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Research Article
22 June 2026

Use of intracardiac echocardiography and three-dimensional mapping during catheter ablation for atrial fibrillation is associated with reduced complications: a retrospective analysis of United States Medicare Fee-For-Service Database

Authors: Yiran Rong https://orcid.org/0000-0002-8571-3872, Tom Wei, Kevin Corriveau, and Rahul Khanna https://orcid.org/0000-0002-2478-1724 [email protected]Author Info & Affiliations
https://doi.org/10.57264/cer-2026-0037
PDFFormats

Abstract

Aim: This retrospective cohort study assessed differences in procedure-related complications and death among old patients with atrial fibrillation (AF) undergoing catheter ablation (CA) procedure with versus without use of intracardiac echocardiography (ICE) and advanced three-dimensional (3D) electroanatomical mapping. Materials & methods: Using the Medicare Database, a retrospective cohort of AF patients ≥65 years of age who underwent CA procedure were identified, and categorized into two cohorts: CA without ICE/3D mapping versus CA with ICE/3D mapping. Outcomes including a composite of complications (any), cardiac perforation, esophageal fistula and death, respectively, in the 30-day period post-CA were assessed. Inverse probability of treatment weighting method was used for covariate balancing. Cox regression models were performed to evaluate outcomes. Results: There were 35,490 patients in CA without ICE/3D mapping cohort and 170,762 in the CA with ICE/3D mapping cohort. Cox regression model revealed that patients who underwent CA without ICE/3D mapping use were ∼3.5-times more likely to have 30-day any complication versus those who had CA with ICE/3D mapping (7.3% vs 2.2%, log-rank test p < 0.001; hazard ratio: 3.507; 95% CI: 3.307–3.720, p < 0.001). The incidence of cardiac perforation (2.5% vs 0.1%, log-rank test p < 0.001), atrio-esophageal fistula (0.03% vs 0.01%, log-rank test p = 0.03) and death (1.6% vs 0.2%, log-rank test p < 0.001) were significantly higher among patients without ICE/3D mapping versus those who had CA with ICE/3D mapping. Conclusion: The absence of ICE and 3D mapping during CA procedures was associated with significantly increased risk of complications and death among Medicare eligible patients with AF.

Plain language summary

What is this article about?

Atrial fibrillation (AF) is the most common heart rhythm disorder that increasingly be treated with a procedure called catheter ablation (CA). During the procedure, intracardiac echocardiography (ICE) and electroanatomical mapping (EAM) systems help make the treatment better by creating a real-time, detailed picture of the heart. This study compared 30-day complications and death after CA performed between older patients without versus with ICE/3D mapping during the procedure.

What were the results?

Analyzing the data of 206,252 Medicare patients with AF treated with CA, older patients treated without ICE/3D mapping use were ∼3.5-times more likely to have 30-day any complication versus those who had CA with ICE/3D mapping. Older patients who underwent CA without ICE/3D mapping were also more likely to die during or within 30 days of CA. Similar results were observed in patients who had ablation procedure in hospitals without on-site cardiac surgery support.

What do the results mean?

These findings suggest that use of ICE and ED mapping during CA may offer an advantage in preventing complications and death during or post procedure. As CA increasingly expands to smaller hospitals, this study highlighted the importance of having ICE and 3D mapping as a part of a comprehensive CA workflow.

Supplementary Material

File (supplementary figures.docx)

Reference

Papers of special note have been highlighted as: • of interest; •• of considerable interest
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