Background and aims: Atrial fibrillation (AF) ablation traditionally relies on fluoroscopy, exposing both patients and operators to ionizing radiation and lead apron-related occupational harm. Contemporary electroanatomical mapping and intracardiac echocardiography now enable zero-fluoroscopy (ZF) workflows, but comparative evidence regarding their safety and effectiveness remains limited. This study evaluated radiation exposure, procedural safety, procedural duration, and 12-month atrial arrhythmia-free recurrence after ZF versus conventional fluoroscopy (CF)-guided AF ablation.
Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA. PubMed, MEDLINE, Embase, and Cochrane were searched from January 1, 2014 to 2025 2, March for comparative studies comparing ZF with CF-guided atrial fibrillation ablation in adults. Primary outcomes were radiation exposure, peri-procedural complications, and 12-month atrial arrhythmia-free recurrence. Procedure duration was assessed as a secondary endpoint. Random-effects models were used to pool mean differences and odds ratios, with 95% confidence intervals.
Results: Twelve studies involving 1998 patients were included, comprising two randomized controlled trials and ten observational cohorts. Of these, 1098 underwent ZF-guided ablations, and 900 underwent CF-guided ablations. Compared with CF-guided ablation, ZF-guided ablation significantly reduced fluoroscopy time (MD -6.94 min, 95% CI -11.84 to -2.04, p = 0.006) and radiation dose (MD -31.39 mGy, 95% CI -37.44 to -25.35, p < 0.00001). There was no significant difference in 12-month freedom from atrial arrhythmia recurrence (OR 0.98, 95% CI 0.62 to 1.57, p = 0.74) or overall procedural complications (OR 0.73, 95% CI 0.35 to 1.55, p = 0.42). Procedure duration was not significantly different between groups (MD -7.16 min, 95% CI -15.38 to 1.06, p = 0.20).
Conclusion: ZF-guided ablation for AF substantially reduces radiation exposure without evidence higher procedural complication, 12-month freedom from atrial arrhythmia recurrence or procedure duration compared with CF-guided AF ablation. These findings support broader adoption of ZF-guided ablation in centres with appropriate imaging and mapping expertise, although the certainty of evidence remains limited by heterogeneity and the predominance of observational data included in this study.
Keywords: atrial fibrillation; catheter ablation; efficacy; radiation exposure; safety; zero‐fluoroscopy.
© 2026 The Author(s). Pacing and Clinical Electrophysiology published by Wiley Periodicals LLC.