Key result
Percutaneous RA-to-LV puncture and ablation achieves non-inducibility and prevents VT recurrence at 5 months.
Why the study?
VT catheter ablation is challenging with mechanical aortic and mitral valves due to prosthesis damage risk, and real-world experience with percutaneous RA-to-LV puncture remains limited.
Does RA-to-LV percutaneous puncture through the inferoseptal process enable safe and effective LV access for VT ablation in a patient with double mechanical left-sided valves?
Case Report (n=1)
No
Does RA-to-LV percutaneous puncture through the inferoseptal process enable safe and effective LV access for VT ablation in a patient with double mechanical left-sided valves?
Percutaneous RA-to-LV access via the inferoseptal process is a feasible and safe strategy for VT ablation in highly selected patients with 'no-entry' ventricles when supported by multimodality imaging.
May enable LV access for VT ablation in select mechanical-valve patients; hypothesis-generating and requires prospective validation before adoption.
Background Catheter ablation of ventricular tachycardia (VT) in patients with both mechanical aortic and mitral valves remains challenging, as conventional retrograde or transseptal approaches are not feasible due to the risk of damaging prostheses. Alternative strategies such as thoracotomy, epicardial access, or stereotactic radiotherapy may be unsuitable due to anatomical or technical constraints. The right atrium-to-left ventricle (RA-to-LV) puncture through the inferoseptal process (ISP) has recently emerged as a potential solution, yet real-world experience remains limited. Case summary An 81-year-old man with rheumatic heart disease, double mechanical left-sided valve replacement, chronic kidney disease, and recurrent drug-refractory VT was referred for catheter ablation. Multimodal imaging using cardiac magnetic resonance (CMR) and contrast-enhanced CT processed with ADAS3D software enabled identification of the arrhythmogenic substrate in the basal lateral LV and preprocedural planning of a safe puncture trajectory. Under general anaesthesia and uninterrupted anticoagulation, a percutaneous RA-to-LV puncture was performed with real-time guidance from electroanatomical mapping, CT-fluoroscopy integration and intracardiac echocardiography (ICE). High-density mapping revealed a basal lateral scar with areas of conduction deceleration. Targeted ablation eliminated abnormal potentials and rendered VT non-inducible. A small restrictive iatrogenic Gerbode defect was observed without hemodynamic impact at 4-month follow-up echocardiogram. The patient recovered uneventfully and remained free of VT and ICD therapies at 5-month follow-up. Discussion This case suggests that RA-to-LV access is feasible and safe in a highly selected patient when thorough multimodal planning is undertaken. This report represents the first European experience and supports the potential role of this technique in patients with no-entry ventricle.
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Sanaú et al. (2026) conducted a case report in Recurrent drug-refractory ventricular tachycardia in a no-entry left ventricle (n=1). Right atrium-to-left ventricle (RA-to-LV) percutaneous puncture and catheter ablation was evaluated on Freedom from ventricular tachycardia recurrence and ICD therapies. RA-to-LV percutaneous puncture and targeted ablation successfully eliminated abnormal potentials and rendered VT non-inducible, leaving the patient free of VT recurrence and ICD therapies at 5-month follow-up.
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