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\begin{document}

\title{Comparison Of Minimal Versus Zero Fluoroscopic Catheter Ablations In
Gestational Supraventricular Arrhythmias}



\author[1]{Joseph You}%
\author[1]{Eric Pagan}%
\author[1]{Ramanak Mitra}%
\affil[1]{North Shore University Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Introduction: Management of gestational supraventricular tachycardia
(SVT) is challenging and requires a multidisciplinary approach for
optimal management. Antiarrhythmic pharmacologic therapy has variable
efficacy and carries potential risks to both mother and fetus. Catheter
ablation during pregnancy has traditionally been considered a last
option due to procedural safety and ionizing radiation risks. Recent
advances including intracardiac echocardiography and multi-electrode
electroanatomic mapping have greatly enhanced the safety and efficacy
profile to successfully perform ablations with minimal to no fluoroscopy
even during pregnancy; however, most of the literature publications are
case reports. Though the use of fluoroscopy-guided catheter ablations
for refractory cardiac arrhythmias in pregnancy have been extensively
studied, there are still a paucity of data about the efficacy, safety,
and aggregate outcomes of purely zero-fluoroscopic ablations in
comparison to minimal fluoroscopic approaches. Methods: A literature
search was performed for catheter ablations in the past fifteen years
for gestational arrhythmias that used minimal or no fluoroscopy. Sixteen
cases describing catheter ablations with zero-fluoroscopy were compared
to twenty-four cases using minimal fluoroscopy, defined as total
documented exposure time of less than 10 minutes. Baseline
characteristics, techniques, and outcomes of both groups were compared.
Results: Analysis of both groups demonstrated that zero-fluoroscopic
approaches for treatment of gestational SVT, though underutilized, have
comparable successful outcomes without additional risk compared to
minimally fluoroscopic procedures. Utilization of electroanatomic
mapping with or without concomitant intracardiac echocardiography in the
zero-fluoroscopy group further demonstrated equal efficacy rates of
successful ablation when compared to the control group. Furthermore,
there were no reported immediate or long term periprocedural
complications in either group, including delivery outcomes. Conclusions:
Zero-fluoroscopy catheter ablation for SVT in pregnancy appears to be as
effective and safe when compared to minimal fluoroscopy ablations while
eliminating the theoretical risks of ionizing radiation.%
\end{abstract}%



\sloppy


\emph{Comparison Of Minimal Versus Zero Fluoroscopic Catheter Ablations
In Gestational Supraventricular Arrhythmias}

Joseph You MD\textsuperscript{1}, Eric Pagan MD\textsuperscript{2} ,
Raman Mitra MD PhD\textsuperscript{2}

\textsuperscript{1}North Shore University Hospital, Department of
Internal Medicine, Manhasset, NY

\textsuperscript{2} Department of Cardiology, Zucker School of Medicine
at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY

Correspondence to: Joseph You, MD

Department of Internal Medicine

300 Community Drive

Manhasset, NY 11030

Phone: 516-582-5266

Running Header: {[}Zero Versus Minimal Fluoroscopic Catheter Ablation{]}

\emph{Acknowledgments} : There are no acknowledgements for this study.

\emph{Sources of Funding:} There were no sources of funding provided for
this original study.

\emph{Disclosures} :

All authors that this manuscript is original and has not been published
elsewhere, nor is it currently under consideration for publication
elsewhere. There are no perceived or potential conflicts of interest or
disclosures.

\emph{Abstract}

\emph{Introduction} : Management of gestational supraventricular
tachycardia (SVT) is challenging and requires a multidisciplinary
approach for optimal management. Antiarrhythmic pharmacologic therapy
has variable efficacy and carries potential risks to both mother and
fetus. Catheter ablation during pregnancy has traditionally been
considered a last option due to procedural safety and ionizing radiation
risks. Recent advances including intracardiac echocardiography and
multi-electrode electroanatomic mapping have greatly enhanced the safety
and efficacy profile to successfully perform ablations with minimal to
no fluoroscopy even during pregnancy; however, most of the literature
publications are case reports. Though the use of fluoroscopy-guided
catheter ablations for refractory cardiac arrhythmias in pregnancy have
been extensively studied, there are still a paucity of data about the
efficacy, safety, and aggregate outcomes of purely zero-fluoroscopic
ablations in comparison to minimal fluoroscopic approaches.

\emph{Methods} : A literature search was performed for catheter
ablations in the past fifteen years for gestational arrhythmias that
used minimal or no fluoroscopy. Sixteen cases describing catheter
ablations with zero-fluoroscopy were compared to twenty-four cases using
minimal fluoroscopy, defined as total documented exposure time of less
than 10 minutes. Baseline characteristics, techniques, and outcomes of
both groups were compared.

\emph{Results:} Analysis of both groups demonstrated that
zero-fluoroscopic approaches for treatment of gestational SVT, though
underutilized, have comparable successful outcomes without additional
risk compared to minimally fluoroscopic procedures. Utilization of
electroanatomic mapping with or without concomitant intracardiac
echocardiography in the zero-fluoroscopy group further demonstrated
equal efficacy rates of successful ablation when compared to the control
group. Furthermore, there were no reported immediate or long term
periprocedural complications in either group, including delivery
outcomes.

\emph{Conclusions} : Zero-fluoroscopy catheter ablation for SVT in
pregnancy appears to be as effective and safe when compared to minimal
fluoroscopy ablations while eliminating the theoretical risks of
ionizing radiation.

Key Words:

\begin{itemize}
\tightlist
\item
  Catheter ablation
\item
  Fluoroscopy
\item
  Arrhythmias
\item
  Pregnancy / Gestation
\item
  Supraventricular tachycardia
\end{itemize}

\emph{Introduction} :

Supraventricular tachycardia poses a clinical challenge during pregnancy
and necessitates careful risk-benefit considerations to both mother and
fetus. Though non-sustained arrhythmias are common in pregnancy,
symptomatic tachyarrhythmias warrant careful investigation. The
mechanism of increased arrhythmia burden remains unclear though hormonal
and autonomic changes likely play key roles in physiologic changes
precipitating to arrhythmias. Furthermore, studies have shown that
patients with pre-existing SVT may experience exacerbations during
pregnancy due to stretching of atrial and ventricular myocytes,
resulting in early after depolarizations, shortened refractoriness,
slowed conduction, and spatial dispersion through activation of
stretch-activated ion channels\textsuperscript{1}.

Catheter ablation is an alternative to pharmacologic therapy and
advancements in electrophysiology techniques have allowed for successful
ablations during pregnancy. However, one area of concern is the exposure
of ionizing radiation to both mother and fetus. With the more widespread
use of electroanatomic mapping and intracardiac echocardiography,
fluoroscopy-free ablations are now feasible, though rarely described in
the literature. Here, we review the characteristics of supraventricular
tachyarrhythmias and outcomes of pregnant women who underwent
zero-fluoroscopy ablations in comparison with cases of the more
traditional minimal fluoroscopy approach.

\emph{Methods} :

A Pub-Med, Medline, and Embase search were performed for catheter
ablations in the past fifteen years for gestational arrhythmias that
used minimal or no fluoroscopy. Sixteen cases describing catheter
ablations with zero-fluoroscopy were compared to twenty-four cases using
minimal fluoroscopy, defined as total documented exposure time of less
than 10 minutes. The following data points were analyzed: maternal and
gestational age, prior pharmacological therapy, presenting symptoms,
arrhythmia etiology, and location. Cases describing cases of ventricular
arrhythmias or arrhythmias secondary to recent surgical complications
were not included in the data analysis. EKG findings, ablation procedure
techniques, use of anesthesia, and complications were also included in
the data.

Means and standard deviations along with the proportions of baseline
clinical characteristics are reported with respect to the total number
of patients in both the zero-fluoroscopy and minimal fluoroscopy groups.
Mean gestational and maternal age at time ablations were analyzed. A
comparative analysis of arrhythmias in both groups including subtype and
left versus right-sided etiologies were completed. A 2-sample t-test was
performed for continuous variables and a Chi-squared test was used for
categorical variables when comparing parameters between the minimal
fluoroscopy group and the zero-fluoroscopy group. A p-value of less than
0.05 was considered statistically significant.

\emph{Ablation Procedures}

Supraventricular arrhythmias in both groups were AVNRT, AVRT, WPW, and
atrial tachycardia arrhythmias (Table 1). In the zero-fluoroscopy group,
87.5\% of procedures utilized electroanatomic mapping with and without
intracardiac echocardiography, with 68.75\% utilizing Ensite NavX and
the remainder CARTO as the electroanatomic mapping tool. The majority of
clinical arrhythmias in the zero-fluoroscopy group arose from the right
side with six cases reported left-sided etiologies of arrhythmias and 3
requiring transseptal approaches. Similarly, the majority of cases in
the minimal fluoroscopy group had culprit arrhythmias originating from
right-sided regions (Table 2) Though there was no uniform documentation
of the use of local versus general anesthesia in these cases, only two
reported the use of generalized anesthesia in the zero-fluoroscopy
group.

\emph{Results} :

The majority of the ablations in the study group were performed in the
second and third trimester of pregnancy, regardless of fluoroscopy use.
The mean gestational age was 21.1 \selectlanguage{ngerman}± 7.3 weeks

weeks with a maternal age of 31 ± 8 years in the zero-fluoroscopy group
versus a mean maternal age of 27 ± 4 years weeks and a gestational age
of 25.8 ± 7.1 weeks in the minimal fluoroscopy group (Table 3). There
was no statistical significance between the means for both groups in
respect to maternal and gestational ages at time of ablation therapy. On
average, patients undergoing zero-fluoroscopy ablations were at younger
gestational ages (p = 0.0591) in comparison to the minimal fluoroscopy
group, though the former had a greater maternal age (p = 0.0597). Three
were of advanced maternal age, defined here as above 35 years old, in
the zero-fluoroscopy group with no reported cases in the minimal
fluoroscopy group.

Most patients initially presented with symptoms of palpitations,
dizziness, and tachycardia. The majority had previously been on a
beta-blocker regimen prior to recurrence. Three cases described the
prior use of amiodarone, sotalol, or digoxin for arrhythmias.

A comparative breakdown of ablations performed based on etiology,
location of arrhythmia, and approach for left sided arrhythmias can be
seen in Table 4. All ablation procedures led to successful ablation of
the culprit supraventricular tachycardia. There was no statistically
significant difference in arrhythmia type including AVRT, AVNRT, and AT
(p-values of 0.739, 0.601, 0.922, respectively.) In addition, there was
no statistically significant difference between the two groups with
respect to left sided procedures (p=0.792). Lastly, analysis of
transeptal versus retrograde aortic approaches for left-sided ablations
in both groups did not demonstrate statistical significance (p-values of
0.375 and 0.856, respectively).

There were no reported immediate perioperative complications and all
reported fetal outcomes resulting in the successful delivery of healthy
children. In addition to the advantage of zero exposure to ionizing
radiation to the fetus and mother, all documented peri-procedural
outcomes, both immediate and long-term complications were negligible.

\emph{Discussion} :

This is the first systematic review comparing minimal to
zero-fluoroscopic ablation for gestational supraventricular arrhythmias
and demonstrates comparable safety and outcomes. Normal physiologic
changes in pregnancy i.e., increased effective circulating volume,
cardiac output, and resting heart rate may attribute to
arrhythmogenesis. Sustained supraventricular tachycardias (SVTs) may
occur in up to 1.3\% of all pregnant women without structural heart
disease and those with a history of arrhythmias are at significant
recurrence risk\textsuperscript{2}.

Antiarrhythmic drugs, though effective, are not without risk in
pregnancy as many cross the placental barrier with equivocal side
effects. Most common pharmacologic options for gestational SVT remain a
Food and Drug Administration category C, meaning risks could not be
ruled out. The current lack of randomized trials and systematic data of
the efficacy and safety of anti-arrhythmic drugs in pregnancy have
caused a recent shift towards therapeutic catheter ablation
procedures\textsuperscript{3}. However, theoretical fluoroscopic
radiation exposure to the fetus remains a particular concern of ablation
therapy, especially in the first trimester during
organogenesis\textsuperscript{4}. Though the exposure levels for fetal
abnormalities varies, a reasonable threshold for concern on fetal
exposure is 50 mGy, a dose which has not been associated with fetal
anomalies or pregnancy loss\textsuperscript{24}. One study demonstrated
that with proper abdominal shielding, theoretical fetal exposure during
a catheter ablation procedure was \textless{}1 mGy\textsuperscript{25}.
Nevertheless, given the risks above, fluoroscopic free ablation is
gaining wider acceptance as an alternative to treat pregnant patients
with refractory arrhythmias\textsuperscript{26}.

Our baseline demographic data demonstrated similar findings in both
groups including clinical presentations, with most arrhythmias
consisting of Wolff-Parkinson-White, AVNRT, and atrial tachycardia. The
majority of arrhythmias were right-sided in etiology with initial
presentations of symptomatic tachycardia. Utilization of electroanatomic
mapping with or without concomitant intracardiac echocardiography in the
zero-fluoroscopy group were utilized in 87.5\% of the cases.
Furthermore, there was a trend towards a statistically significant
difference between both maternal and gestational ages at time of
ablation therapy. There were more zero-fluoroscopic ablations being
performed at earlier gestational times, with minimal fluoroscopic
ablations completed later in the third trimester. These findings are
reflective of the inherent benefits of utilizing no ionizing radiation
with zero-fluoroscopic procedures. Our findings demonstrated equal
efficacy rates of successful ablation when compared to the minimal
fluoroscopy group. There was no significant difference in the etiology
of arrhythmias, whether it was right or left sided. In addition, there
was similar rates of transeptal and retrograde aortic approaches for
left-sided ablations. Regardless of techniques, there were equal
successful outcomes in both groups. There were no documented immediate
or long-term perioperative complications in the zero-fluoroscopy group,
including delivery outcomes.

In rare cases where the culprit arrhythmia is refractory to both medical
and ablative therapy or the patient is a poor candidate for ablations,
sustained control of maternal tachyarrhythmias should ultimately be
prioritized in the setting of hemodynamic compromise. Strategies may
include initiation or escalation of pharmacotherapy with close inpatient
monitoring and consideration of a timely cesarean
section\textsuperscript{5}. Ultimately, it is imperative to have shared
decision making and collaboration amongst cardiology, maternal fetal
medicine and obstetric specialists to ensure maximum safety to both
mother and fetus.

One major limitation of our review was the lack of uniform documentation
as all data points were derived from individual case reports or series,
including use of anesthesia, duration of post-procedural follow up,
obstetric complications, and prior pharmacologic strategies for rhythm
control.

Our study shows that zero-fluoroscopy catheter ablation for
supraventricular tachycardia ablation in pregnancy using current
electroanatomic mapping systems with or without ICE have equivalent
safety and efficacy compared to minimal fluoroscopy ablations, while
eliminating the risk of ionizing radiation exposure to both the mother
and fetus.

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\emph{Tables}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
Source & Maternal Age & Gestational age (weeks) & Arrhythmia &
Pharmacologic Therapy & Mapping Modality & Anesthesia & Success
(arrhythmia / ablation site) & Right vs Left-Sided
Etiology\tabularnewline
Omaygenc\textsuperscript{3} & 27 & 21 & AVRT-WPW & Metoprolol & Ensite
NavX & Local & Successful; AVRT-WPW; retrograde & Left\tabularnewline
& 21 & 30 & AVNRT & Metoprolol & Ensite NavX & Local & Successful; AVNRT
& Right\tabularnewline
& 25 & 12 & WPW & Metoprolol & Ensite NavX & Local & Successful; WPW &
Right\tabularnewline
Guangzhi, Chen\textsuperscript{4} & 33 & 31 & PVC & Beta blocker &
Ensite NavX & Local & Successful; PVC & Right\tabularnewline
& 22 & 25 & AVRT-WPW & Beta blocker & Ensite NavX & Local & Successful;
AVRT-WPW/ tricuspid annulus & Right\tabularnewline
Bongiomi\textsuperscript{5} & 32 & 10 & AVNRT & None & ICE & Local &
Successful; AVNRT & Right\tabularnewline
Bigelow\textsuperscript{6} & 27 & 22 & AVNRT & Propranolol, flecainide &
Ensite Nav X / Velocity & Local & Successful; AVNRT &
Right\tabularnewline
Ferguson\textsuperscript{7} & 20 & 27 & AT & Beta blocker, calcium
channel blocker, amiodarone & ICE & N/A & Successful: focal left AT &
Left\tabularnewline
Barros\textsuperscript{8} & 32 & 12 & AT & Propafenone and sotalol &
Ensite NavX & Local & Successful; para-Hisian AT / non-coronary cusp ;
transeptal approach & Left\tabularnewline
Greyling\textsuperscript{9} & 26 & 17 & AT & Beta blocker & Ensite NavX
& General & Successful; AT ; transeptal approach & Left\tabularnewline
Kalinsek\textsuperscript{10} & 32 & 22 & AVRT; orthodromic & None &
ICE/Ensite NavX & N/A & Successful; AVRT; transeptal approach &
Left\tabularnewline
Zuberi\textsuperscript{11} & 48 & 30 & AT & Labetalol, digoxin & Ensite
NavX & Local & Successful; AT / lateral to mid crista terminalis &
Right\tabularnewline
Said\textsuperscript{12} & 49 & 28 & AVNRT & Labetalol & CARTO 3D
(Biosense) & N/A & Successful; AVNRT / His cloud & Right\tabularnewline
Jeong\textsuperscript{13} & 36 & 13 & WPW, a-fib & None & CARTO 3D
(Biosense)/ICE & N/A & Successful; WPW, afib / tricuspid annulus &
Right\tabularnewline
Kaspar\textsuperscript{14} & 34 & 11 & SVT & Sotalol, amiodarone & CARTO
3D (Biosense) & N/A & Successful; SVT w/ long PR & Right\tabularnewline
Leiria \textsuperscript{23} & 33 & 26 & ORT, LL AP & Sotalol & Ensite
NavX & General & Successful; ORT, LL AP; retrograde &
Left\tabularnewline
\bottomrule
\end{longtable}

Table 1: Zero fluoroscopy ablation procedure techniques, outcomes, and
location of clinical arrhythmia

AT: atrial tachycardia ; AVNRT: AV nodal re-entry tachycardia ; WPW:
Wolf-Parkinson White ; PVC: premature ventricular contraction ; ORT:
orthodromic reciprocating tachycardia ; SVT: supraventricular
tachycardia; ICE: intracardiac echocardiography\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Source\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Maternal Age (yrs)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Gestational Age (weeks)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Arrhythmia (Ablation Site If Defined)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Fluoroscopy Time\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Clinical Presentation\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Right vs Left-Sided Etiology\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Berruezo\textsuperscript{15}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / right atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8 min 1 s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Palpitations\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
22\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
ORT, left atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1 min 49s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Palpitations / Chest Pain\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Bombelli\textsuperscript{16}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
29\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
WPW\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6 min 48s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left ; retrograde\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
28\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AVNRT\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8 min 36s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Szumowski\textsuperscript{17}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
29\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
37\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / tricuspid annulus\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1 min 10 s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Syncope\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
34\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
38\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AVRT\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
28s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
35\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AVNRT\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
53s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
ORT , left atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1 min 46s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Syncope\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left ; retrograde\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
22\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
ORT, left atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
57s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Palpitations and Syncope\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left ; retrograde\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
ORT, left atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
60s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Palpitations and Syncope\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left; retrograde\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Kanjwal\textsuperscript{18}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
32\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
22\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
WPW-AVRT / lateral mitral isthmus\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
7 min 37s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Palpitations/Chest Pain\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left ; transeptal\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Wu\textsuperscript{19}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
32\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / right atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
55s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Palpitations / Dyspnea\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Raman\textsuperscript{20}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
33\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / mitral annulus\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1 min 18s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Palpitations/Dyspnea\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left ; transeptal\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yang\textsuperscript{21}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
17\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / sinus venosus\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6 min\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Chest flutters/Dyspnea\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
32\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / right atrial free wall\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1 min\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia / Dyspnea\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Hung\textsuperscript{22}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / right atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2 min 24s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
19\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
28\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AT / coronary sinus ostium\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2 min 55s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
32\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
28\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SVT / right ventricular outflow tract\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1 min 44s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
WPW / LFW accessory pathway\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2 min 5s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
25\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AVRT / LFW accessory pathway\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3 min 24s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
WPW / left septal accessory\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3 min 13s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Left\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
25\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
WPW / right posterior free wall accessory\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2 min 12s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
28\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
26\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AVNRT / slow pathway\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
49 s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
26\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
28\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AVNRT / slow pathway\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27 s\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Tachycardia\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Right\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2: Clinical arrhythmias, ablation sites, total duration time and
presenting symptoms in minimal fluoroscopy (\textless{}10 min) ablation
cases. AT: atrial tachycardia ; AVNRT: AV nodal re-entry tachycardia ;
WPW: Wolf-Parkinson White ; AVRT: atrioventricular reentrant
tachycardia; PVC: premature ventricular contraction ; ORT: orthodromic
reciprocating tachycardia ; SVT: supraventricular tachycardia ; LFW:
left free wall\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& \textbf{Zero-Fluoroscopy} & \textbf{Minimal Fluoroscopy} &
\textbf{P-Value (\textless{} .05)}\tabularnewline
\midrule
\endhead
Total Number of Cases (n) & 16 & 24 &\tabularnewline
Mean Fluoroscopy Time (x\selectlanguage{english}) & N/A & 173.79 \selectlanguage{ngerman}± 159.01 seconds
&\tabularnewline
Mean Gestation Week at Time of Ablation (x\selectlanguage{english}) & 21.1 \selectlanguage{ngerman}± 7.3 weeks & 25.8 \selectlanguage{ngerman}±
7.1 weeks & 0.0591\tabularnewline
Mean Maternal Age at Time of Ablation (x\selectlanguage{english}) & 31 \selectlanguage{ngerman}± 8 years & 27 \selectlanguage{ngerman}± 4 years
& 0.0597\tabularnewline
\bottomrule
\end{longtable}

Table 3: Comparison of zero-fluoroscopy vs minimal fluoroscopy
demographics\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Arrhythmias} & \textbf{Zero-Fluoroscopy} & \textbf{Minimal
Fluoroscopy} & \textbf{P-Value (\textless{} .05)}\tabularnewline
\midrule
\endhead
Total Left-Sided Arrhythmias (n) & 6 & 10 & 0.792\tabularnewline
Total AVRT Arrhythmias & 6 & 11 & 0.739\tabularnewline
Left-sided AVRT Arrhythmias & 3 & 9 & 0.169\tabularnewline
Total AVNRT Arrhythmias & 4 & 4 & 0.601\tabularnewline
Total AT Arrhythmias & 5 & 8 & 0.922\tabularnewline
Left-sided AT Arrhythmias & 3 & 1 & 0.2\tabularnewline
Transeptal Approach (Left-Sided) & 3 & 2 & 0.375\tabularnewline
Aortic Retrograde Approach (Left-Sided) & 2 & 4 & 0.856\tabularnewline
Unspecified Approach & 1 & 4 &\tabularnewline
\bottomrule
\end{longtable}

Table 4: Zero-fluoroscopy vs minimal Fluoroscopy by arrhythmia type and
left atrial location (values listed are represented as numbers for
categorical variables)

\selectlanguage{english}
\FloatBarrier
\end{document}

