title: Transseptal access and atrial fibrillation ablation guided by intracardiac echocardiography in patients with atrial septal closure devices.
abstract: BACKGROUND
  Percutaneous positioning of closure devices is a well-established treatment of atrial septal defects (ASDs). However, patients who have undergone the procedure are at increased risk for developing atrial fibrillation (AF), and treatment by catheter ablation is underutilized due to the perceived difficulty of obtaining transseptal access in the presence of the closure device.
  
  
  OBJECTIVE
  The purpose of this study was to report the acute and long-term results of radiofrequency catheter ablation of AF in patients with ASD closure devices.
  
  
  METHODS
  Thirty-nine patients (age 54 ± 6 years, 72% males) with drug-refractory AF (33% paroxysmal, 51% persistent, 16% long-standing persistent) and ASD closure devices (82% Amplatzer, 18% CardioSEAL) underwent radiofrequency catheter ablation. A double transseptal access guided by intracardiac echocardiography was obtained in all patients.
  
  
  RESULTS
  In 35 of 39 patients (90%), the transseptal access was obtained in a portion of the native septum, whereas in 4 of 39 patients (10%), a direct access through the device was required. The latter group had a significantly longer time for achieving the double transseptal access (73.6 ± 1.1 minutes vs. 4.3 ± 0.4 minutes, P < .001), longer fluoroscopy time (122 ± 5 minutes vs. 80 ± 8 minutes, P < .001), and total procedural time (4.1 ± 0.2 hours vs. 3.1 ± 0.3 hours, P < .001). At follow-up of 14 ± 4, months the overall success rate was 77% (85% in paroxysmal AF, 73% in nonparoxysmal AF). Transthoracic contrast-enhanced echocardiography with the Valsalva maneuver, performed between 3 and 6 months after the procedure, failed to detect shunt in all patients.
  
  
  CONCLUSIONS
  Radiofrequency catheter ablation of AF is feasible, safe, and effective in patients with ASD closure devices. Transseptal access can be obtained in portions of the native septum in the majority of cases. Direct transseptal puncture of the device is feasible and safe but requires longer time for each transseptal access.
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.forename: Rodney
authors.initials: R
authors.lastname: Horton
authors.forename: Javier
authors.initials: J
authors.lastname: Sanchez
authors.forename: Shane
authors.initials: S
authors.lastname: Bailey
authors.forename: Jason D
authors.initials: JD
authors.lastname: Zagrodzky
authors.forename: Dhanunjaya
authors.initials: D
authors.lastname: Lakkireddy
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.forename: Prasant
authors.initials: P
authors.lastname: Mohanty
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.forename: Richard
authors.initials: R
authors.lastname: Hongo
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D001281:Atrial Fibrillation / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D004452:Echocardiography / Q000379:methods*; D019160:Endosonography; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006344:Heart Septal Defects, Atrial / Q000150:complications* / Q000601:surgery; D006346:Heart Septum; D006801:Humans; D008297:Male; D008875:Middle Aged; D055989:Septal Occluder Device; D016896:Treatment Outcome