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Septum Opening Plugged? You Can Still Have a Catheter Ablation to Fix your A-Fib

Septum Opening Plugged? You Can Still Have a Catheter Ablation to Fix your A-Fib

Septum Opening Plugged?

by Steve S. Ryan, PhD

According to conventional A-Fib practice, if someone had a closure device installed to plug a hole in the septum, then they couldn’t have a catheter ablation. It would be difficult to get the catheter through the septum wall since the plug occupied part of the septum wall. The plugging device would block the trans-septal puncture needed to get to the left atrium.

But a recent study at the Texas Cardiac Arrhythmia Center in Austin, Texas by doctors Pasquale Santangeli and Luigi Di Biase demonstrated that it is feasible and safe to do a catheter ablation on patients with a septal occlusion device (Amplatzer, CardioSEAL).

In most cases (35) the doctors were able to puncture the septum in an area not covered by the closure device. In four cases the doctors were able to puncture through the closure device itself using normal procedures and instruments, though this did take longer and involved more fluoroscopy time.

A-Fib Patients with a Septal Closure Device Often Need Aggressive Treatment

The patients in this study all had A-Fib before the septum plug was installed. They all progressed to highly symptomatic A-Fib and were not helped by drugs. Over a period of at least four years 11 patients progressed to persistent A-Fib. Five with persistent A-Fib progressed  to permanent long-standing A-Fib. These patients obviously needed an aggressive treatment.

(A septum opening between the left and right atria can lead to clot formation and stroke. Closing off this septal defect helps prevent stroke and is considered to decrease the risk of developing A-Fib. But if one already has A-Fib, closing off the septal defect opening doesn’t halt the progression of A-Fib.)

Catheter Ablation Successful through a Septal Closure Device

After a mean follow-up of around 14 months, 77% were free of A-Fib and atrial tachycardia (this is a high success rate considering that 67% of the patients had persistent or long-standing persistent A-Fib which is more difficult to ablate). There were no significant differences in outcome between those who had transseptal puncture or puncture through the closure device. No patients at three and six months intervals had “interatrial shunt;” i.e., the puncture holes all closed up by themselves.

The doctors concluded that catheter ablation in patients with the septal closure device was “feasible, safe and effective.” They added, “Transseptal puncture can easily be performed in a portion of the native septum not covered by the device in the majority of patients. Direct access through the device is also feasible and safe but requires significantly longer time.”

Editor’s Comments:
Closing a septal opening decreases the risk of stroke and possibly also of developing A-Fib. But if someone already has A-Fib, closing this septal defect doesn’t halt the progression of A-Fib. These patients often need aggressive treatment such as surgery ( Cox-Maze or Mini Maze).
If you have a closure or plug device installed in your septum, you now have another option besides surgery to fix your A-Fib. But be aware that most catheter ablation centers will still be reluctant to do a PVI in your case and will likely refer you to a surgeon. Even though PVIs in patients with  septal closure devices can be “easily performed,” It may take a while for the techniques and experiences of the Texas Cardiac Arrhythmia Center to become common practice in other catheter ablation centers. Right now you may need to go to Texas or to another center with experience doing PVIs on patients with septal closure devices.
If you have a septal closure device installed, be sure and ask the doctor(s) you are working with if they have experience in ablating patients with septal closure devices.
References for this Article
Santangeli, P, Di Biase, L, et al. “Transseptal access and atrial fibrillation ablation guided by intracardiac echocardiography in patients with atrial septal closure devices.” Heart Rhythm. 2011 Nov;8(11):1669-75. Epub 2011 Jun 22.

January 31, 2012

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