Zero Fluoro AF Ablation Approach: Interview With Dr. Matthew Evans

The Heart Hospital Baylor Denton in Texas is now performing zero fluoro atrial fibrillation (AF) ablations. In this interview we speak with Matthew Evans, MD, an electrophysiologist with Arrhythmia Management Heart Rhythm Specialists, a Baylor Scott & White Health – HealthTexas Affiliate, in Denton, Texas. 

Tell us about your EP program at The Heart Hospital Baylor Denton. 

The Heart Hospital Baylor Denton is the sister to our flagship hospital, The Heart Hospital Baylor Plano. It is truly a self-contained heart hospital, consisting of 22 beds, 1 dedicated EP lab, 1 hybrid lab (where we’re doing convergent cases), 2 cath labs, and 2 surgical ORs. We have dedicated EP techs and nurses who are exceptionally enthusiastic and motivated. The hospital also enjoys a 5-star patient satisfaction rating. 

How many AF ablation cases do you perform on average?

We are still in the process of ramping up our program, but on average, I perform 3-6 AF cases per week. It is my goal to be able to perform 3-4 such cases per day in the near future, and I think that we are on track to get there with some of the recent adjustments that we have made to the work flow. 

What was your approach prior to achieving zero fluoro? What techniques have you used to achieve a zero fluoro approach? Why was it important to transition to a zero fluoro approach? 

I’m pretty fresh out of fellowship, finishing at the end of December at our Baylor Scott & White facility in Temple, Texas (a Texas A & M affiliated program). I trained under a number of operators who had vastly different approaches as far as their utilization of three-dimensional (3D) mapping, intracardiac echo (ICE), and fluoroscopy. However, I have the benefit of having trained in the era of advanced 3D mapping, with a heavy reliance on intracardiac echo and minimization of fluoro, and had mentors that really embraced this technology. Out of fellowship, my fluoro times were usually between 5-10 minutes during an AF case. Once I decided to move toward elimination of fluoro, I had to change some aspects of the procedure that relied on x-ray. For instance, I tried placing the coronary sinus (CS) catheter with 3D mapping instead of fluoro, after getting some right atrial geometry. I found this to actually be one of the easiest transitions to make, using a split screen of LAO and RAO projections. 

The next thing I worried about was transseptal catheterization: how are you going to do the transseptal if you can’t see the wires within the SVC on fluoro? By advancing the ICE catheter into the SVC and deflecting slightly backwards, you actually get a great view of the SVC lumen. Then, I advance the long J wire into the SVC and make sure that I can visualize it on ICE. Almost always, I will see the wire come past the catheter, although once or twice I have needed to make a few passes with the wire to redirect it into the SVC. I like to keep the body of the wire in the plane, and then pin it, and advance my transseptal sheath over the wire. Then you can visualize exactly where the tip of your sheath has landed and its orientation. From there, it is a simple pull down of the ICE catheter to the level of the fossa ovalis, and in so doing, you can even get an idea of how much clockwise rotation you will need to apply to the sheath to get it into an optimal position for transseptal puncture. I then remove the wire, insert my transseptal needle, and withdraw while clocking until I see the sheath drop onto the superior limbus of the fossa. Previously, I would watch this under fluoro, but I feel that under ICE you actually get an earlier indication that the sheath is coming into position and can better adjust your final approach. Once I’m in a desirable position, I use a BRK-1 extra sharp needle (St. Jude Medical) and do my transseptal under ICE visualization. This is another step that I would have always done with the addition of fluoro, but you don’t lose anything by just using ICE. If anything, you gain something because you can actually see where that needle and sheath are relative to the walls of the left atrium, how the dilator-sheath transition is interacting with the septum, how deep the tip of the dilator is within the LA, and whether it is pointing toward the pulmonary veins or the appendage. 

Once transseptal and while waiting for the ACT to be titrated to goal, I visualize the esophagus on ICE. I then ask the anesthesiologist to slowly insert and remove the temperature probe until I can clearly see the tip traversing the posterior wall of the left atrium. I then guide it into position at the level of the mid-posterior LA wall and mark the position on the 3D map, as well as the location of the entire esophageal stripe. If it’s a big left atrium, I can even place it superiorly while I’m working on the superior portion of the posterior wall, and then advance it deeper as I move to the more inferior aspect of my line. 

Once the ACT is near goal, I insert a PENTARAY (Biosense Webster, Inc., a Johnson & Johnson company), through the transseptal sheath and map out the geometry of the left atrium, merging that with the CT, and doing my initial mapping of pulmonary vein activity. I then exchange the PENTARAY for the ablation catheter and do an empiric wide area circumferential ablation (WACA) for each side with a connecting roof line. I then will do a quick test of the veins with the ablation catheter just to get an idea of whether they’re isolated, and if it looks like they are, I come back in with a PENTARAY and do a voltage map of the veins. I will also splay the catheter across the roof line to pace and record from one side of the line to the other in each direction, and compare with CS activation to confirm bidirectional block. If the veins are indeed isolated and roof blocked, I will then reinsert the catheter into the PVs and administer adenosine for each PV to test for latent conduction. If there is no evidence of latent conduction, the procedure is concluded.  

When did you start utilizing a zero fluoro approach? How many AF ablation procedures have been performed now with zero fluoro? Do you use lead at all now?

I did my first fluoro-free case about two months ago. We have done about two dozen cases since then, during which we have not used one second of fluoro. In fact, we all leaded up for the first fluoro-free case, and I was ready to use it if I had to, but that case went so smoothly that for the very next case, we didn’t wear lead. From that point on, we haven’t worn lead at all, with the exception of a few anesthesiologists who don’t quite believe it yet. There may come a time where there is difficult anatomy and we may have to use it, but so far it has not come to that, so I figure, why subject everyone’s backs to lead if the worse case scenario is I need to scrub out, put on lead, and scrub back in? Plus, I don’t want to be tempted to step on that pedal, which I now use as a foot stool!

In what other ways has a zero fluoro approach affected your work flow? 

Oddly enough, I really don’t miss it. I feel that the procedures have actually been much more efficient since moving to a fluoro-free approach, primarily because I believe that through ICE and 3D mapping, you have superior data available. With the exception of the first four cases, which I consider the learning curve, a zero fluoro approach has definitely not increased my time. I’m now averaging about 60-120 minutes for double WACA and a roofline with drug testing and a confirmation of block across the roofline. No complications have occurred. I think that particularly with complex procedures like pulmonary vein isolation, there is a strong bias to do things the same way every time to minimize the risks, and that is potentially the biggest impediment to going fluoro free — taking the leap to rely on different data. I think it may be easier for those of us who were trained more recently to do without it, because it’s been slowly working its way out of the procedure. 

In what cases do you utilize zero fluoro? Only AF ablations? 

We started the zero fluoro approach with AF ablations. In his June 2016 EP Lab Digest article (https://bit.ly/28ZuQTB), Dr. David Weisman said he started with flutter. I read that and thought, why I didn’t start with flutter? That would have been so much easier! My typical flutter and fibrillation cases are fluoro free. I have also since performed two accessory pathways, one AVNRT, and one PVC case fluoro free. As for AV node ablations? I don’t know. From a cost perspective, when you start putting mapping into an AV node ablation, especially with the small amount of fluoro that you really need for most cases, it is probably not very cost effective. Otherwise, I think it is possible in any non-epicardial ablation. 

What has been the staff feedback to not using lead? 

They absolutely love it! When new people work with me, they still think they need to put on their lead, even though we tell them that they don’t need to wear it — they don’t believe it. To me, it makes sense from not only a patient safety perspective, but also in terms of occupational safety for the entire lab staff. Plus, we can all finally agree on a room temperature!  

Do you have any tips for other labs seeking a zero fluoro approach?

I may be too young to be giving anyone else pointers — I’m still learning the game myself. However, when I first started out, my professional mentor, Dr. J. Brian DeVille, gave me a valuable piece of advice. It’s one of those things I repeat to myself during every case: if you’re doing every case the exact same way, you’re not doing it right, because you should be learning and trying to improve during every single case, and seeing how you can do things more safely, quickly, and effectively. Anytime you can find a way to modify any of those three variables, you’re improving the care you’re delivering. That was the idea behind cutting out fluoro. It’s very clear that if I can do this procedure at least as safely and quickly without fluoro, then I’m hitting the metric of making the procedure safer. It has become my manta: quicker, safer, better.

Disclosure: The author has no conflicts of interest to report regarding the content herein.