The change in the fluoroscopy-guided transseptal puncture site and difficult punctures in catheter ablation of recurrent atrial fibrillation

Aims: A second procedure for recurrent atrial fibrillation (AF) may be associated with the need for a different positioning of the puncture site and may increase the difficulty and complications. This study investigated whether the transseptal puncture site changed and whether the difficult punctures increased in the patients who received a repeat ablation procedure for recurrent AF. Methods and results: Twenty-nine AF patients (52 ± 12 years old, 20 males) underwent catheter ablation for a recurrence of AF. Compared with the first procedure, the height between the transseptal puncture site and coronary sinus ostium was higher in the second procedure during both the atrial end-systolic phase (38.0 ± 4.7 vs. 34.8 ± 5.3 mm, P = 0.036), and end-diastolic phase (43.0 ± 4.8 vs. 39.1 ± 5.4 mm, P = 0.004) in the 30° right anterior oblique view. No significant change in the vertical atrial diameter was noted between the first and second procedures. A higher incidence of a difficult puncture was noted during the second procedure than in the first procedure (28 vs. 7%, P = 0.014). All those difficult punctures were overcome by using a large-curved transseptal needle. No differences of age, gender, AF duration, interval between first and second procedures, procedure time of the first procedure, and left atrial anteroposterior diameter were noted between easy and difficult transseptal punctures during the second procedure. Conclusion: The incidence of a difficult puncture was higher in the second procedure compared with the first procedure. The transseptal puncture site moved higher in the second procedure. Chronic scarring over the previous transseptal site is a reasonable hypothesis to explain the observations. The difficult punctures experienced during the second procedure might be overcome by changing the needle curve from a small curve to a large curve design.