Near-Zero Fluoroscopy Ablation Workflow with a Circular Multielectrode Pulsed-Field Ablation Catheter

Near-Zero Fluoroscopy Ablation Workflow with a Circular Multielectrode Pulsed-Field Ablation Catheter | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Near-Zero Fluoroscopy Ablation Workflow with a Circular Multielectrode Pulsed-Field Ablation Catheter Kennosuke Yamahita, Yosuke Kikuchi, Keita Yoshiyama, Daiki Kumazawa, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6998499/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Pulmonary vein isolation (PVI) using pulsed field ablation (PFA) is effective for treating atrial fibrillation (AF) but often requires fluoroscopy, posing risks of radiation exposure. Using a circular multi-electrode PulseSelect TM catheter along with 3D electroanatomical mapping (3D-EAM) and intracardiac echocardiography (ICE) enables pulmonary vein isolation (PVI) with near-zero fluoroscopy. Methods: All procedures were managed under general anesthesia. Following transseptal puncture, pre-mapping was conducted using a multi-electrode catheter. Based on these initial mappings, the PulseSelect catheter and guiding wire were visualized on the 3D-EAM to perform PVI. After the procedure, post-mapping was carried out to confirm that there was no electrical reconnection in the treated areas. Results: The median times for isolation of the left and right pulmonary veins were 9.0 and 11.0 minutes, respectively. Total procedure time averaged 48.5 minutes, with fluoroscopy time limited to 0.1 minutes for initial registration. Pre- and post-mapping indicated minimal deviations in catheter positioning, demonstrating controlled ablation without significant procedural complications. Holter monitoring at three months showed a low recurrence rate of atrial arrhythmias. Conclusion: The near-zero fluoroscopy PFA workflow using the PulseSelect™ catheter, combined with 3D-EAM and ICE, significantly reduces radiation exposure, enhances procedural safety, and maintains efficacy in AF ablation. This approach confirms the feasibility of reducing reliance on fluoroscopy while ensuring accurate and safe ablation outcomes. Cardiac & Cardiovascular Systems Pulmonary vein isolation Pulsed field ablation Atrial fibrillation Zero-fluoroscopy Three-dimensional electroanatomical mapping Intracardiac echocardiography Figures Figure 1 Figure 2 Figure 3 Introduction Pulmonary vein isolation (PVI) using pulsed field ablation (PFA) has emerged as a widely adopted approach for treating atrial fibrillation (AF), thanks to its favorable safety and efficacy demonstrated in clinical trials such as the Pulsed AF trial 1 – 3 . However, traditional PFA workflows rely heavily on fluoroscopy 4 , which exposes patients and operators to ionizing radiation, increasing the risk of radiation burns, genetic mutations, and malignant diseases. Advances in technologies such as three-dimensional electroanatomical mapping systems (3D-EAM) and intracardiac echocardiography (ICE) have significantly reduced fluoroscopy usage, providing integrated visualization of electrical and anatomical structures 5 – 7 . While previous studies have described zero-fluoroscopy workflows using cryoballoons or thermal energy sources, this is the first report to systematically detail a near-zero fluoroscopy workflow using the PulseSelect™ pulsed field ablation catheter combined with CARTO3 and ICE. This study demonstrated a near-zero fluoroscopy PFA workflow for AF ablation using the PulseSelect™ catheter (Medtronic, Minneapolis, MN) in combination with the CARTO3 system (Biosense Webster, Diamond Bar, CA) and ICE. Methods Patient Sedation and Respiratory Management To minimize procedural interruptions caused by patient movement or reflexive coughing during PFA, general anesthesia was used with a combination of propofol and rocuronium, targeting a BIS score of < 60. Two venous punctures were performed under echocardiographic guidance: An 8.5Fr SL0 sheath for the transseptal puncture. A 10Fr, 30 cm long sheath for the ICE catheter (ViewFlex™ Xtra, Abbott Medical). An RF needle was introduced into the SL0 sheath and advanced to the fossa ovalis visualized in ICE, and the puncture was confirmed via ICE (Fig. 1 B). The SL0 sheath was replaced with a FlexCath Advance sheath (Medtronic). The Octaray catheter (Biosense Webster) was used to create the 3D geometry and magnetic field of the LA to visualize the PulseSelect™ catheter and the guiding wire. Preoperatively, the PulseSelect™ catheter was registered as having a 9-electrode circular design, 25-mm diameter, electrode spacing of 3.75 mm, electrode width of 3 mm, and 5 Fr catheter size based on the specifications provided in the product catalog (Fig. 1 C). Also, the guiding wire was registered with 2 electrodes, 5-mm tip spacing, 1.0-mm electrode width, and 2 Fr catheter size (Fig. 1 D). These pre-registration settings were developed independently at our institution to facilitate visualization on CARTO3, as no standardized registration method currently exists for this catheter and the guiding wire. The proximal of the guiding wire was clipped to enable visualization on the CARTO3 system (Fig. 1 E). The PulseSelect™ catheter was advanced over the guiding wire into the LA (Supplemental Video 1). ICE confirmed the catheter deployment in a circular ring configuration. Ablation targeted the ostium and antrum of the LSPV and RSPV with 10–14 applications for the superior PVs and 8–12 for the inferior PVs (Fig. 2 and Supplemental Video 2). Catheter positions at the application site were recorded in real-time using snapshots to avoid duplication and prevent unintended connections between isolation lines. Post-ablation mapping confirmed the controlled ablation area, demonstrating entrance and exit block of all PVs using voltage mapping, and ICE verified the absence of any pericardial effusion (Fig. 3 and Supplemental Video 3). Additional applications on the posterior wall of the LA were performed at the operator's discretion in cases of conduction delay or anatomical considerations. Results The procedural summary is shown in the Table, and the numbers are shown as the median (interquartile range (IQR)). The time required for the isolation of the LPVs and RPVs was 9.0 (IQR 8.0–10.0) min and 11.0 (IQR 10.0–12.0) min, respectively. The premapping and postmapping times were 7.0 (IQR 6.0–8.3) min and 7.0 (IQR 6.5–9.0) min, with a total procedure time of 48.5 (IQR 46.0–52.3) min. The fluoroscopy time was 0.0 (IQR 0.0–0.1) min and was limited to the CARTOUNIVU™ registration. The results were comparable to those reported by Hirata et al. 7 In one case (Case No. 10), the patient had an inferior common pulmonary vein (PV), and a wide antral isolation of the bilateral superior pulmonary veins was performed, resulting in a posterior wall isolation configuration. Although a posterior wall isolation was added for anatomical reasons, the procedure time was 53 minutes, showing no significant prolongation compared to the other cases. Pulmonary vein isolation was achieved in all cases, and no additional applications were required after the post-mapping. No cases of procedural complications, such as a pericardial effusion, esophageal injury, phrenic nerve palsy, or anesthesia-related issues, were reported. All patients were discharged on the following day without any adverse events. At three months post-procedure, Holter monitoring or 7-day long-term electrocardiography revealed that only one patient experienced a recurrence of paroxysmal atrial fibrillation, and another exhibited a recurrence of typical atrial flutter, with no recurrences noted in other cases. Discussions This workflow combines CARTO3 mapping and ICE to enable PFA catheter navigation and achieve near-zero fluoroscopy. It offers a reproducible approach for overcoming the lack of catheter visualization in mapping systems. The PulseSelect™ catheter is not integrated into the 3D mapping, necessitating certain strategies to minimize fluoroscopy during procedures. Firstly, it is essential to display both the PulseSelect™ and the guiding wire on the 3D mapping system. A potential limitation of this approach is that visualization of both the catheter and the guiding wire is based solely on impedance rather than magnetic integration. This may reduce positional precision in anatomically complex areas. However, to overcome this, we consistently combine impedance-based 3D mapping with real-time anatomical guidance using ICE. In particular, ICE plays a critical role in confirming the positions of both the PulseSelect™ catheter and the tip of the guiding wire, ensuring accurate localization and safe energy delivery. This multimodal strategy enables reliable catheter navigation and tissue contact assessment, thereby allowing for safe and effective ablation without reliance on fluoroscopy. In general, impedance-based catheter visualization has an estimated positional accuracy of ± 3 mm, which is less precise than the ± 1 mm accuracy typically achieved with magnetic sensor-based systems 8 . Therefore, operators must be fully aware of this limitation when navigating the catheter and guiding wire. Although the 3D electroanatomical map provides the foundational spatial framework for the procedure, it is critical to supplement this with active use of ICE to visualize the pulmonary vein ostia and to continuously confirm catheter positioning. This integration of modalities contributes significantly to improved procedural accuracy and lesion durability. Furthermore, since impedance values can dynamically change during the procedure, each application should be delivered in a continuous manner without excessive catheter movement between applications. It is generally accepted that each PFA application creates a lesion width of approximately ≥ 6 mm 9 . Therefore, instead of repositioning the catheter widely after each application, we recommend shifting it incrementally by around 6 mm before delivering the next application. This stepwise approach facilitates the creation of linear, contiguous lesions around the pulmonary veins, enhancing the likelihood of durable isolation. Premapping with catheters equipped with magnetic sensor, such as the Octaray catheter, is necessary to acquire a magnetic field. The median duration for this process in the context of the current report is approximately 7 minutes, which is not considered time-consuming because post-mapping is also conducted, not only to confirm pulmonary vein isolation but also to evaluate areas of low voltage outside the treatment site. Although the displayed catheter configuration does not perfectly match its true shape, visualization of the distal tip of the guiding wire allows the operator to determine which pulmonary vein is being cannulated. Furthermore, by identifying the position of the fifth electrode, which is tilted approximately 20 degrees anteriorly, and delivering applications in a segmental manner, elimination of local potentials can be reliably achieved. By comparing post-mapping with pre-mapping images, it is possible to determine whether the low voltage areas were pre-existing or unintentionally affected during the procedure. To ensure the precise and stable display of the left atrial anatomical information, we perform procedures under general anesthesia to eliminate patient movements and coughing during treatment. Additionally, we have investigated the potential for geometry shifts caused by the interference of pulse energy with the magnetic field of 3D mapping. It seems like the comparative analysis of pre- and post-mapping data indicated minimal deviations in catheter positioning, with the results being as follows: vertical displacement was 2 mm (interquartile range [IQR] 1–4 mm), horizontal displacement was 3 mm (IQR 1–4 mm), and angular deviation was 1.3° (IQR 0.5–3.0°). Therefore, significant geometry shifts were not observed. The utility of ICE involves demonstrating tissue contact, although it may prolong the procedure time 6 , 10 . The PulseSelect™ catheter is relatively thinner and ring-shaped compared to the pentaspline ablation catheter, accurately determining which electrodes are in contact with the tissue can be somewhat challenging. However, when retracting or deploying the catheter and wires from the sheath, or when transitioning from linear to circular configurations, entanglements can occur 11 . Thus, in the absence of fluoroscopy, the visualization provided by ICE becomes indispensable and highly beneficial (Supplemental Video 1). This data highlights the feasibility of a near-zero fluoroscopy PFA workflow using the PulseSelect™ catheter in combination with CARTO3 and ICE. Key advantages include: Reduced Radiation Exposure : Integration of 3D-EAM and ICE eliminates the need for fluoroscopy. Enhanced Safety : Real-time visualization reduces the risk of complications, such as an atrial wall perforation and entanglement of the catheter 2 . Reproducibility and Cost-effectiveness : The workflow minimizes the procedural complexity and catheter use. Future studies with larger cohorts are required to confirm the long-term efficacy and reproducibility of this workflow. Conclusion Near-zero fluoroscopy PFA using the PulseSelect™ catheter combined with CARTO3 and ICE represents a significant advancement in AF ablation, offering reduced radiation exposure, enhanced procedural safety, and sustained efficacy. Abbreviations AF atrial fibrillation AT atrial tachycardia CT computed tomography ICE intracardiac echocardiography IQR interquartile range LA left atrium LAA left atrial appendage LIPV left inferior pulmonary vein LPV left pulmonary vein LSPV left superior pulmonary vein PFA pulsed field ablation PV pulmonary vein PVI pulmonary vein isolation RA right atrium RIPV right inferior pulmonary vein RPV right pulmonary vein RSPV right superior pulmonary vein 3D-EAM three-dimensional electroanatomical mapping Declarations Author contributions KY, YK, and KY drafted the manuscript. SI, DK, YM, KO, and TN critically revised the manuscript for its important intellectual content. All the authors approved the final version of the manuscript. Ethics Approval: The ethical committee of Sendai Kousei Hospital waived the requirement for obtaining ethical approval because this research was neither a clinical study nor an animal experiment. Data availability: Raw data were generated at Sendai Kousei Hospital. Derived data supporting the findings of this study are available from the corresponding author Kennosuke Yamashita on request. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest: All the authors have no conflicts to disclose. Informed consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images. Clinical trial registration: N/A References Verma A, Boersma L, Haines DE et al (2022) First-in-human experience and acute procedural outcomes using a novel Pulsed Field Ablation system: The PULSED AF pilot trial. Circ Arrhythm Electrophysiol 15(1):e010168 Duytschaever M, De Potter T, Grimaldi M et al (2023) Paroxysmal Atrial Fibrillation Ablation Using a Novel Variable-Loop Biphasic Pulsed Field Ablation Catheter Integrated With a 3-Dimensional Mapping System: 1-Year Outcomes of the Multicenter inspIRE Study. Circ Arrhythm Electrophysiol 16(3):e011780 Reddy VY, Gerstenfeld EP, Natale A et al (2023) Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation. N Engl J Med 389(18):1660–1671 Kariki O, Mililis P, Saplaouras A et al (2024) Investigating the role of electroanatomical mapping in single-shot pulsed field catheter ablation. J Arrhythm 40(6):1374–1378 Palmeri NO, Alyesh D, Keith M et al (2024) Pulsed-field ablation for atrial fibrillation without the use of fluoroscopy. J Interv Card Electrophysiol Published online August 23. 10.1007/s10840-024-01904-w Rauber M, Manninger M, Eberl AS, Scherr D (2024) Zero-fluoroscopy ablation with multielectrode pulse field ablation system: Case series. Pacing Clin Electrophysiol 47(1):117–120 Hirata S, Nagashima K, Watanabe R et al (2024) Workflow of the zero-fluoro pulsed field ablation. J Arrhythm 40(6):1529–1532 Bourier F, Fahrig R, Wang P et al (2014) Accuracy assessment of catheter guidance technology in electrophysiology procedures: a comparison of a new 3D-based fluoroscopy navigation system to current electroanatomic mapping systems: A comparison of a new 3D-based fluoroscopy navigation system to current electroanatomic mapping systems. J Cardiovasc Electrophysiol 25(1):74–83 Howard B, Verma A, Tzou WS et al (2022) Effects of electrode-tissue proximity on cardiac lesion formation using pulsed field ablation. Circ Arrhythm Electrophysiol 15(10):e011110 Dello Russo A, Tondo C, Schillaci V et al (2024) Intracardiac echocardiography-guided pulsed-field ablation for successful ablation of atrial fibrillation: a propensity-matched analysis from a large nationwide multicenter experience. J Interv Card Electrophysiol 67(5):1257–1266 Mountantonakis S, Beccarino N, Abrams M et al (2024) Methods and techniques to optimize energy delivery using the circular array pulsed field ablation catheter. Heart Rhythm 0(0). 10.1016/j.hrthm.2024.10.045 Additional Declarations The authors declare potential competing interests as follows: All the authors have no conflicts to disclose. Supplementary Files SupplementalVideo1wireandpulseselect.mp4 Supplemental Video 1 Under the guidance of intracardiac echocardiography and 3D mapping, a 0.032-inch J wire was inserted into the left atrium (Case 19). Following this, a PulseSelect TM catheter was deployed in a ring shape and then inserted into the left superior pulmonary vein. Untitled.mp4 Supplemental Video 2 In the workflow for pulmonary vein isolation (Case 19), treatments are sequentially administered to the left superior pulmonary vein, left inferior pulmonary vein, right superior pulmonary vein, and right inferior pulmonary vein. Additional ablations are extended to the carina region to connect the isolation of the superior and inferior veins. Prior to the procedure, a 3D geometry is constructed based on pre-procedural CT scans. Design lines (white lines) are then marked on this model to guide the creation of the lesion set. During the application, the position of the PulseSelect catheter is captured in snapshots to facilitate understanding of the treated areas. Post-procedure, the isolation boundaries are estimated and marked with red lines based on the final snapshots. In this case, a total of 44 applications were performed. SupplementalVideo3PostMapping.mp4 Supplemental Video 3 In this case (Case 19), pre-mapping images are displayed on the right panel, while the left panel is used for generating post-mapping images using the Octaray system. As demonstrated in Supplemental Video 2, the pulmonary vein isolation line was created following a red line, which was based on the observed lesion set. This method allows for differentiation between lesions caused inadvertently by catheter contact and those originating from pre-existing low-voltage areas. Furthermore, when lesions on the posterior wall are closely spaced, additional applications may be considered to achieve complete isolation of the posterior wall. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6998499","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":477764510,"identity":"1ec04b05-249b-4f26-80c4-ddbd3a2f2ad8","order_by":0,"name":"Kennosuke Yamahita","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYBACCShtAKVr5EDkgQdEamFsYGA4ZgzWkkCCFubEBhAXnxbJ9t5jDz78OWzMz8D8/NHNHLb0+WGHHwJtsZPTbcCuRZrnXLrhzLbDZpINbIbNudtkcjfeTjMAakk2NjuAXYucRI6ZNG/DYRuDAwwgLWy5G2cngLQcSNyGS4v8GzNpnj+HbewPsH8EamFON5yd/gGvFmkJHqAWtsNmBgw8IFuYE+Slc/DbItmTYyY5sy3dWOIwT+Hs3G3HDDdI5xQcSDDA7ReJ42fMJD78sTbsb2/f8Dl3W428/Oz0zR8+VNjJ4dKCAMxQ2gCs0gC3Qkwg30CK6lEwCkbBKBgJAADvUV5sPnauyAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-5630-1975","institution":"Sendai Kosei Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kennosuke","middleName":"","lastName":"Yamahita","suffix":""},{"id":477764511,"identity":"2f65e0fc-9f64-4669-92a5-e6629074747b","order_by":1,"name":"Yosuke Kikuchi","email":"","orcid":"","institution":"Sendai Kosei Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yosuke","middleName":"","lastName":"Kikuchi","suffix":""},{"id":477764512,"identity":"77aa5346-d56b-45bd-8088-a835e424e139","order_by":2,"name":"Keita Yoshiyama","email":"","orcid":"","institution":"Sendai Kosei Hospital","correspondingAuthor":false,"prefix":"","firstName":"Keita","middleName":"","lastName":"Yoshiyama","suffix":""},{"id":477764513,"identity":"8f15955f-2fa7-4b9d-893a-3b9c8aa25ae3","order_by":3,"name":"Daiki Kumazawa","email":"","orcid":"","institution":"Sendai Kosei Hospital","correspondingAuthor":false,"prefix":"","firstName":"Daiki","middleName":"","lastName":"Kumazawa","suffix":""},{"id":477764514,"identity":"8d31ebfb-f151-4436-997c-fd898b22baf9","order_by":4,"name":"Yosuke Mizuno","email":"","orcid":"","institution":"Sendai Kosei Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yosuke","middleName":"","lastName":"Mizuno","suffix":""},{"id":477764515,"identity":"63820378-cd9d-46e8-967a-45d0a76c9839","order_by":5,"name":"Kosuke Onodera","email":"","orcid":"","institution":"Sendai Kosei Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kosuke","middleName":"","lastName":"Onodera","suffix":""},{"id":477764516,"identity":"4f2f4e13-8508-43b2-b16e-96f4f9550548","order_by":6,"name":"Takehiro Nomura","email":"","orcid":"","institution":"Sendai Kosei Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takehiro","middleName":"","lastName":"Nomura","suffix":""}],"badges":[],"createdAt":"2025-06-28 14:41:24","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6998499/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6998499/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85820782,"identity":"4f7f487d-0a11-4172-b3ad-9df481b9d7d2","added_by":"auto","created_at":"2025-07-02 06:31:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":651700,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e The Octaray catheter, inserted through the SL0 sheath, is advanced into the hepatic vein to collect respiratory information (yellow arrow). Simultaneously, CARTOUNIVU\u003csup\u003eTM\u003c/sup\u003e registration is performed.\u003cbr\u003e\n\u003cstrong\u003eB:\u003c/strong\u003e The transseptal puncture is performed under ICE guidance, targeting the low anterior region for the puncture.\u003cbr\u003e\n\u003cstrong\u003eC/D:\u003c/strong\u003e Display of the PulseSelect™ catheter and 0.032\" wire pre-registered in the CARTO3 system.\u003cbr\u003e\n\u003cstrong\u003eE:\u003c/strong\u003e The 0.032\" wire is visualized on CARTO3 by clipping the proximal end of the wire with an alligator clip.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-6998499/v1/d2ddbfc50e32af658acf0b26.png"},{"id":85820784,"identity":"9c10d515-ca49-422b-a424-158836e8ac87","added_by":"auto","created_at":"2025-07-02 06:31:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":506356,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA/B:\u003c/strong\u003e The yellow arrow indicates the tip of the wire, and the green arrow represents the PulseSelect\u003csup\u003eTM\u003c/sup\u003e catheter. Typically, the PA view or AP view is used to assess the depth between the pulmonary vein ostium and the catheter, while the inner view is utilized to confirm which part of the catheter's 5th electrode is in contact with the tissue for treatment. A challenging area for treatment is the ridge between the LSPV and the LAA (white double line). In this scenario, the 5th electrode is positioned toward the 3 o'clock direction, resulting in the treatment being delivered deeper than the pulmonary vein ostium. This carries a risk of residual potentials on the ridge.\u003cbr\u003e\n\u003cstrong\u003eC/D:\u003c/strong\u003e Pulling the PulseSelect\u003csup\u003eTM\u003c/sup\u003e catheter back into the left atrium and then rotating the sheath counterclockwise allows the catheter to move toward the LAA. Advancing the catheter in this position causes it to catch on the ridge, enabling an effective ablation. However, it is important to note that the actual ablation on the ridge occurs between electrodes 2–3 and 6–7, while electrodes 3–4–5 remain suspended in the air. Therefore, additional ablation is necessary to eliminate any residual potentials.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-6998499/v1/82d3aa202318d13ebc768b24.png"},{"id":85820786,"identity":"17e47744-c315-4758-a26e-e08e57a1fbc5","added_by":"auto","created_at":"2025-07-02 06:31:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":555266,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative Figures (Case 15)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA/B:\u003c/strong\u003e Lesion set of the left pulmonary veins (PA view and inner view). A total of 20 applications were delivered: 12 to the LSPV and 8 to the LIPV.\u003cbr\u003e\n \u003cstrong\u003eC/D:\u003c/strong\u003e Lesion set of the right pulmonary veins (PA view and inner view). A total of 21 applications were delivered: 13 to the RSPV and 8 to the RIPV.\u003cbr\u003e\n \u003cstrong\u003eE/F:\u003c/strong\u003e Post-mapping images. Areas with voltages below 0.2 mV are shown in red, and those above 0.5 mV are shown in purple. Complete isolation of all four pulmonary veins is confirmed.\u003c/p\u003e\n\u003cp\u003eRA, right atrium; LA, left atrium; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein; LAA, left atrial appendage\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-6998499/v1/ef540519287ea70aea1ac63e.png"},{"id":85822465,"identity":"5dc19703-26ff-4dc3-ab98-3cac76775261","added_by":"auto","created_at":"2025-07-02 06:47:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2121901,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6998499/v1/173ec2fa-5f6b-466e-9b0e-b7986adb6a0d.pdf"},{"id":85820795,"identity":"9816fe55-ca56-47f4-a4c4-2ec2d8a8e77b","added_by":"auto","created_at":"2025-07-02 06:31:04","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18079422,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental Video 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnder the guidance of intracardiac echocardiography and 3D mapping, a 0.032-inch J wire was inserted into the left atrium (Case 19). Following this, a PulseSelect\u003csup\u003eTM\u003c/sup\u003e catheter was deployed in a ring shape and then inserted into the left superior pulmonary vein.\u003c/p\u003e","description":"","filename":"SupplementalVideo1wireandpulseselect.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6998499/v1/b2f6268cc4a4f0c4ee4af6e1.mp4"},{"id":85820797,"identity":"12cfa8d4-766c-42b6-a47d-45d2e54291fc","added_by":"auto","created_at":"2025-07-02 06:31:04","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":45380797,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental Video 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the workflow for pulmonary vein isolation (Case 19), treatments are sequentially administered to the left superior pulmonary vein, left inferior pulmonary vein, right superior pulmonary vein, and right inferior pulmonary vein. Additional ablations are extended to the carina region to connect the isolation of the superior and inferior veins. Prior to the procedure, a 3D geometry is constructed based on pre-procedural CT scans. Design lines (white lines) are then marked on this model to guide the creation of the lesion set. During the application, the position of the PulseSelect catheter is captured in snapshots to facilitate understanding of the treated areas. Post-procedure, the isolation boundaries are estimated and marked with red lines based on the final snapshots. In this case, a total of 44 applications were performed.\u003c/p\u003e","description":"","filename":"Untitled.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6998499/v1/178b2388f8f50028b165b185.mp4"},{"id":85820798,"identity":"6cace104-4c64-47c4-accd-294194caab97","added_by":"auto","created_at":"2025-07-02 06:31:05","extension":"mp4","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":77537000,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental Video 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this case (Case 19), pre-mapping images are displayed on the right panel, while the left panel is used for generating post-mapping images using the Octaray system. As demonstrated in Supplemental Video 2, the pulmonary vein isolation line was created following a red line, which was based on the observed lesion set. This method allows for differentiation between lesions caused inadvertently by catheter contact and those originating from pre-existing low-voltage areas. Furthermore, when lesions on the posterior wall are closely spaced, additional applications may be considered to achieve complete isolation of the posterior wall.\u003c/p\u003e","description":"","filename":"SupplementalVideo3PostMapping.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6998499/v1/19a3585da03c5b0290779cac.mp4"}],"financialInterests":"The authors declare potential competing interests as follows: All the authors have no conflicts to disclose.","formattedTitle":"\u003cp\u003eNear-Zero Fluoroscopy Ablation Workflow with a Circular Multielectrode Pulsed-Field Ablation Catheter\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePulmonary vein isolation (PVI) using pulsed field ablation (PFA) has emerged as a widely adopted approach for treating atrial fibrillation (AF), thanks to its favorable safety and efficacy demonstrated in clinical trials such as the Pulsed AF trial\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. However, traditional PFA workflows rely heavily on fluoroscopy\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, which exposes patients and operators to ionizing radiation, increasing the risk of radiation burns, genetic mutations, and malignant diseases. Advances in technologies such as three-dimensional electroanatomical mapping systems (3D-EAM) and intracardiac echocardiography (ICE) have significantly reduced fluoroscopy usage, providing integrated visualization of electrical and anatomical structures\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. While previous studies have described zero-fluoroscopy workflows using cryoballoons or thermal energy sources, this is the first report to systematically detail a near-zero fluoroscopy workflow using the PulseSelect™ pulsed field ablation catheter combined with CARTO3 and ICE. This study demonstrated a near-zero fluoroscopy PFA workflow for AF ablation using the PulseSelect™ catheter (Medtronic, Minneapolis, MN) in combination with the CARTO3 system (Biosense Webster, Diamond Bar, CA) and ICE.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cem\u003ePatient Sedation and Respiratory Management\u003c/em\u003e \u003c/p\u003e\u003cp\u003eTo minimize procedural interruptions caused by patient movement or reflexive coughing during PFA, general anesthesia was used with a combination of propofol and rocuronium, targeting a BIS score of \u0026lt; 60.\u003c/p\u003e\u003cp\u003eTwo venous punctures were performed under echocardiographic guidance: An 8.5Fr SL0 sheath for the transseptal puncture. A 10Fr, 30 cm long sheath for the ICE catheter (ViewFlex™ Xtra, Abbott Medical). An RF needle was introduced into the SL0 sheath and advanced to the fossa ovalis visualized in ICE, and the puncture was confirmed via ICE (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The SL0 sheath was replaced with a FlexCath Advance sheath (Medtronic). The Octaray catheter (Biosense Webster) was used to create the 3D geometry and magnetic field of the LA to visualize the PulseSelect™ catheter and the guiding wire. Preoperatively, the PulseSelect™ catheter was registered as having a 9-electrode circular design, 25-mm diameter, electrode spacing of 3.75 mm, electrode width of 3 mm, and 5 Fr catheter size based on the specifications provided in the product catalog (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Also, the guiding wire was registered with 2 electrodes, 5-mm tip spacing, 1.0-mm electrode width, and 2 Fr catheter size (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). These pre-registration settings were developed independently at our institution to facilitate visualization on CARTO3, as no standardized registration method currently exists for this catheter and the guiding wire. The proximal of the guiding wire was clipped to enable visualization on the CARTO3 system (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE). The PulseSelect™ catheter was advanced over the guiding wire into the LA (Supplemental Video 1). ICE confirmed the catheter deployment in a circular ring configuration. Ablation targeted the ostium and antrum of the LSPV and RSPV with 10–14 applications for the superior PVs and 8–12 for the inferior PVs (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Supplemental Video 2). Catheter positions at the application site were recorded in real-time using snapshots to avoid duplication and prevent unintended connections between isolation lines. Post-ablation mapping confirmed the controlled ablation area, demonstrating entrance and exit block of all PVs using voltage mapping, and ICE verified the absence of any pericardial effusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Supplemental Video 3). Additional applications on the posterior wall of the LA were performed at the operator's discretion in cases of conduction delay or anatomical considerations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe procedural summary is shown in the Table, and the numbers are shown as the median (interquartile range (IQR)). The time required for the isolation of the LPVs and RPVs was 9.0 (IQR 8.0\u0026ndash;10.0) min and 11.0 (IQR 10.0\u0026ndash;12.0) min, respectively. The premapping and postmapping times were 7.0 (IQR 6.0\u0026ndash;8.3) min and 7.0 (IQR 6.5\u0026ndash;9.0) min, with a total procedure time of 48.5 (IQR 46.0\u0026ndash;52.3) min. The fluoroscopy time was 0.0 (IQR 0.0\u0026ndash;0.1) min and was limited to the CARTOUNIVU\u0026trade; registration. The results were comparable to those reported by Hirata et al.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In one case (Case No. 10), the patient had an inferior common pulmonary vein (PV), and a wide antral isolation of the bilateral superior pulmonary veins was performed, resulting in a posterior wall isolation configuration. Although a posterior wall isolation was added for anatomical reasons, the procedure time was 53 minutes, showing no significant prolongation compared to the other cases. Pulmonary vein isolation was achieved in all cases, and no additional applications were required after the post-mapping. No cases of procedural complications, such as a pericardial effusion, esophageal injury, phrenic nerve palsy, or anesthesia-related issues, were reported. All patients were discharged on the following day without any adverse events. At three months post-procedure, Holter monitoring or 7-day long-term electrocardiography revealed that only one patient experienced a recurrence of paroxysmal atrial fibrillation, and another exhibited a recurrence of typical atrial flutter, with no recurrences noted in other cases.\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eThis workflow combines CARTO3 mapping and ICE to enable PFA catheter navigation and achieve near-zero fluoroscopy. It offers a reproducible approach for overcoming the lack of catheter visualization in mapping systems. The PulseSelect\u0026trade; catheter is not integrated into the 3D mapping, necessitating certain strategies to minimize fluoroscopy during procedures. Firstly, it is essential to display both the PulseSelect\u0026trade; and the guiding wire on the 3D mapping system. A potential limitation of this approach is that visualization of both the catheter and the guiding wire is based solely on impedance rather than magnetic integration. This may reduce positional precision in anatomically complex areas. However, to overcome this, we consistently combine impedance-based 3D mapping with real-time anatomical guidance using ICE. In particular, ICE plays a critical role in confirming the positions of both the PulseSelect\u0026trade; catheter and the tip of the guiding wire, ensuring accurate localization and safe energy delivery. This multimodal strategy enables reliable catheter navigation and tissue contact assessment, thereby allowing for safe and effective ablation without reliance on fluoroscopy. In general, impedance-based catheter visualization has an estimated positional accuracy of \u0026plusmn;\u0026thinsp;3 mm, which is less precise than the \u0026plusmn;\u0026thinsp;1 mm accuracy typically achieved with magnetic sensor-based systems\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Therefore, operators must be fully aware of this limitation when navigating the catheter and guiding wire. Although the 3D electroanatomical map provides the foundational spatial framework for the procedure, it is critical to supplement this with active use of ICE to visualize the pulmonary vein ostia and to continuously confirm catheter positioning. This integration of modalities contributes significantly to improved procedural accuracy and lesion durability. Furthermore, since impedance values can dynamically change during the procedure, each application should be delivered in a continuous manner without excessive catheter movement between applications. It is generally accepted that each PFA application creates a lesion width of approximately\u0026thinsp;\u0026ge;\u0026thinsp;6 mm\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Therefore, instead of repositioning the catheter widely after each application, we recommend shifting it incrementally by around 6 mm before delivering the next application. This stepwise approach facilitates the creation of linear, contiguous lesions around the pulmonary veins, enhancing the likelihood of durable isolation.\u003c/p\u003e \u003cp\u003ePremapping with catheters equipped with magnetic sensor, such as the Octaray catheter, is necessary to acquire a magnetic field. The median duration for this process in the context of the current report is approximately 7 minutes, which is not considered time-consuming because post-mapping is also conducted, not only to confirm pulmonary vein isolation but also to evaluate areas of low voltage outside the treatment site. Although the displayed catheter configuration does not perfectly match its true shape, visualization of the distal tip of the guiding wire allows the operator to determine which pulmonary vein is being cannulated. Furthermore, by identifying the position of the fifth electrode, which is tilted approximately 20 degrees anteriorly, and delivering applications in a segmental manner, elimination of local potentials can be reliably achieved. By comparing post-mapping with pre-mapping images, it is possible to determine whether the low voltage areas were pre-existing or unintentionally affected during the procedure.\u003c/p\u003e \u003cp\u003eTo ensure the precise and stable display of the left atrial anatomical information, we perform procedures under general anesthesia to eliminate patient movements and coughing during treatment. Additionally, we have investigated the potential for geometry shifts caused by the interference of pulse energy with the magnetic field of 3D mapping. It seems like the comparative analysis of pre- and post-mapping data indicated minimal deviations in catheter positioning, with the results being as follows: vertical displacement was 2 mm (interquartile range [IQR] 1\u0026ndash;4 mm), horizontal displacement was 3 mm (IQR 1\u0026ndash;4 mm), and angular deviation was 1.3\u0026deg; (IQR 0.5\u0026ndash;3.0\u0026deg;). Therefore, significant geometry shifts were not observed.\u003c/p\u003e \u003cp\u003eThe utility of ICE involves demonstrating tissue contact, although it may prolong the procedure time \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The PulseSelect\u0026trade; catheter is relatively thinner and ring-shaped compared to the pentaspline ablation catheter, accurately determining which electrodes are in contact with the tissue can be somewhat challenging. However, when retracting or deploying the catheter and wires from the sheath, or when transitioning from linear to circular configurations, entanglements can occur\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Thus, in the absence of fluoroscopy, the visualization provided by ICE becomes indispensable and highly beneficial (Supplemental Video 1).\u003c/p\u003e \u003cp\u003eThis data highlights the feasibility of a near-zero fluoroscopy PFA workflow using the PulseSelect\u0026trade; catheter in combination with CARTO3 and ICE. Key advantages include:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eReduced Radiation Exposure\u003c/b\u003e: Integration of 3D-EAM and ICE eliminates the need for fluoroscopy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEnhanced Safety\u003c/b\u003e: Real-time visualization reduces the risk of complications, such as an atrial wall perforation and entanglement of the catheter\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eReproducibility and Cost-effectiveness\u003c/b\u003e: The workflow minimizes the procedural complexity and catheter use.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eFuture studies with larger cohorts are required to confirm the long-term efficacy and reproducibility of this workflow.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNear-zero fluoroscopy PFA using the PulseSelect\u0026trade; catheter combined with CARTO3 and ICE represents a significant advancement in AF ablation, offering reduced radiation exposure, enhanced procedural safety, and sustained efficacy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eatrial fibrillation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eatrial tachycardia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintracardiac echocardiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft atrium\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft atrial appendage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLIPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft inferior pulmonary vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft pulmonary vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLSPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft superior pulmonary vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epulsed field ablation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epulmonary vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePVI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epulmonary vein isolation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eright atrium\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRIPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eright inferior pulmonary vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eright pulmonary vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRSPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eright superior pulmonary vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e3D-EAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethree-dimensional electroanatomical mapping\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKY, YK, and KY drafted the manuscript. SI, DK, YM, KO, and TN critically revised the manuscript for its important intellectual content. All the authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u0026nbsp;\u003c/strong\u003eThe ethical committee of Sendai Kousei Hospital waived the requirement for obtaining ethical approval because this research was neither a clinical study nor an animal experiment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e Raw data were generated at Sendai Kousei Hospital. Derived data supporting the findings of this study are available from the corresponding author Kennosuke Yamashita on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e All the authors have no conflicts to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration:\u0026nbsp;\u003c/strong\u003eN/A\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVerma A, Boersma L, Haines DE et al (2022) First-in-human experience and acute procedural outcomes using a novel Pulsed Field Ablation system: The PULSED AF pilot trial. Circ Arrhythm Electrophysiol 15(1):e010168\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuytschaever M, De Potter T, Grimaldi M et al (2023) Paroxysmal Atrial Fibrillation Ablation Using a Novel Variable-Loop Biphasic Pulsed Field Ablation Catheter Integrated With a 3-Dimensional Mapping System: 1-Year Outcomes of the Multicenter inspIRE Study. Circ Arrhythm Electrophysiol 16(3):e011780\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy VY, Gerstenfeld EP, Natale A et al (2023) Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation. N Engl J Med 389(18):1660\u0026ndash;1671\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKariki O, Mililis P, Saplaouras A et al (2024) Investigating the role of electroanatomical mapping in single-shot pulsed field catheter ablation. J Arrhythm 40(6):1374\u0026ndash;1378\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalmeri NO, Alyesh D, Keith M et al (2024) Pulsed-field ablation for atrial fibrillation without the use of fluoroscopy. J Interv Card Electrophysiol Published online August 23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10840-024-01904-w\u003c/span\u003e\u003cspan address=\"10.1007/s10840-024-01904-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRauber M, Manninger M, Eberl AS, Scherr D (2024) Zero-fluoroscopy ablation with multielectrode pulse field ablation system: Case series. Pacing Clin Electrophysiol 47(1):117\u0026ndash;120\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirata S, Nagashima K, Watanabe R et al (2024) Workflow of the zero-fluoro pulsed field ablation. J Arrhythm 40(6):1529\u0026ndash;1532\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBourier F, Fahrig R, Wang P et al (2014) Accuracy assessment of catheter guidance technology in electrophysiology procedures: a comparison of a new 3D-based fluoroscopy navigation system to current electroanatomic mapping systems: A comparison of a new 3D-based fluoroscopy navigation system to current electroanatomic mapping systems. J Cardiovasc Electrophysiol 25(1):74\u0026ndash;83\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoward B, Verma A, Tzou WS et al (2022) Effects of electrode-tissue proximity on cardiac lesion formation using pulsed field ablation. Circ Arrhythm Electrophysiol 15(10):e011110\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDello Russo A, Tondo C, Schillaci V et al (2024) Intracardiac echocardiography-guided pulsed-field ablation for successful ablation of atrial fibrillation: a propensity-matched analysis from a large nationwide multicenter experience. J Interv Card Electrophysiol 67(5):1257\u0026ndash;1266\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMountantonakis S, Beccarino N, Abrams M et al (2024) Methods and techniques to optimize energy delivery using the circular array pulsed field ablation catheter. Heart Rhythm 0(0). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.hrthm.2024.10.045\u003c/span\u003e\u003cspan address=\"10.1016/j.hrthm.2024.10.045\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sendai Kosei Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pulmonary vein isolation, Pulsed field ablation, Atrial fibrillation, Zero-fluoroscopy, Three-dimensional electroanatomical mapping, Intracardiac echocardiography","lastPublishedDoi":"10.21203/rs.3.rs-6998499/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6998499/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Pulmonary vein isolation (PVI) using pulsed field ablation (PFA) is effective for treating atrial fibrillation (AF) but often requires fluoroscopy, posing risks of radiation exposure. Using a circular multi-electrode PulseSelect\u003csup\u003eTM\u003c/sup\u003e catheter along with 3D electroanatomical mapping (3D-EAM) and intracardiac echocardiography (ICE) enables pulmonary vein isolation (PVI) with near-zero fluoroscopy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e All procedures were managed under general anesthesia. Following transseptal puncture, pre-mapping was conducted using a multi-electrode catheter. Based on these initial mappings, the PulseSelect catheter and guiding wire were visualized on the 3D-EAM to perform PVI. After the procedure, post-mapping was carried out to confirm that there was no electrical reconnection in the treated areas.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The median times for isolation of the left and right pulmonary veins were 9.0 and 11.0 minutes, respectively. Total procedure time averaged 48.5 minutes, with fluoroscopy time limited to 0.1 minutes for initial registration. Pre- and post-mapping indicated minimal deviations in catheter positioning, demonstrating controlled ablation without significant procedural complications. Holter monitoring at three months showed a low recurrence rate of atrial arrhythmias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The near-zero fluoroscopy PFA workflow using the PulseSelect™ catheter, combined with 3D-EAM and ICE, significantly reduces radiation exposure, enhances procedural safety, and maintains efficacy in AF ablation. This approach confirms the feasibility of reducing reliance on fluoroscopy while ensuring accurate and safe ablation outcomes.\u003c/p\u003e","manuscriptTitle":"Near-Zero Fluoroscopy Ablation Workflow with a Circular Multielectrode Pulsed-Field Ablation Catheter","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 06:30:59","doi":"10.21203/rs.3.rs-6998499/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"455dca8d-adaf-45aa-85bc-cad27d09bb57","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50731599,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2025-07-02T06:30:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-02 06:30:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6998499","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6998499","identity":"rs-6998499","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}