Medtronic's PulseSelect and Boston Scientific's Farapulse. 

Use of ICE and mapping to keep PFA free of fluoroscopy 

A requirement for durable PFA ablation lesions is precise contact and overlapping lesions. She said traditionally fluoroscopy has been used to assess this contact, but ICE is a superior alternative. By utilizing ICE, she can achieve near-field visibility and excellent contact assessment, ensuring effective lesion formation without radiation exposure.

"When I perform procedures, I take my ICE catheter into the left atrium for near visibility and excellent contact assessment. This allows me to see the catheter in contact with the tissue, ensuring durable lesions from the first application," Nair noted.

This contact is important to be able to clearly see on ICE, because PFA is different from RF and cryo in that you will lose the ability to visualize the electrical activity in the tissue immediately after the first application of PFA energy. 

"The problem with PFA is that after the first application, you've lost your electrograms. So you have no target to go after, which is not the case with thermal ablation. So it's very, very important for us to make sure that the first and every other lesion has contact and that we have enough overlap," she explained.  

Nair integrates her ICE with the 3D mapping system. She uses the ICE to assess contact, and the 3D mapping to assess lesion overlap.

Benefits of zero-fluoroscopy ablation procedures

The shift to zero-fluoroscopy and zero-lead procedures has significant benefits for both patients and medical staff. Traditional fluoroscopy involves radiation exposure from the angiography system, posing long-term health risks. By eliminating fluoroscopy, Nair said she has improved the working environment for her team, reducing the need for lead aprons and minimizing orthopedic issues related to their use.

"Everybody in the lab is leadless, which improves the morale. People don't mind working in EP labs anymore because it's a chill place. We've shown the safety and efficiency of this approach in over 250 patients," she said.

Learning how to shed the lead in the EP lab

Nair is optimistic about the wider adoption of these techniques, emphasizing that the transition to no-fluoroscopy and no-lead procedures is driven by a passion for improving both patient outcomes and operator health. She encourages other specialists to consider this approach for its numerous benefits.

"There is a learning curve, but it's about developing a passion for it. As an operator, you need to think about your health too. Low-fluoro procedures reduce malignancy risk and radiation exposure, but no-fluoro takes it further, eliminating orthopedic issues. This is an adoptable approach in any lab if you're passionate about learning it," Nair concluded.