Cardiac Anatomy for Electrophysiologist

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Zero fluoroscopy technique for atrial fibrillation ablation: Anatomical step by step guide.

Alejandro Jimenez Restrepo 1,2, Jason Appelbaum 2. 1. University of Maryland School of Medicine. Baltimore, MD, USA. 2. Florida Electrophysiology Associates. Atlantis, Florida, USA.

Step guide 5-6


Step 5.

LA mapping and ablation. Combined anatomical (FAM) and bipolar voltage map is created following the CartoSound anatomical landmarks annotated in step 2 (Video 6). Sequential movements from the left veins to the LAA ridge, mitral annulus, LA roof and posterior wall, right veins, and septum using a multielectrode catheter allow for a dense point LA map in a few minutes.

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Video 6. Fast anatomical map (FAM) of the LA (patient in AF) at 4X speed. Observe the synchronous movements between the TS sheath and the multielectrode catheter during mapping.


The multielectrode catheter is then exchanged for an ablation catheter. Pulmonary vein isolation plus additional lesion sets as indicated are performed. Catheter to tissue contact and real time formation of edema on ICE are combined with contact force measurements, electrogram analysis and impedance values to guide ablation. The Vizigo sheath and catheters are visualized accurately within the 3DEAM environment (Video 7).

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Video 7. ICE and 3DEAM guided ablation. Sequence of ablation presented is LIPV, LAA ridge, posterior wall near the RSPV and RIPV. A stability protocol including low tidal volume and CS pacing was used to minimize catheter movement. Catheter contact is confirmed with ICE views and force vector.

Anatomical variants, such as middle pulmonary veins are easily identified on ICE and 3DEAM (Figure 3).

Figure 3. Anatomical variant with right superior (RS), middle (RM) and inferior (RI) pulmonary veins seen on ICE and 3DEAM during ablation for paroxysmal atrial fibrillation. The ICE FOV is shown to highlight the tangential view transecting all three PV ostia.

Step 6.

Confirmation of pulmonary vein isolation and other lesion sets. The catheters are exchanged again and the multielectrode catheter is used to confirm anatomical block by bipolar voltage (Figure 4). Differential pacing maneuvers are performed by placing electrodes of the multispline catheter on both sides of the ablation lines.  

Figure 4. Pre (panels A and B) and post (C and D) ablation bipolar voltage LA maps after pulmonary vein and posterior wall isolation for persistent AF.


Effective and safe ablation for AF can be performed in a fluoroless environment using a simplified standardized mapping protocol, and combined with published workflows to optimize catheter stability and lesion delivery 5 can result in reproducible shorter procedural times. This anatomically guided protocol obviates the need for preprocedural imaging to define LA anatomy and uses ICE and 3DEAM to understand each patient’s unique anatomy.


  1. Romero J, Patel K, Briceno D, et al. Fluoroless Atrial Fibrillation Catheter Ablation: Technique and Clinical Outcomes. Card Electrophysiol Clin. 2020;12(2):233-245.
  2. Lerman BB, Markowitz SM, Liu CF, Thomas G, Ip JE, Cheung JW. Fluoroless catheter ablation of atrial fibrillation. Heart Rhythm. 2017;14(6):928-934.
  3. Falasconi G, Penela D, Soto-Iglesias D, et al. A standardized stepwise zero-fluoroscopy approach with transesophageal echocardiography guidance for atrial fibrillation ablation. J Interv Card Electrophysiol. 2022;64(3):629-639.
  4. A Jimenez Restrepo and others, Comparison of zero fluoroscopy versus fluoroscopy guided ablation for atrial fibrillation: A single center experience, EP Europace, Volume 25, Issue Supplement_1, June 2023, euad122.128,


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Video 6

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Video 7

Figure 4
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