Transseptal Approach Shields Brain During Ablation

TOPLINE:

The occurrence of acute brain lesions was lower with a transseptal puncture than with a conventional retrograde aortic approach in patients undergoing left ventricular catheter ablation, with no significant difference in the safety or efficacy profile between both approaches.

METHODOLOGY:

• Previous studies suggested that catheter ablation for atrial fibrillation results in new brain lesions in approximately 15%-25% of cases.
• Researchers conducted this multicenter randomized trial (2019-2023) at 19 sites to compare the occurrence of new brain lesions in patients undergoing endocardial left ventricular catheter ablation by a transseptal puncture (n = 74; mean age, 65.3 years; 24% women) or by a retrograde aortic approach (n = 72; mean age, 63.2 years; 17% women).
• A total of 69 patients in the transseptal group and 62 patients in the retrograde aortic approach group underwent a brain MRI on postoperative day 1.
• The primary outcome was the presence of an acute brain lesion detected by an MRI. The other outcomes evaluated were clinically manifest complications and procedural efficacy at postoperative day 1, 1 month, and 6 months, and neurocognitive assessments at 6 months.

TAKEAWAY:

• An acute brain lesion was observed in 45% of patients in the retrograde aortic approach group compared with 28% of those in the transseptal puncture group (P = .036).
• The number of brain infarcts measured as acute brain emboli was higher in patients in the retrograde aortic approach group than in the transseptal puncture group (P = .029).
• No significant differences were observed in the clinically manifest procedural complications or efficacy between the two approaches.
• A higher proportion of patients in the retrograde aortic approach group than in the transseptal group showed a strong likelihood of neurocognitive impairment at 6 months, though substantial loss to follow-up was present.

IN PRACTICE:

“It is important to note that both the overall complication rates and efficacy of the two approaches were similar. Therefore, it does not appear that selecting a transseptal approach to mitigate brain lesions should compromise either safety or other benefits,” wrote the study authors.

“All else being equal, it is better to avoid brain lesions if an alternative is readily available,” they added.

SOURCE:

This study was led by Gregory M. Marcus, MD, MAS, of the University of California, San Francisco. It was published online on February 24, 2025, in Circulation.

LIMITATIONS:

While 90% of the patients underwent a postoperative MRI, those without a postoperative MRI were excluded from the primary analysis. Some operators may have declined to enroll patients with specific locations of ventricular arrhythmia that might be better suited to one approach over the other. Substantial loss to follow-up at 6 months affected the confidence in neurocognitive outcomes.

DISCLOSURES:

This trial was funded by the Comparative Effectiveness Research grant from the Patient-Centered Outcomes Research Institute. Several authors reported receiving speaker honoraria, consulting fees, or grant funding or having other financial ties with multiple pharmaceutical and medical equipment companies, including Abbott, Biotronik, and Medtronic among others.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.