ST-segment elevation during transseptal puncture: A case report of a severe procedural complication

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Symptomatic persistent atrial fibrillation undergoing transseptal puncture for pulmonary vein isolation (n=1). Intervention: Transseptal puncture for left atrial pulsed field ablation. Primary outcome: Procedural ST-segment deviation and hemodynamic instability.

Q: What does this research mean for the field?

Transseptal puncture can trigger recurrent generalized ST-segment deviations and severe hemodynamic collapse leading to cardiac arrest, likely mediated by a severe Bezold-Jarisch reflex. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Marisa van der Graaf; Isabelle N. Bax; Benno Rensing; Jippe C. Balt; Lucas V.A. Boersma

doi:10.1016/j.hrcr.2025.10.015

October 18, 2025HeartRhythm Case ReportsOpen Access

ST-segment elevation during transseptal puncture: A case report of a severe procedural complication

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Key result

Transseptal puncture triggers recurrent severe shock and cardiac arrest via suspected Bezold-Jarisch reflex.

n=1

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Why the study?

Complications during transseptal puncture can be life-threatening, and differentiating between mechanisms of ST-segment deviation is crucial because treatment strategies differ.

Key Points

Evaluate the clinical mechanisms and therapeutic implications of recurrent, life-threatening ST-segment elevation and hemodynamic collapse triggered by transseptal puncture.
Clinical evaluation and procedural monitoring of a 61-year-old male with persistent atrial fibrillation undergoing elective pulmonary vein isolation via radiofrequency transseptal puncture.
Assessment of hemodynamic collapse, electrocardiographic deviations, and urgent coronary angiography across two separate catheter ablation procedures.
During the initial procedure, transseptal puncture was followed by widespread ST-segment deviations, profound hypotension, and cardiac arrest requiring 30 minutes of resuscitation, with subsequent coronary angiography showing no air or thrombus.
A second procedure resulted in identical recurrent ST-segment deviations and hemodynamic deterioration despite preventive measures, pointing to a severe Bezold-Jarisch reflex.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 male patient (age 61) with symptomatic persistent atrial fibrillation, hypertension, recovered tachycardiomyopathy, and left bundle branch block undergoing two elective pulmonary vein isolation procedures 4 months apart.

I

Intervention

Transseptal puncture (using radiofrequency needle NRG C1 RF in first procedure and Brockenbrough BRK1 needle in second procedure 4 months later) for planned elective pulmonary vein isolation using pulsed field ablation under general anesthesia (intravenous propofol, fentanyl, rocuronium).

O

Outcome

Procedural complications including generalized ST-segment deviations, profound hemodynamic instability, and cardiac arrest.safety

This case highlights that transseptal puncture can trigger a life-threatening Bezold-Jarisch reflex causing generalized ST-segment elevation and cardiac arrest, requiring prompt recognition and differentiation from air embolism or coronary spasm to guide appropriate treatment with anticholinergics and inotropes.

Limitations

Single-patient case report
Presence of preexistent left bundle branch block delayed initial detection of ST-segment deviations
Exact underlying mechanism (severe Bezold-Jarisch reflex vs coronary artery spasm) remains a clinical hypothesis

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Implication

May prompt differentiation of Bezold-Jarisch reflex from embolism in post-puncture shock; hypothesis-generating for reflex-mediated complications in AF ablation.

Abstract

Left atrial ablation is routinely performed in patients with atrial fibrillation that seek an alternative to anti-arrhythmic drugs. Accessing the left atrium by a transseptal puncture (TSP) is widely used and generally considered safe. However, this procedure is associated with a small but non-negligible risk of complications (approximately 1%), most commonly cardiac tamponade1–3. In some patients transient ST-segment elevation may occur shortly after TSP, which is usually considered to be due to systemic air embolisms, thromboembolic events or a parasympathetic reflex2.

Discussion

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Cite This Study

Graaf et al. (2025) conducted a case report in Symptomatic persistent atrial fibrillation undergoing transseptal puncture for pulmonary vein isolation (n=1). Transseptal puncture for left atrial pulsed field ablation was evaluated on Procedural ST-segment deviation and hemodynamic instability. Transseptal puncture provoked recurrent generalized ST-segment deviations and severe hemodynamic shock (including a 30-minute cardiac arrest) across two ablation procedures, likely due to a Bezold-Jarisch reflex.

synapsesocial.com/papers/6a0909bf29af591ab7017442 https://doi.org/10.1016/j.hrcr.2025.10.015

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ST-segment elevation during transseptal puncture: A case report of a severe procedural complication

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

ST-segment elevation during transseptal puncture: A case report of a severe procedural complication

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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