Efficacy and safety of transseptal puncture-assisted atrial fibrillation ablation in patients with atrial septal occluder devices: an updated systematic review and meta-analysis

Background Transseptal puncture (TSP) is required for most catheter ablation (CA) procedures for atrial fibrillation (AF) because it enables left atrial access. In patients with atrial septal occluder (ASO) devices, device-related changes in septal anatomy may affect procedural planning, feasibility, and safety. We performed an updated systematic review and meta-analysis to evaluate reported outcomes of TSP-assisted CA in patients with ASO. Methods We searched PubMed, Embase, and the Cochrane Library from inception to April 28, 2026, including studies evaluating TSP-assisted CA in patients with ASO. Outcomes were AF recurrence, periprocedural complications, and procedural success, reported as proportions with 95% confidence intervals (CIs). Results Nine observational studies comprising 207 patients were included (36.7% female; mean age, 47.9 years; mean follow-up, 21.5 months). AF recurrence had a pooled incidence of 23.95% (95% CI 18.08% to 31.00%; I2 = 0.0%). In studies reporting 12-month follow-up, pooled AF recurrence was 18.18% (95% CI 10.07% to 30.60%; I2 = 0.0%). Periprocedural complication rate was 0.45% (95% CI 0.00% to 2.09%; I2 = 14.5%). Procedural success was 96.64% (95% CI 84.26% to 100.00%; I2 = 75.1%) and 97.87% (95% CI 86.38% to 99.70%; I2 = 0.0%) in a sensitivity analysis restricted to studies with comparable definitions. Conclusion Observational evidence suggests that TSP-assisted CA in patients with ASO is feasible and has a low reported complication rate in experienced centers, although the certainty of these findings is limited by small, noncomparative studies.