Clinical significance of the DUS4ABL strategy for systematically guiding left atrial and ventricular electrophysiological procedures
Authors: Augustin N , Spieker M , Gloeckner D , Angendohr S , Schmidt J , Brinkmeyer C H , Kelm M , Rana O , Bejinariu A 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
The ultrasound evolved as an indispensable tool to guide electrophysiological (EP) procedures (i.e., gain femoral access, transseptal puncture or exclude pericardial effusion). However, there are no data regarding the course and safety features of ablation procedures in a systematic ultrasound-guided approach.

Purpose
The aim of this study was to investigate if the systematic use of ultrasound in the course of all ablation procedures with transseptal punction benefits the outcome especially reducing major complication rates and benefitting the process with a reduction of procedure time and fluoroscopy time and dose. This approach consisted of for elements: Firstly the transesophageal echocardiography ruling out left atrial thrombi in the EP laboratory, secondly the ultrasound guided femoral vein puncture, thirdly the transesophageal guided transseptal punction (TSP) and fourthly ruling out pericardial effusion peri and post procedural (TTE), summarized as the DUS4ABL strategy.

Methods
A cohort of 222 patients undergoing LA or LV electrophysiological ablation guided by the DUS4ABL strategy were compared to a historical cohort of 299 undergoing the same type of procedure using only TTE post procedural to rule out pericardial effusion and in some cases having ruled out left atrial thrombi via TEE in an independent examination up to 7 days prior to the electrophysiological procedure. In the standard group the femoral access was performed by palpation only, the transseptal punction was managed pressure and fluoroscopy guided. Comorbidities, medication and epidemiological data were recorded and analyzed such as major complications specifically: Pericardiac tamponade, strokes, pseudoaneurysms of the femoral vein and artery, atrio-esophageal fistula, phrenic lesions and death.

Results
All 521 patients (43% female) were included into the final analysis: 43.8% of patients presented with paroxysmal atrial fibrillation, 35.3% had persistent atrial fibrillation, 10.9% had atrial tachycardia and 10% arrhythmias arising from the left ventricle. Baseline characteristics of the patients did not differ significantly between both groups. Results show a significantly lower complication rate in the DUS4ABL group compared to the standard group with 0 major complications occurring in the DUS4ABL group and 11 complications in the standard group (p=.001). Complications included 4 pericardial tamponades and 7 pseudoaneurysms of the femoral artery, all of which were successfully managed. Other complications such as strokes, phrenic lesions and death did not occur in either of the groups.
There was no significant difference in procedure time between the groups but a significant difference in fluoroscopy time and dose both of which were significantly lower in the DUS4ABL group (p=0.002 and p=0.013).

Conclusion
The DUS4ABL strategy significantly reduced the overall complication rate, and also resulted in positive effects for fluoroscopy time and dose.