Fluoroscopy‐Free Pulsed Field Ablation for Atrial Fibrillation: A Systematic Review of Procedural Feasibility and Safety

BACKGROUND: Fluoroscopy reduction has become a priority in electrophysiology to mitigate radiation exposure and the musculoskeletal burden of lead apron use. Pulsed field ablation (PFA) offers a favorable safety profile and efficient pulmonary vein isolation (PVI), making it an attractive platform for fluoroscopy-free workflows. Our aim is to evaluate the feasibility, procedural characteristics, and safety of fluoroscopy-free PFA for atrial fibrillation (AF). METHODS: We searched PubMed/MEDLINE, Embase, and Web of Science from inception through November 2025 for studies evaluating zero- or near-zero-fluoroscopy PFA in adults with paroxysmal or persistent AF. Eligible studies reported at least one feasibility or safety outcome (fluoroscopy time, acute PVI success, procedure duration, complications, or arrhythmia-free survival). Case reports, non-PFA energy sources, and pediatric studies were excluded. Data was extracted on study design, patient characteristics, procedural strategy, and outcomes. The protocol was registered in PROSPERO (CRD420251245538). RESULTS: Five observational studies published in 2025, comprising 260 patients, met inclusion criteria. Mean or median age ranged from 60 to 68 years, and most patients had paroxysmal AF. All procedures used contemporary PFA systems (Farawave, VARIPULSE, or PulseSelect) integrated with EnSite X or CARTO 3 mapping and ICE and/or TEE guidance. Four studies reported fluoroscopy times of 0 min; in the AdmIRE subgroup, fluoroscopy was 0 min in the zero-fluoroscopy group versus a median 2.7 min in the low-fluoroscopy group. Acute PVI was achieved in 100% of cases in all studies reporting this endpoint. Among cohorts with follow-up, freedom from AF ranged from 72.1% to 80%. Major complications were rare: no cardiac tamponade was reported in any fluoroscopy-free cohort, isolated cerebrovascular events occurred only in the larger registry without excess risk in the zero-fluoroscopy group. CONCLUSIONS: Fluoroscopy-free PFA for AF appears highly feasible, with uniform acute PVI success and low complication rates. Integration of echocardiographic guidance enables effective catheter navigation and lesion delivery without radiation. Larger, prospective multicenter studies with longer follow-up are needed to confirm long-term efficacy and safety.