Transseptal Puncture and Catheter Ablation of Atrial Fibrillation in Patients With Atrial Septal Occluder Devices: Procedural Techniques and Outcomes

Figure 1. Cardiac computed tomography assessment of native septum for transseptal puncture. (A) Cardiac computed tomography image showing the infero-posterior puncturable native septum (arrow) adjacent to the ASO device. (B) Cardiac computed tomography image showing the ASO device covering most of the interatrial septum, leaving no identifiable puncturable native septum. ASO, atrial septal occluder.

Figure 2. Optimal puncture areas on two types of atrial septal occluder devices. Schematic illustrations comparing the structural configuration of the Amplatzer Septal Occluder (A) and the Figulla Flex II Septal Occluder (B). In both devices, the optimal puncture area is indicated by the shaded region, corresponding to the off-centre waist where the nitinol mesh is relatively sparse and the number of layers to traverse is minimized. In the FFII device, the hubless left atrial disc allows a broader safe zone, whereas in the Amplatzer device, the central hub and denser mesh restrict the feasible puncture area to a narrower off-centre region.

Figure 3. Step-by-step procedural sequence of TSP through an ASO device. (A) RA angiography (LAO fluoroscopic view) delineates the interatrial septum and the ASO device relationship. (B) The optimal puncture area is located at the 5–7 o’clock position on the device under the RAO fluoroscopic view (shaded area). (C) A puncture is performed using a mechanical transseptal needle inserted into an SL-0 sheath. (D) After confirming LA entry by contrast injection, a 0.014-inch guidewire is advanced into the LA. If the tip of the inner dilator in the sheath can be advanced into the LA at this point, the needle and 0.014-inch guidewire should be exchanged for a 0.032-inch guidewire. (E) Initial dilation is performed using a 4–5 mm balloon. (F) If the sheath cannot penetrate the ASO device, balloon is upsized to 6–8 mm. (G) The sheath is advanced into the LA while the balloon is being deflated (the deflate-and-dive technique). (H) Using a 0.032-inch guidewire, the SL-0 is exchanged for a steerable sheath. (I) Then, an ablation catheter is inserted into the steerable sheath, and the ablation procedure is initiated. ASO, atrial septal occlude; LA, left atrium; LAO, left anterior oblique; RA, right…

Figure 4. Key technical steps for transseptal puncture through an ASO device. (A) Use of a mechanical needle: A mechanical needle with a distal tip hole was used to enable passage of a 0.014-inch guidewire for balloon delivery through the needle lumen. (B) Deflate-and-dive technique: After septal dilation with a balloon, the outer sheath is advanced across the septum in synchrony with balloon deflation to minimize resistance and prevent mesh recoil. ASO, atrial septal occluder; LA, left atrium; RA, right atrium.

Figure 5. Left atrial angiography. LA angiography demonstrating pulmonary vein anatomy and the spatial relationship between the pulmonary veins and the ASO device. See Supplementary material online, Video S7. LA, left atrium; ASO, atrial septal occluder.

Figure 6. Pulmonary vein isolation line. The ablation line created along the pulmonary vein antrum. The LA disc of the ASO device interrupted the intended ablation line, requiring the anterior isolation line of the right pulmonary veins to be placed more distally. LA, left atrium; ASO, atrial septal occluder.

Figure 7. Residual shunt on transthoracic echocardiography. A transthoracic echocardiographic image delineating a residual interatrial shunt within 2 months after ASO device puncture. The residual shunt flow (arrow) was minimal in size and haemodynamically insignificant. ASO, atrial septal occluder; LA, left atrium; RA, right atrium.