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Background Left atrial appendage (LAA) closure is an alternative to chronic oral anticoagulation for stroke prevention in patients with atrial fibrillation (AF) at high bleeding risk. Patients with a previous percutaneous closure of a patent foramen ovale (PFO) present an increased risk for developing AF during their life, and the presence of an atrial septal device renders future percutaneous left atrial access more challenging. Very few cases of LAA occlusion in patients with a preexisting PFO closure device have been previously reported. Case summary A 74-years old woman was admitted to our hospital for symptomatic severe anaemia during direct oral anticoagulant treatment. Her past medical history reported an ischaemic stroke at the age of 55, at that time a PFO was diagnosed and a STARFlex™ PFO occluder (NMT Medical, Boston, MA, USA) was implanted. During the current hospitalization, the patient underwent a colonoscopy that showed colonic angiodysplasias unsuitable for endoscopic treatment and LAA closure was indicated for stroke prevention. After a multimodality pre-procedural planning that included a transoesophageal echocardiogram, a cardiac computed tomography scan and a three-dimensional cardiac model printing, the procedure was planned and the LAA successfully occluded. Discussion LAA closure can be performed safely and effectively in patients carrying a previously implanted PFO occlusion device. In complex settings, a pre-procedural multimodality imaging is critical for improving the procedural safety and success rate. We describe the first case of percutaneous LAA closure in a patient with a prior PFO occlusion with the implantation of a STARflex™ septal occlusion device.

Left atrial procedures requiring large sheaths and manipulation within the left atrium are increasingly common in electrophysiology. Iatrogenic atrial septal defects (iASD) created for these procedures are generally benign and do not require closure. In this report we describe 2 hemodynamically significant atrial septal defects (ASD) that occurred after cryoballoon ablation for pulmonary vein isolation.

In cardiac resynchronisation therapy, failure to implant a left ventricular lead in a coronary sinus branch has been reported in up to 10% of cases. Although surgical insertion of epicardial leads is considered the standard alternative, this is not without morbidity and technical limitations. Endocardial left ventricular pacing can be an alternative as it has been associated with a favourable acute haemodynamic response compared with epicardial pacing in both animal and human studies. In this paper, we discuss left ventricular endocardial pacing and compare it with epicardial surgical implantation. Ease of application and procedural complications and morbidity compare favourably with epicardial surgical techniques. However, with limited experience, the most important concern is the still unknown long-term risk of thromboembolic complications. Therefore, for now endovascular implants should remain reserved for severely symptomatic heart failure patients and patients at high surgical risk of failed coronary sinus implantation.

Objectives This study aims to compare the performance of electrophysiology fellows in transseptal catheterization (TSP-C) after conventional (Conv-T) or simulator training (Sim-T). Background Current training for TSP-C, an increasingly used procedure, relies on performance on patients with supervision by an experienced operator. Virtual reality, a new training option, could improve post-training performance. Methods Fellows inexperienced in TSP-C were enrolled and randomly assigned to Conv-T or Sim-T. The post-training performance of each fellow was evaluated and scored in 3 consecutive patient-based procedures by an experienced operator blinded to the fellow's training assignment. Results Fourteen fellows were randomized to Conv-T (n = 7) or to Sim-T (n = 7) and, after training, performed 42 TSP-Cs independently. Training time was significantly longer for Conv-T than for Sim-T (median 30 days vs. 4 days; p = 0.0175). The Conv-T fellows had significantly lower post-training performance scores (median 68 vs. 95; p = 0.0001) and a higher number of recurrent errors (median 3 vs. 0; p = 0.0006) when compared with Sim-T fellows. Conclusions The TSP-C training with virtual reality results in shorter training times and superior post-training performance.

Aims Transseptal catheterization (TSP-C) is a demanding procedure and at the same time one of the key points of atrial fibrillation ablation, an increasingly diffused procedure. This study prospectively evaluates the usefulness of a novel sharp-tip, J-shaped 0.014'' transseptal guidewire (TSP-GW) to facilitate TSP-C in case of resistant atrial septum (AS). Methods and results Consecutive patients undergoing TSP-C for arrhythmia ablation in a single centre were considered for the study. TSP-C was performed according to a standardized technique. The criterion to use the TSP-GW was a resistant AS, defined as inability to perforate the fossa ovalis by applying moderate pressure to a standard Brockenbrough needle. The TSP-GW was inserted in the needle lumen and advanced to puncture the AS and enter the left atrium; subsequently, the transseptal assembly was advanced over the TSP-GW. Double transseptal puncture was routinely performed for ablation of atrial fibrillation. Eighty-one patients (54 males, 27 females; mean age 54 +/- 17 years, range 12-81) undergoing TSP-C were enrolled; 132 TSP-C procedures were planned and accomplished. Nineteen patients (23%) in 27 procedures showed a resistant AS. In all these procedures, the TSP-GW was safely and successfully used to accomplish the TSP-C. In patients with a resistant AS, only a significantly lower prevalence of structural heart disease was observed when compared with controls. No complication related to TSP-C was observed. Conclusion The TSP-GW facilitates TSP-C in 23% of the patients, in whom a resistant AS is encountered. In this population, there was no clinical predictor of such anatomy.

We describe the case of a patient who developed a thrombus on the transseptal sheath in the right atrium before transseptal puncture for circumferential pulmonary vein isolation for paroxysmal atrial fibrillation treatment. The use of intracardiac echocardiography allowed to its identification and probably prevented the patient from suffering a serious thromboembolic complication.