Iatrogenic atrial septal defect following pulsed field ablation using left atrial ICE
M Mraiyan, B Doty, M Khan, D NairAbstract
Background
Pulsed field ablation (PFA) has become a preferred modality for atrial fibrillation (AF) ablation because of its myocardial selectivity and lower collateral injury risk. Iatrogenic atrial septal defect (iASD) remains a consideration during transseptal access, particularly when left atrial intracardiac echocardiography (LA ICE) is used. Most defects are small, hemodynamically insignificant, and close spontaneously; however, real-world data on persistent iASD after PFA with LA ICE remain limited.
Objective
To assess the incidence, characteristics, and clinical implications of persistent iASD after PFA using LA ICE.
Methods
We performed a prospective imaging analysis of patients who underwent PFA for AF with LA ICE using a single transseptal puncture. Baseline echocardiograms were compared with one-year follow-up studies to determine iASD persistence, and patients were monitored for related symptoms or complications.
Results
A total of 772 patients (mean age 72 ± 12 years; 52% male) underwent PFA with LA ICE using 10– 14F transseptal sheaths and 8–10F ICE catheters. At one year, persistent iASD was identified in 14.2%, all showing left-to-right shunting; 10.1% were small (<3 mm) and hemodynamically insignificant, while 4.1% were moderate. No patient developed right-sided dilation, paradoxical embolism, or required closure. Migraine symptoms occurred in 1.2%, resolving by six months in most; four had symptoms at one year. Patients with persistent iASD had longer septal dwell time (52 ± 12 vs. 31 ± 11 min), greater use of larger-diameter sheaths, higher LA pressure (28 ± 4 vs. 12 ± 3 mmHg), and lower LVEF (32 ± 11% vs. 54 ± 14%). They were slightly younger (69 ± 9 vs. 71 ± 11 years) and more often female (65% vs. 52%).
Conclusion
PFA with LA ICE is associated with a low rate of clinically significant persistent iASD. Risk appears influenced by sex, sheath size, LA dwell time, and LA pressure. Continued follow-up and multicenter validation are needed as LA ICE–guided PFA workflows evolve.iASD TableiASD chart