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With the emergence of three\u2010dimensional electroanatomic mapping (EAM) systems and intracardiac echocardiography (ICE), zero\u2010 and near\u2010zero fluoroscopy (ZF) approaches have become increasingly feasible across a wide spectrum of EP and structural interventions. This review synthesizes current evidence supporting ZF workflows, highlighting their efficacy, safety, and expanding clinical applicability. Contemporary data demonstrate that ZF techniques achieve procedural success, complication rates, and long\u2010term outcomes comparable to conventional fluoroscopy\u2010guided procedures, while substantially reducing radiation exposure and mitigating associated risks such as malignancy, cataract formation, and orthopedic injury. Advances in mapping accuracy and real\u2010time intracardiac imaging\u2014including 3D and 4D ICE\u2014have enhanced anatomical visualization, procedural precision, and early detection of complications. Despite these benefits, ZF workflows introduce unique challenges, including vascular access complications, catheter\u2010related thrombus formation, and navigation errors due to EAM system limitations. Furthermore, certain complex procedures\u2014such as epicardial access, lead extraction, and select device implantations\u2014continue to rely on fluoroscopic guidance. Operator experience, learning curves, and the availability of fluoroscopic \u201cbailout\u201d strategies remain critical considerations. Overall, the transition toward ZF approaches represents a paradigm shift in EP, emphasizing radiation safety without compromising procedural outcomes. Continued technological innovation, standardized training, and robust randomized studies are essential to further validate and optimize these techniques, ultimately advancing safer, patient\u2010centered cardiovascular care.<\/jats:p>","DOI":"10.1111\/pace.70335","type":"journal-article","created":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T17:42:56Z","timestamp":1782495776000},"page":"1301-1311","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Sub\u2010Zero: A Review of the Current Evidence and Evolving Technologies Enabling Zero\u2011Fluoroscopy Procedures"],"prefix":"10.1111","volume":"49","author":[{"given":"Luke","family":"Miller","sequence":"first","affiliation":[{"name":"Department of Medicine University of Louisville  Louisville Kentucky USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Apurv","family":"Agarwal","sequence":"additional","affiliation":[{"name":"Department of Medicine 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