Left Ventricular Entry to Reduce Brain Lesions During Catheter Ablation: A Randomized Trial.

Summary

In a multicenter RCT, transseptal LV entry during VT ablation reduced MRI-detected acute brain lesions (28% vs 45%) compared to retrograde aortic access, without compromising safety or procedural success. Neurocognitive outcomes and complications were similar, supporting a shift toward transseptal access to mitigate embolic injury.

Key Findings

• Primary endpoint: MRI-detected acute brain lesions occurred in 28/69 (28%) transseptal vs 28/62 (45%) retrograde aortic patients.
• No compromise in procedural efficacy or safety events with transseptal access; 6-month neurocognitive assessments did not reveal harm.
• Findings support embolic pathogenesis from arterial manipulation and generalize to procedures requiring LV entry.

Clinical Implications

For left ventricular VT ablation, consider transseptal access to reduce risk of silent cerebral embolic lesions, provided operator expertise and tools are available. Periprocedural strategies may shift to favor transseptal in suitable anatomies.

Limitations

• Moderate sample size with surrogate primary endpoint (MRI lesions) rather than hard clinical events
• Potential generalizability limited by operator expertise and center experience with transseptal LV access

Future Directions

Larger pragmatic trials powered for clinical neurological events; evaluation of embolic protection strategies; cost-effectiveness and training pathways for broader adoption of transseptal LV access.