Focused Review on Zero-Fluoroscopy Transseptal Puncture: Current Evidence and Techniques

Fluoroscopy has traditionally been the gold standard for imaging in interventional cardiology and electrophysiology, but its use exposes both patients and medical staff to ionizing radiation and associated risks. In response, the development of intracardiac echocardiography (ICE) and three-dimensional (3D) electroanatomical mapping (EAM) systems has enabled fluoroless transseptal puncture (TP) techniques and catheter ablation. Zero-fluoroscopy (ZF) TP has emerged as a safe and effective alternative to conventional fluoroscopy-guided TP, using ICE and EAM for real-time visualization of cardiac structures and catheter navigation. Multiple studies, including randomized controlled trials, have confirmed the safety and efficacy of these techniques, showing comparable success rates, shorter procedure times, and reduced radiation exposure. At the University Hospital Centre Zagreb, a structured ZF TP workflow has been implemented, incorporating ICE guidance, EAM integration, and a standardized anticoagulation protocol. However, despite the benefits of the ZF approach, challenges such as higher costs, the need for specialized training, and limited access to advanced imaging technologies may limit its broader adoption.