Feasibility and safety of pulsed-field ablation in atrial fibrillation patients with septal occluder devices: a multicenter case series

Background Transseptal puncture (TSP) for atrial fibrillation (AF) ablation in patients with septal occluder devices (SODs) is technically challenging because of altered septal anatomy and limited residual interatrial septum. The feasibility of pulsed-field ablation (PFA) in this setting has not been systematically evaluated. Purpose To assess the feasibility, safety, and procedural characteristics of TSP and PFA using a variable-loop circular catheter integrated with a three-dimensional mapping system in patients with previous atrial septal or patent foramen ovale closure. Methods This multicenter case series included six consecutive patients with prior SOD implantation who underwent PFA for paroxysmal AF between January and September 2025. All procedures were guided by multimodality imaging (computed tomography, transesophageal and/or intracardiac echocardiography). TSP was performed under fluoroscopic and echocardiographic guidance, targeting the residual native septum. Pulmonary vein isolation (PVI) was achieved using a variable-loop circular PFA catheter capable of both mapping and ablation through a single puncture. Procedural and fluoroscopy times and acute outcomes were recorded. Results TSP was successfully performed through the residual native septum in all patients, most often in the postero-inferior portion, without the need to puncture through the device. Complete PVI was achieved in all cases with no complications (perforation, embolism, device interference, or pericardial effusion). Mean skin-to-skin time ranged from 60 to 95 min, and fluoroscopy time from 12.4 to 30 min. Large devices (up to 32 mm) did not preclude safe access or catheter maneuverability. Integration of imaging and mapping facilitated optimal visualization of the SOD and puncture site. Conclusion This is the first case series demonstrating that PFA with a variable-loop circular catheter is feasible and safe in AF patients with SODs. Careful pre-procedural imaging and echocardiographic guidance allow transseptal access through the native septum even in the presence of large devices. A single-catheter workflow enables both mapping and ablation without additional punctures or catheter exchanges. These findings support the use of PFA as a safe and efficient option for this complex and growing patient population.