Intracardiac echocardiography-guided transseptal puncture in anteroinferior native septum site for patients undergoing atrial fibrillation ablation with atrial septal closure devices: A case series

This case series describes the safety and feasibility of an anteroinferior transseptal puncture (TSP) in patients implanted with atrial septal defect (ASD) closure devices for atrial fibrillation (AF) ablation. Eight AF ablation procedures were performed in seven patients (58.4 ± 8.7 years; two males) with symptomatic AF and percutaneous ASD closure. Typically, the TSP site for patients with an ASD closure device is located in the inferior-posterior region of the native septum. However, with larger devices (>26 mm), limited space in this area can pose challenges for transseptal access. Using transthoracic echocardiography and 3D cardiac computed tomography, TSP sites were pre-determined, targeting the anteroinferior native septum. Closure device diameters averaged 23.8 ± 10.8 mm (range: 10 – 40 mm), with five cases involving devices ≥26 mm. The procedures were guided by fluoroscopy and intracardiac echocardiography, achieving a 100% success rate without TSP-related complications. These findings suggest the anteroinferior TSP approach is a safe and viable alternative for patients with large ASD closure devices.