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New technique may represent desirable alternative to fluoroscopy for AFib patients

par Lee Nelson, Contributing Reporter | June 12, 2017
Cardiology X-Ray
By using a high-frequency sound wave instead of an X-ray beam to get a complete image of the heart, patients with irregular heartbeats or atrial fibrillation (AF) could avoid receiving any radiation exposure.

Physicians at NewYork-Presbyterian and Weill Cornell Medicine in New York City emphasized in a recent review article in Heart Rhythm that a long-time technique called intracardiac echocardiography (ICE) to treat an irregular heartbeat should be used by reluctant doctors rather than the X-ray beam.

“It wasn’t something we did on day one. Slowly and progressively, you become more comfortable with it, and you realize the tremendous power and knowledge you can obtain from it,” Dr. Bruce Lerman told HCB News. He is chief of the Division of Cardiology at Weill Cornell Medicine and New York-Presbyterian, and lead author of the article.

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Atrial fibrillation (AF) is a condition that affects as many as 6.1 million Americans and is characterized by an irregular, often rapid heart rate caused by a misfiring of electrical impulses.

Physicians commonly treat AF with a minimally-invasive procedure called catheter ablation. They insert thin, flexible wires into veins, snaking them up into the heart. Once in, doctors apply radio frequency energy or freezing temperatures to eliminate the abnormal electrical pathways, restoring the heart's regular rhythm.

But to see their way, many cardiologists rely on fluoroscopy which uses a continuous X-ray beam to visualize the heart. It works, but it exposes the patient and care team to high doses of radiation. Just one routine ablation for a patient would be the equivalent of receiving 830 X-rays.

“There are two kinds of injuries that occur with radiation exposure,” Lerman said. “One is a dose-dependent injury such as skin reddening. Plus, the operators can get cataracts over time.”

The other is a non-dose-dependent effect.

“It can cause tumors. There is a latency period with this. Sometimes it’s over 20 years before you develop these things,” Lerman said. “For the operator, over many years, the estimated chance of this occurring is one in 200. For the patient that receives only 60 minutes of fluoroscopy, it is one in 1,000 over 20 years.”

“ICE will become the standard way of doing it over the next couple of years,” he added.

The article emphasized that the biggest obstacle to this happening is doctors’ discomfort and lack of training to use it.

“Once you learn this technology and feel more comfortable with it, you recognize that it is every bit as good,” he said.

He said he hopes doctors across the country begin to take courses in it, use images online to learn it, visit laboratories that do it, or have trainers come to their hospital.

“We hope there will be educational symposiums that can be developed, too, and train fellows,” he said.

“People will look back upon this as a time of transition. Using fluoroscopy will be diminishing for these procedures. Most laboratories around country will migrate toward this approach,” Lerman said. "The most critical requisite for performing fluoroless catheter ablation of AF is a willingness to relinquish an old habit.”

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