Atrial fibrillation ablation using real-time three-dimensional transesophageal echocardiography as the primary intraprocedural imaging modality: a single-center feasibility study

BACKGROUND: Intracardiac echocardiography (ICE) is commonly used during atrial fibrillation (AF) ablation to facilitate transseptal access, catheter positioning, and intraprocedural safety monitoring but adds procedural cost and requires additional vascular access. Real-time three-dimensional transesophageal echocardiography (3D TEE) offers high-quality imaging without disposable intravascular catheters; however, its use as a primary intraprocedural imaging modality during contemporary AF ablation has been limited. This study evaluated the feasibility, safety, and procedural efficiency of using real-time 3D TEE in place of ICE for intraprocedural guidance during AF ablation. METHODS: This single-center feasibility study included 128 consecutive AF ablation procedures performed over an eight-month pilot period using real-time 3D TEE as the primary intraprocedural imaging modality. TEE was used for transseptal puncture guidance, catheter visualization, and intraprocedural safety monitoring. Procedural characteristics, fluoroscopy utilization, acute procedural success, complications, and same-day discharge rates were analyzed. RESULTS: Acute procedural ablation success was achieved in all cases. Procedures included de novo and repeat ablations, cases requiring lesion sets beyond pulmonary vein isolation, and concomitant left atrial appendage occlusion. No major acute complications, including pericardial effusion requiring intervention, clinically apparent esophageal injury, cerebrovascular events, or in-hospital mortality, were observed. Median total procedure time was 40 min (interquartile range (IQR) 32-50), median fluoroscopy time was 8.6 min (IQR 6.2-11.0), and median radiation dose was 39.1 mGy (IQR 23.2-78.9). Same-day discharge was achieved in 87.5% of procedures. CONCLUSION: Real-time 3D TEE can be used as the primary intraprocedural imaging modality for AF ablation, providing effective guidance for transseptal access, catheter positioning, and safety monitoring without reliance on ICE. In centers with advanced echocardiographic expertise and appropriate training frameworks, this approach may represent a viable alternative to ICE with potential advantages in procedural workflow and resource utilization. Real-time three-dimensional transesophageal echocardiography can be used as the primary intraprocedural imaging modality during atrial fibrillation ablation, providing effective guidance for catheter manipulation and safety monitoring while avoiding disposable intracardiac echocardiography catheters and additional vascular access.