Transseptal Puncture Research Articles

Single versus double transseptal puncture for pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation - insights from "Go for Zero Fluoroscopy" registry

Abstract Background Transseptal puncture is one of the most challenging steps in catheter ablation of atrial fibrillation (AF) because of the potential risk of complication. While single TSP reduces the puncture-related risk, double TSP simplifies the procedure (immediate signal visualization in pulmonary veins, avoidance of multiple changes of catheters through the single sheath). The purpose of this study was to analyze the impact of single versus double TSP during pulmonary vein isolation (PVI) with radiofrequency (RF) catheter ablation for AF on the fluoroscopy usage and procedure time. Methods Data reported from the international, multicenter prospective „Go For Zero Fluoroscopy Registry" performed in years 2018–2019 were analyzed. Overall 25 European electrophysiology centers from 14 countries and up to 5 operators from each center were enrolled. Only isolated PVI procedures were analyzed. Results A total data of 393 PVI RF procedures were collected from 25 centers. The median dose-area-product (DAP), fluoroscopy time and overall procedure time were: 810 (325 – 1839) cGy*cm2, 8 (4 – 14) minutes and 124 (92 – 168) minutes, respectively. Single TSP was associated with significantly higher DAP: 984 (459 – 1939) vs 667 (227 – 1469) cGy*cm2 (p=0.002), longer fluoroscopy time: 11 (6 – 19) vs 6 (3 – 11) minutes (p<0.001) and longer overall procedure time: 133 (103 – 168) vs 110 (90 – 168) minutes (p=0.003) as compared with double TSP. Single and double TSP group did not differ significantly in regards of general anesthesia usage, circular and multipolar mapping catheter use (p>0.05). However, single TSP was performed by operators with longer EP lab experience: 10 (4 – 15) vs 3 (0 – 10) years (p<0,001). Conclusions Double TSP is related with lower fluoroscopy usage and shorter overall procedure time of pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation.

LA reservoir strain predicts elevated left atrial pressure in patients with Veno-Arterial (VA) extracorporeal membrane oxygenator (ECMO) support for cardiogenic shock

Abstract Background Veno-arterial (VA) extracorporeal membrane oxygenator (ECMO) is not a left ventricular (LV) support system as it increases aortic pressure and LV afterload due to retrograde blood flow in the aorta. This can lead to complications such as increased LV volume (LV distention), increased LV and left atrial (LA) pressures, and pulmonary edema. We sought to investigate the correlation between LA strain and invasive LA pressure (LAP) in patients with ECMO support for cardiogenic shock undergoing atrial septostomy with stenting. Methods and Results A total of 24 consecutive patients (52±20 years; 83% were male) undergoing atrial septostomy with stenting while being on ECMO support for cardiogenic shock for left heart decompression were analyzed. LAP was measured immediately after transeptal puncture and before deployment of interatrial septal stent. A comprehensive echocardiogram was performed in all patients prior to atrial septostomy. Median time difference between echocardiogram and LAP measurement was 3.5 (0.5-20) hours. LA strain analysis was performed using the TomTec Arena 2D-cardiac performance analysis (CPA) software. LA reservoir strain was measured at peak systole during the reservoir phase in a single apical 4-chamber view. Intraclass correlation coefficients between 2 different investigators were excellent (All> 0.95). Median LA reservoir strain and LAP were 3.2 (0.5-1) % and 23 (8-53) mmHg, respectively. LA reservoir strain significantly correlated with LAP (r=0.53, p=0.034). LA reservoir strain of < 1.5% can effectively predict markedly elevated LAP (LA> 30 mmHg) (OR =9.9, p =0.0016). Conclusions LA reservoir strain significantly correlated with invasive LAP. With the advent of strain imaging software, LA reservoir strain is a feasible, reproducible, noninvasive, and straightforward method to predict the need for left heart decompression and/or to guide optimal afterload management in patients with VA-ECMO for cardiogenic shock. Further a prospective simultaneous echocardiographic and invasive LAP study is needed.

Analysis of the left atrial appendage function by intracardiac echocardiography in patients with atrial fibrillation

Abstract Introduction Intracardiac echocardiography (ICE) is frequently performed during catheter ablation procedures in order to guide the transseptal puncture and has been recently used to evaluate the morphology of the LAA. Purpose The objective of this study was to evaluate the feasibility of using an ICE catheter placed in the coronary sinus (CS) to delineate the LAA function during catheter ablation for atrial fibrillation. Methods We included 21 consecutive patients (age 62±9 years, 5 women, 6 paroxysmal AF) who underwent catheter ablation for AF. An 8-Fr phased-array ICE catheter was used to obtain images of the LAA, while in sinus rhythm. The LAA was visualized with the ICE probe placed sequentially in the left atrium (LA, Figure A), with the ultrasound section plane parallel to the long axis of the left ventricle (LV), and in the CS, with the ultrasound section plane perpendicular to the LV long axis (Figure B). LAA emptying flow velocity, and LAA fractional area change (FAC) were used to evaluate LAA function. There were no procedural complications. Results ICE imaging was possible in all cases. The LAA peak flow velocity was similar when the ICE catheter was placed in the LA and in the CS (64±7 cm/s and 62±5cm/s respectively, P=NS). The LAA FAC was significantly lower when the ICE catheter was placed in the CS when compared to an LA location (14±6% vs 36±14%; P<0.001). The LAA FAC measured from the LA correlated with the mitral annular plane systolic excursion while the LAA FAC measured from the CS did not. Thus, LAA contraction in a plane perpendicular to the LV long axis is independent of the LV longitudinal contraction. These results suggest that in our patient group most of the LAA contraction was due to the longitudinal movement of the LV base during systole and diastole. Conclusions Imaging of LAA using an ICE probe positioned in the LA and CS was feasible in all cases. The LV longitudinal contraction appears to impact the LAA function.

Successful Treatment of Atrial Flutter Post Radiofrequency Ablation for Atrial Fibrillation Following Atrial Septal Defect Occlusion: A Case Report of Pulsed Field Ablation

Abstract Background Atrial flutter (AFL) is a common arrhythmia following radiofrequency ablation (RFA) for atrial fibrillation (AF), with varying incidence depending on the ablation strategy. Patients with prior atrial septal defect (ASD) occlusion pose challenges for ablation, particularly when the lesions are located near the occluder. Pulsed-field ablation (PFA) has emerged as a promising alternative to radiofrequency ablation (RFA) for the treatment of AF or AFL; however, its use in patients with ASD occlusion remains unexplored. Case summary We present the case of a 46-year-old female with a history of ASD occlusion and subsequent RFA for AF. Despite the initial success, she developed symptomatic AFL three months post-procedure. Intracardiac echocardiography-guided transseptal puncture guided by intracardiac echocardiography (ICE) revealed an AFL originating from the slow conduction area around the ASD occluder. PFA was successfully performed, and AFL was terminated without complications. Postprocedural follow-up demonstrated maintenance of sinus rhythm. Discussion Patients with ASD occlusion present unique challenges for ablation, including difficulties in transseptal puncture and risk of injury to the occluder. PFA offers a potential solution, with studies showing fewer reconnected pulmonary veins and larger lesion creation compared with traditional methods. In our case, PFA effectively terminated the refractory AFL, highlighting its utility in this patient population. Moreover, the use of the Jinjiang PFA catheter with pulse circuit self-checking technology ensured procedural safety, particularly near the occluder.

Workflow of the zero‐fluoro pulsed field ablation

AbstractBackgroundZero‐fluoroscopic pulsed field ablation (PFA) is the next step in advancing pulmonary vein isolation (PVI) for atrial fibrillation (AF).MethodsA workflow incorporating a variable‐loop circular PFA catheter, intracardiac echocardiography (ICE), and a visualized sheath was applied to 15 paroxysmal AF patients.ResultsIt consisted of three steps: (1) positioning a non‐magnetic mapping catheter in the coronary sinus after creating a right atrial matrix, (2) transseptal puncture with the sheath advancement to the left atrium under ICE guidance, and (3) PFA confirming catheter‐tissue contact with tissue proximity indication.ConclusionsThis zero‐fluoro PFA workflow is feasible without advanced technique.

Randomized Controlled Trial Comparing Training of Transseptal Puncture With or Without Intracardiac Echocardiography.

Intracardiac echocardiography (ICE) has been widely used in the catheter ablation of atrial fibrillation (AF). However, the value of ICE in the training of transseptal puncture (TSP) is unclear. ICE-Training Study was a single-center, parallel-group, unmasked, randomized controlled trial registered in ChineseClinicalTrials.gov. Participants were randomly assigned (1:1) to different groups (1) the ICE simulator training group (ICE-ST), in which TSP was trained and performed under the guidance of both ICE and x-ray; and (2) the conventional simulator training group (Con-ST), in which TSP was trained and performed only under the guidance of x-ray. The trainees need to undergo the training stage and the evaluation stage. From October 2022 to December 2022, 18 consecutive fellows (age 32.4±4.4years, 12 males) without experience of TSP were included. The training period (16.9±6.6 vs. 29.6±8.7 times, p=0.003) and the fluoroscopy time (120.3±25.3 vs. 189.3±40.2s, p<0.001) of the ICE-ST group was significantly shorter than that of the Con-ST group. No significant difference was found in the comprehensive performance of TSP in the ICE-ST group (composite score 96.7±5.7) and the Con-ST group (composite score 95.9±6.3, p=0.62), but the selection of TSP sites in the ICE-ST group was commonly better than that in the Con-ST group. ICE could improve the efficiency of TSP training and optimize the site of TSP to facilitate catheter manipulation in the ablation. ChineseClinicalTrials.gov identifier: ChiCTR2200058377.

3D printed polymers for transseptal puncture simulation

PurposeThis study aims to examine the efficacy of 3D printing polymers to realistically mimic the fossa ovalis (FO) – a cardiac structure that is positioned in the interatrial septum – for simulating transseptal puncture (TP) procedures.Design/methodology/approachSpecimen of different materials and thicknesses were prepared and tested simulating the puncturing of the FO using a 12F ID/14F OD TP catheter. Force and tenting length results were compared with literature references. Scanning electron microscope images of the specimen were acquired to observe the perforated region as well as the structure of the specimen in the unaffected area.FindingsSignificant changes in the properties of interest were registered for the same material on specimens tested at different moments after fabrication. Suturable vessel wall polyjet material offers the best characteristics to replicate FO anatomy and mimic its behavior to puncturing.Originality/valueThe originality of the work lies in the test of different commercial materials. Similar works are already present in literature but specifically designed materials are used. Demonstrating that off-the-shelf materials could be viable for FO specimens would simplify the design of realistic TP simulators in the future.

TCT-545 Integrated Transseptal Puncture and Therapy Delivery Systems Provide Highly Efficient and Consistent Left Atrial Appendage Closure Solutions

TCT-545 Integrated Transseptal Puncture and Therapy Delivery Systems Provide Highly Efficient and Consistent Left Atrial Appendage Closure Solutions

Impact of the transseptal puncture location on the fossa ovalis on first-pass pulmonary vein isolation

Impact of the transseptal puncture location on the fossa ovalis on first-pass pulmonary vein isolation

Clinical experience of pulmonary vein isolation via single transseptal puncture in atrial fibrillation patients: Comprehensive characterization and follow-up

BackgroundAtrial fibrillation is the most commonly observed cardiac rhythm disorder. Pulmonary vein isolation (PVI) is an effective treatment option to maintain sinus rhythm. This study evaluates the safety, efficacy, clinical outcomes and radiation exposures using a standardized single transseptal puncture (STP)-strategy. MethodsWe analyzed data from patients who underwent our STP-ablation technique with transesophageal echocardiography (TEE) guidance at a university hospital and a regional tertiary health center in Switzerland between January 1, 2017, and May 30, 2022. Collected data included demographics, symptoms, echocardiography results, procedural details, complications and outcomes. Mean follow-up time was 21.4 ± 16 months. ResultsThe study population included 304 patients with a median age of 67 years, who had at least one ablation using our STP-approach. Among these, 248 (82 %) patients underwent de novo PVI with this technique. Ablation was successful in all patients with isolation of all pulmonary veins, with an average procedure duration of 120 min and an average fluoroscopy time of 3 min, resulting in a mean X-ray dose of 252 cGy × cm2. TEE guidance was performed in 235 (95 %) patients. During the first intervention, 17 complications occurred in 13 patients (5 %). After the first PVI, 135 (54 %) patients experienced no recurrence during the follow-up period. The one-year recurrence rate for atrial fibrillation requiring therapy was 30 %. ConclusionOur STP- approach demonstrated comparable success rates to traditional methods, with similar procedural durations, low radiation exposure and a low complication rate. Therefore, this method may offer procedural, economic and safety benefits without compromising efficacy or safety.

Does Sinus Rhythm Restoration in Patients With Atrial Fibrillation Undergoing Pulmonary Vein Isolation Have Acute Hemodynamic Benefits?

Although the restoration and maintenance of sinus rhythm (SR) in patients with atrial fibrillation (AF) have long-term benefits, few studies have investigated the acute hemodynamic benefits immediately after SR restoration. Therefore, we investigated whether hemodynamic changes occurred in the first few minutes after cardioversion from AF to SR. We retrospectively enrolled 145 patients with AF and divided them into a pre-AF group comprising patients in whom SR was restored by electrical cardioversion during pulmonary vein isolation (PVI; n = 74) and a control group comprising patients who were in SR throughout the procedure (n = 71). The pre-AF group was subdivided into subgroups according to AF classification (paroxysmal AF (PAF), persistent AF (PerAF), and long-standing persistent AF (LSPAF)) and into quartiles based on the AF-heart rate (HR). The mean arterial pressure (MAP) and left atrial pressure (LAP) were measured immediately after transseptal puncture (pre-measurement) and before withdrawal from the left atrium after PVI (post-measurement). The changes in MAP and LAP between the pre- and post-measurement (ΔMAP and ΔLAP) were calculated by subtracting the pre-measurements (MAPpre and LAPpre) from the post-measurements (MAPpost and LAPpost). In the pre-AF group, the time from cardioversion to post-measurement was 19 ± 16 min. When ΔMAP and ΔLAP were compared with the control group, ΔMAP was significantly smaller (4.9 ± 17.8 vs. 11.0 ± 14.2 mm Hg, respectively; P = 0.025), and ΔLAP was not significantly different between the groups. In the subgroup analyses, although ΔLAP was not significantly different among AF types, ΔMAP was significantly increased in the PAF group compared to the PerAF and LSPAF groups (24.0 ± 18.5 vs. 3.1 ± 16.8 and 4.5 ± 18.1 mm Hg, respectively; P = 0.042). The HRpre in the quartiles with the lowest, second, third, and highest AF-HR were approximately 58, 74, 86, and 109 beats per minute (bpm), respectively. The ΔLAP and ΔMAP were not significantly different among the AF-HR quartile groups. In patients with PAF, atrial contractions may resume quickly, which leads to hemodynamic improvement immediately after SR restoration. As for AF-HR, there was no significant impairment of ventricular diastolic filling at approximately < 109 bpm.

Intracardiac ultrasound-guided transseptal puncture in horses: Outcome, follow-up, and perioperative anticoagulant treatment.

Cardiac catheterizations in horses are mainly performed in the right heart, as access to the left heart traditionally requires an arterial approach. Transseptal puncture (TSP) has been adapted for horses but data on follow-up and closure of the iatrogenic atrial septal defect (iASD) are lacking. To perform TSP and assess postoperative complications and iASD closure over a minimum of 4 weeks. Eleven healthy adult horses. Transseptal puncture was performed under general anesthesia. Serum cardiac troponin I concentrations were measured before and after puncture. Weekly, iASD closure was monitored using transthoracic and intracardiac echocardiography. Relationship between activated clotting time and anti-factor Xa activity during postoperative enoxaparin treatment was assessed in vitro and in vivo. Transseptal puncture was successfully achieved in all horses within a median duration of 22 (range, 10-104) minutes. Balloon dilatation of the puncture site for sheath advancement was needed in 4 horses. Atrial arrhythmias occurred in 9/11 horses, including atrial premature depolarizations (N = 1), atrial tachycardia (N = 5), and fibrillation (N = 3). Serum cardiac troponin I concentrations increased after TSP, but remained under the reference value in 10/11 horses. Median time to iASD closure was 14 (1-35) days. Activated clotting time correlated with anti-factor Xa activity in vitro but not in vivo. Transseptal puncture was successfully performed in all horses. The technique was safe and spontaneous iASD closure occurred in all horses. Clinical application of TSP will allow characterization and treatment of left-sided arrhythmias in horses.

Ma fermeture d'auricule s'est compliquée : traitement percutané d'une rupture d'auricule gauche

An 81-year-old patient was referred for left atrial appendage closure. Anatomical LAA analysis by CT scan showed an inverted chicken wing morphology. The procedure was performed through i an infero-anterior transseptal puncture and led to “sandwich” closure strategy using an AMPLATZER AMULET 25 mm device. Despite successful deployment of the occluder, a hemopericardium soon developed related to an iatrogenic LAA perforation/partial rupture and leading to major hemodynamic instability. After pericardocentesis, it was decided to inject activated thrombin into the pericardial sac to achieve in situ hemostasis. This strategy enabled coagulation of the hemopericardium and cessation of active bleeding, without recourse to surgical treatment.

Intracardiac Echocardiography-Guided Transseptal Puncture Invisible by Transesophageal Echocardiography After Secundum Atrial Septal Defect Closure

Intracardiac Echocardiography-Guided Transseptal Puncture Invisible by Transesophageal Echocardiography After Secundum Atrial Septal Defect Closure

Minimizing Exposure to Ionizing Radiation in Catheter-Based Treatment of Atrial Fibrillation: Safety and Efficacy

Pulmonary vein isolation using radiofrequency ablation is the most common method of catheter treatment for atrial fibrillation. Performing this procedure involves the use of X-ray radiation, which at certain stages of the procedure is an indispensable method for navigation and visualization of intracardiac structures. Approaches to minimize X-ray exposure during catheter interventions are attracting increased attention of the electrophysiology community due to the potential risks of adverse effects of ionizing radiation on patients and medical personnel. The aim. To evaluate the effectiveness and safety of performing the pulmonary vein isolation procedure with the intention to minimize X-ray exposure of patients and medical personnel. Materials and methods. Forty-three patients with various forms of atrial fibrillation were selected for the study: 28(65%) with paroxysmal and 15 (35%) with persistent forms. All the patients underwent pulmonary vein isolation usingcatheter radiofrequency ablation with the intention to minimize X-ray exposure at the National Amosov Institute of Cardiovascular Surgery in the period from June 2023 to April 2024. Results. In all 43 patients it was possible to electrically isolate all the veins. Catheter ablation of the cavotricuspidisthmus was performed in 5 (31.2%) patients from group A (“Zero-fluoro”), 7 (33.3%) from group B (“Near Zero-fluoro”) and 3 (50%) from group C (“Non Zero-fluoro”) (p = 0.696). Intraoperative reconnection of the pulmonary veins with the left atrium was observed in 6 (37.5%) patients of group A, 11 (52.3%) of group B, and 4 (66%) of group C (p = 0.429). X-ray time for transseptal puncture did not differ between groups A and B (3.56 ± 2.37 vs. 3.69 ± 2.3 min., p = 0.532), however, X-ray time for pulmonary vein isolation in group A was significantly less than that in group B (0.27 ± 0.13 vs. 1.96 ± 1.21 min., p &lt; 0.001). The total time in the left atrium was not statistically different between these two groups (81.33 ± 22.32 vs. 98.6 ± 29.83 min., p = 0.106). In group C (“Non Zero-fluoro”), the aforementioned parameters were not recorded. Total dose area product (DAP) and total radiation dose, as well as total X-ray time and total procedure time, were significantly lower when using the ionizing exposure minimization approach. DAP and total radiation dose in group A were the lowest (7.29 ± 5.16 Gy/cm2 and 76.62 ± 70.82 mGy, respectively) and significantly differed from those in group C (107.67 ± 97.59 Gy/cm2 and 882.32 ± 868.62 mGy, p &lt; 0.001 and p = 0.001, respectively). No intraoperative complications were observed in the studied sample. Conclusions. Minimizing X-ray exposure using modern navigation systems during pulmonary vein isolation using catheter radiofrequency ablation is not associated with increased intraprocedural complications in patients with paroxysmal and persistent atrial fibrillation. This approach allows you to significantly lower total DAP and the radiation dosewithout increasing the time of performing the pulmonary vein isolation procedure.

Incidence and predictors of persistent iatrogenic atrial septal defect following catheter ablation

BackgroundThe left atrium approach for atrial fibrillation (AF) ablation requires an atrial transseptal puncture that may cause an iatrogenic atrial septal defect (iASD). This study aimed to investigate the incidence and predictors of iASD in catheter ablation, assessed by transthoracic echocardiography (TTE), a relatively non-invasive technique frequently employed in follow-up. MethodsThis retrospective study included 639 patients (489 male; 60.2±10.7years) who underwent initial catheter ablation for AF between May 2005 and June 2018. All patients underwent preprocedural transesophageal echocardiography (pre-TEE), preprocedural TTE (pre-TTE), and TTE one day after the procedure (post-TTE). iASD incidence after 6months (6M), preprocedural characteristics, and procedure methods were evaluated. ResultsPatent foramen ovale (PFO) was diagnosed in 42 patients (6.6%) using pre-TEE and in 11 patients using pre-TTE (26.2% of the patients with PFO in pre-TEE). Among the 597 patients without PFO, 497 underwent 6M-TTE. iASD was observed in 59.6% of patients using post-TTE and 4.6% using 6M-TTE. In the univariate logistic regression analysis, the total diameter of the sheath through the septum (odds ratio 1.15, p<0.001) or two sheaths through a single puncture (odds ratio 4.17, p=0.001) were independent risk factors on iASD incidence in 6M-TTE. iASD was also more likely to occur via cryoballoon ablation using a larger sheath than radiofrequency catheter ablation. ConclusionsiASD was not a rare complication. A larger sheath diameter or two sheaths through a single puncture were associated with the incidence of iASD.

The challenge of transseptal access for catheter ablation of left-sided arrhythmia substrate in infants and small children under 6 years of age

Abstract Background Young age and small cardiac dimensions are increased risk factors for catheter ablation (CA), therefore ablation below 15 kg should be recommended only in selected drug-refractory cases. The need for a transseptal puncture (TSP) may be an additional risk factor. Persistent foramen ovale (PFO) in infants can mitigate this risk and paradoxically, decrease the complication rate in the very young. Purpose This study aimed to compare the results of left-sided CA in infants under 1 year and in children between 1-6 years of age. Methods Between January 2010 and September 2023, 1703 pediatric CAs were performed, of which 17 left-sided ablations in children under 6 years without structural heart disease were retrospectively evaluated. CA results below 1 year and between 1-6 years of age were compared in terms of body size, procedural parameters, left atrial (LA) access, complication, and success rate. Results The patient group below 1 year (Group 1, n=5) has a mean age=0.13±0.03 years, mean body weight=3.6±1.1 kg, mean height=52.3±3.6 cm. Patients between 1-6 years (Group 2, n=12) have mean age=5.0±1.1 years, mean body weight=17.9±2.2 kg, mean height=111.2±7.4 cm. The arrhythmia substrate was an overt pathway in 3 pts (17.6%), concealed accessory pathway in 7 pts (41.2%), and focal LA tachycardia in 7 pts (41.2%). Foramen ovale was persistent in all 5 children in Group 1 and TSP was not required. In Group 2, only 2 pts (16.7%) had PFO, and, all other procedures required TSP. TSP was successful in 9/10 cases (90%). No complications related to LA access or other adverse events occurred in Group 1. In Group 2, there was one case of pericardial effusion that spontaneously regressed and one case of mechanical-induced advanced AV block that resolved after six days. There were no significant differences in procedure time, fluoroscopic time, and radiation dose between the two groups (Group 1: 126.4±47.0 min, 6.4±4.5 min, 4.0±5.3 cGycm2 vs. Group 2: 162.6±49.2 min, 7.9±9.4 min, 9.0±12.4 cGycm2, p&amp;gt;0.05). All CAs were performed with RF energy. The acute success rate of the procedures was 100%. Conclusion CA of left-sided arrhythmias in infants and small children may offer a safe and effective therapeutic option in selected cases. The high prevalence of PFO may explain the paradoxically less complication under 1 year of age.

Intra-procedural three-dimensional rotational angiography in cryoballoon ablation of atrial fibrillation - results from a randomised clinical trial

Abstract Introduction There are a variety of approaches for pre-procedural imaging to facilitate atrial fibrillation (AF) ablation. Intra-procedural three-dimensional rotational angiography (3DRA) is the least employed method and it can be advantageous regarding efficiency and procedural logistics (1). There is an open question whether LA imaging could improve safety and outcomes of cryoballoon (CB) ablation. Purpose The aim of this study is to evaluate possible benefits of 3DRA for procedural success, safety and long-term outcomes of CB ablation. Methods We designed a single-centre unblinded randomised clinical trial and recruited 134 patients (64.2% male, 59.0±11.6 years) with paroxysmal (93.3%) and early-persistent AF. Patients were randomised to no imaging or 3DRA which was performed intra-procedurally after trans-septal puncture. Angiographic images were segmented and overlaid to the fluoroscopy screen to guide the ablation procedure. Patients were scheduled for follow-up visits and twenty-four hour ECG recordings at 3, 6 and 12 months, and every 6 months thereafter. Results Of all the patients recruited, 66 (49.3%) were randomised to 3DRA and angiography was successfully performed in all but one patient (1.5%). Procedure time was significantly longer when 3DRA was performed (86.7±27.8 min compared to 67.2±22.1 in non-3DRA group, p&amp;lt;0.001). Total radiation dose (447.4±485.0 vs. 133.9±166.2 mGy, p&amp;lt;0.001) and contrast administration (131.8±28.3 vs. 40.8±26.5 ml, p&amp;lt;0.001) were significantly higher in the 3DRA group (Table 1). In patients who received no imaging one pulmonary vein (PV) couldn’t be isolated in 2 patients while this occurred in 3 patients in the 3DRA group (OR 1.57, 95% CI 0.25-9.72). Only minor complications were reported in both groups. Five patients developed large haematoma (4 in the 3DRA group vs. 1 in the control group). In each group there were 3 incidents of impending or transient phrenic nerve palsy. During 12 months of follow-up, 88.2% of patients in the control group and 81.8% in the 3DRA group were free of atrial fibrillation (OR 1.67, 95% CI 0.63-4.38). Two patients from the control group developed atrial flutter and were treated by ablation. In total, 10 patients underwent redo procedures (7 in the control and 3 in the 3DRA group respectively) and PV reconnections were detected in 9 cases. Conclusion 3DRA is a safe and efficient intra-procedural imaging method to guide CB ablation of AF. However, it significantly increases procedure duration, total radiation dose and contrast expenditure. In our trial it did not have any impact on the acute success rate of PV isolation or freedom from atrial fibrillation during 12-month follow-up.

Single versus double transseptal puncture for pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation - insights from "Go for Zero Fluoroscopy" registry

Abstract Background Transseptal puncture is one of the most challenging steps in catheter ablation of atrial fibrillation (AF) because of the potential risk of complication. While single TSP reduces the puncture-related risk, double TSP simplifies the procedure (immediate signal visualization in pulmonary veins, avoidance of multiple changes of catheters through the single sheath). The purpose of this study was to analyze the impact of single versus double TSP during pulmonary vein isolation (PVI) with radiofrequency (RF) catheter ablation for AF on the fluoroscopy usage and procedure time. Methods Data reported from the international, multicenter prospective „Go For Zero Fluoroscopy Registry" performed in years 2018–2019 were analyzed. Overall 25 European electrophysiology centers from 14 countries and up to 5 operators from each center were enrolled. Only isolated PVI procedures were analyzed. Results A total data of 393 PVI RF procedures were collected from 25 centers. The median dose-area-product (DAP), fluoroscopy time and overall procedure time were: 810 (325 – 1839) cGy*cm2, 8 (4 – 14) minutes and 124 (92 – 168) minutes, respectively. Single TSP was associated with significantly higher DAP: 984 (459 – 1939) vs 667 (227 – 1469) cGy*cm2 (p=0.002), longer fluoroscopy time: 11 (6 – 19) vs 6 (3 – 11) minutes (p&amp;lt;0.001) and longer overall procedure time: 133 (103 – 168) vs 110 (90 – 168) minutes (p=0.003) as compared with double TSP. Single and double TSP group did not differ significantly in regards of general anesthesia usage, circular and multipolar mapping catheter use (p&amp;gt;0.05). However, single TSP was performed by operators with longer EP lab experience: 10 (4 – 15) vs 3 (0 – 10) years (p&amp;lt;0,001). Conclusions Double TSP is related with lower fluoroscopy usage and shorter overall procedure time of pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation.

Acute haemodynamic changes during left atrial appendage closure

Abstract Purpose Left atrial appendage closure (LAAC) presents an alternative treatment for stroke prevention in atrial fibrillation (AF) in patients with contraindication for long-term anticoagulation. However, even in patients in AF, left atrial appendage plays an important role in reservoir function of left atrium. The purpose of this study was to assess acute hemodynamic effects during LAAC. Methods Consecutive patients indicated for LAAC from January 2022 to October 2023 were enrolled. The invasive hemodynamic measurements were done at the beginning of the procedure after transseptal puncture, and at the end from the procedure after device deployment. Following parameters were measured: systolic, and diastolic blood pressure, and pressure in left atrium (LA), all measurements were done at rest and after 3 minute isometric exercise (handgrip). Results Thirty-two patients were included (age 76,2+7,1 yrs, 22 (69%) males, 23 (72%) permanent AF, left ventricular ejection fraction 52+11,8%). No patients experienced moderate/severe mitral insufficiency, the saline intake during procedure was 738 ml. Isometric exercise significantly increased the LA pressure: the LA pressures (rest/exercise) were 13.7+6.7 mmHg/16.7+8.8 mmHg (p=0.003) at the beginning of the procedure, and 17.0+7.3mmHg/20.0+7.3 mmHg (p=0.005) after device deployment. The LA pressure obtained after device deployment (both rest/exercise) were significantly higher compared to values obtained at the beginning of the procedure. (p=0.003). Conclusions LAAC is associated acute increase of both rest and exercise LA pressure. Whether its acute negative effect remains over time needs further investigation.