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We describe the case of a patient presenting with an atrial flutter mechanically induced by a stent migration from the superior vena cava to the right atrium.

Background: Percutaneous left atrial appendage closure (LAAC) exposes to the risk of device thrombosis in patients with atrial fibrillation who frequently have a contraindication to full anticoagulation. Thereby, dual antiplatelet therapy (DAPT) is usually preferred. No randomized study has evaluated nonvitamin K antagonist oral anticoagulant after LAAC, and we decided to evaluate the efficacy and safety of reduced doses of rivaroxaban after LAAC. Methods: ADRIFT (Assessment of Dual Antiplatelet Therapy Versus Rivaroxaban in Atrial Fibrillation Patients Treated With Left Atrial Appendage Closure) is a multicenter, phase IIb study, which randomized 105 patients after successful LAAC to either rivaroxaban 10 mg (R 10 , n=37), rivaroxaban 15 mg (R 15 , n=35), or DAPT with aspirin 75 mg and clopidogrel 75 mg (n=33). The primary end point was thrombin generation (prothrombin fragments 1+2) measured 2 to 4 hours after drug intake, 10 days after treatment initiation. Thrombin-antithrombin complex, D-dimers, rivaroxaban concentrations were also measured at 10 days and 3 months. Clinical end points were evaluated at 3-month follow-up. Results: The primary end point was reduced with R 10 (179 pmol/L [interquartile range (IQR), 129–273], P 15 (163 pmol/L [IQR, 112–231], P 10 and R 15 while rivaroxaban concentrations increased significantly from 184 ng/mL (IQR, 127–290) with R 10 to 274 ng/mL (IQR, 192–377) with R 15 , P Conclusions: Thrombin generation measured after LAAC was lower in patients treated by reduced rivaroxaban doses than DAPT, supporting an alternative to the antithrombotic regimens currently used after LAAC and deserves further evaluation in larger studies. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03273322.

Background The aim of this study was to identify the factors associated with bleeding complications in patients taking apixaban and undergoing a catheter ablation in everyday clinical practice. Methods AMPER ABLATION is a multicenter, observational, prospective study of patients with non-valvular atrial fibrillation (AF) undergoing a catheter ablation. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥ 3 weeks before the procedure and were followed for 30 days afterwards. Results A total of 595 patients (65[interquartile range 59, 72] years, 67% male, mean CHA2DS2-VASc score 1.85 ± 1.37) were enrolled at 25 academic/nonacademic centers in France; 524 patients (88%) were receiving apixaban 10 mg/day and 71(12%) 5 mg/day. 323 patients (54%) underwent an AF ablation, and 272 (46%) an atrial flutter (AFL) ablation. Mean creatinine clearance (Cockcroft-Gault) was 82 ± 34 mL/min. Overall, 264 patients were switched to unfractionated heparin or enoxaparin (238 for AF ablations and 26 for AFL ablations). The median duration of switch was 29 hours Complications were reported at 30 days, and included 12 bleeding events (1 tamponade needing drainage,1 pericardial effusion without drainage, 7 International Society on Thrombosis and Haemostasis [ISTH] non major bleedings for AF ablations and 1 pericardial effusion without drainage, and 2 ISTH non-major bleedings for AFL ablations) and 1 embolic event (non disabling stroke for an AF ablation). Comparing patients with and without a bleeding event revealed a higher rate of heparin or low-molecular-weight heparin (LMWH) switching in patients with a bleeding event (60% vs. 35%; P = 0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1], 7.1; P = 0.01). Conclusion Heparin or LMWH switch in the periprocedural AF and AFL-ablation period is associated with an increased rate of bleeding complications at 30 days.

Background The aim of this study was to identify the factors associated with bleeding complications in patients taking apixaban and undergoing a catheter ablation in everyday clinical practice. Methods AMPER ABLATION is a multicenter, observational, prospective study of patients with non valvular atrial fibrillation (AF) undergoing a catheter ablation. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥3 weeks before the procedure, and were followed for 30 days afterwards. Results A total of 595 patients (65 [interquartile range 59, 72] years, 67% male, mean CHA2DS2-VASc score 1.85±1.37) were enrolled at 25 academic/nonacademic centers in France; 524 patients (88%) were receiving apixaban 10 mg/day and 71 (12%) 5 mg/day. 323 patients (54%) underwent an AF ablation, and 272 (46%) an atrial flutter (AFL) ablation. The most prevalent concomitant disorders were hypertension (51% of patients), diabetes (15%) and vascular disease (10%). Mean creatinine concentration was 1.06±0.28 mg/dL, median weight was 83±18 kg and mean creatinine clearance (Cockcroft-Gault) was 82±34 mL/min. The management of apixaban in the periprocedural period was left to the investigator's preference. Overall, 264 patients were switched to unfractionated heparin or enoxaparin (238 for AF ablations and 26 for AFL ablations). The median duration of switch was 29 hours. Complications were reported at 30 days, and included 12 bleeding events (1 tamponade needing drainage, 1 pericardial effusion without drainage, 7 International Society on Thrombosis and Haemostasis [ISTH] non major bleedings for AF ablations and 1 pericardial effusion without drainage, and 2 ISTH non major bleedings for AFL ablations) and 1 embolic event (non disabling stroke for an AF ablation). Comparing patients with and without a bleeding event revealed a higher rate of heparin or low-molecular-weight heparin (LMWH) switching in patients with a bleeding event (60% vs 35%; p=0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1, 7.1]; p=0.01). Conclusion Heparin or LMWH switch in the periprocedural AF and AFL-ablation period is associated with an increased rate of bleeding complications at 30 days. Acknowledgement/Funding Financial support from BMS

Background Implantation of permanent pacemakers (PPMs) or implantable cardiac defibrillators (ICDs) may be complicated by the development of pocket hematomas. Purpose To evaluate bleeding complications in patients taking apixaban and undergoing a pacemaker or ICD implantation in everyday clinical practice. Methods It is a multicenter, observational, prospective study of patients with non-valvular atrial fibrillation (AF) undergoing a pacemaker or implantable cardioverter defibrillator [ICD]. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥ 3 weeks before the procedure, and were followed for 30 days afterwards. Results A total of 115 patients (80 [72,85] years, 63% male, mean CHA2DS2-VASc score 3, mean HAS BLED score 3) were enrolled at 25 academic/non-academic centres in France; 68 patients (59%) were receiving apixaban 10 mg/day and 47 (41%) 5 mg/day. The most prevalent concomitant disorders were hypertension (55% of patients), diabetes (15%), vascular disease (10%) and a history of stroke (6%). Mean creatinine value was 93 ± 25 μmol/L, median weight was 83 ± 18 kg and mean creatinine clearance (Cockroft − Gault) was 82 ± 34 mL/min. The implantation was a planned procedure in 102 (89%) of cases. The mean duration of procedure was 51 min. The management of apixaban in the periprocedural period was let to the investigators preference. Median withdrawal time was 25 h. Bleeding events were detected in 4 (3.5%) cases. One of them was a pocket hematoma with infection treated by the extraction of the device. Three patients presented minor bleedings according to ISTH classification without prolongation of hospitalization. Conclusion These observational data of patients on apixaban undergoing pacemaker/ICD implantation in everyday practice show a management of apixaban according to guidelines with a low rate of bleeding events.

Purpose To evaluate the factors associated with bleeding complications in patients taking apixaban and undergoing a rhythmology procedure in everyday clinical practice. Methods AMPER AF is a multicenter, observational, prospective study of patients with non-valvular atrial fibrillation (AF) undergoing a rhythmology procedure (ablation, pacemaker or implantable cardioverter defibrillator [ICD], or cardioversion). Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥ 3 weeks before the procedure, and were followed for 30 days afterwards. Results A total of 1013 patients (69 [60,76] years,71% male, mean CHA2DS2-VASc score 1.9 ± 1.4) were enrolled at 25 academic/non-academic centres in France; 842 patients (84.8%) were receiving apixaban 10 mg/day and 171 (15.2%) 5 mg/day.56 patients (5.5%) had a history of stroke. Median weight was 82.7 ± 17.9 kg and mean creatinine clearance (Cockroft − Gault) was 81.8 ± 34 mL/min. 126 (12.43%) patients underwent a pacemaker or ICD implantation, 323 (31.9%) AF ablation, 272 (26.8%) flutter ablation and 278 (27.4%) electric cardioversion. Complication rates at 30 days are shown in Table 1 . Comparing patients with a bleeding event to patients without a bleeding complication revealed a higher rate of heparin or LMWH switching (3.7% vs. 2.2%; P = 0.02) in patients having a bleeding complication in patients undergoing an AF or atrial flutter ablation. This difference remains significant in patients undergoing AF and atrial flutter ablation (60% vs. 35%; P = 0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1], 7.1; P = 0.01). Conclusion These observational data of patients on apixaban undergoing rhythmology procedures in everyday practice show thatheparin or LMWH switch in the periprocedural AF or flutter ablation period is associated with an increased rate of bleeding complications at 30 days.

Purpose To evaluate thromboembolic complications in patients taking apixaban and undergoing a cardioversion procedure in everyday clinical practice. Methods It is a multicenter, observational, prospective study of patients with non-valvular atrial fibrillation (AF) undergoing cardioversion (electric or medical). Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥ 3 weeks before the procedure, and were followed for 30 days afterwards. Results A total of 278 patients (68 [61,76] years, 71% male, mean CHA2DS2-VASc score 2, mean HAS BLED score 2) were enrolled at 25 academic/non-academic centres in France; 248 patients (89%) were receiving apixaban 10 mg/day and 29 (11%) 5 mg/day. The most prevalent concomitant disorders were hypertension (50% of patients) and diabetes (15%). The mean creatinine clearance (Cockroft − Gault) was 81 ± 34 mL/min. The majority of patients had an electric cardioversion (264, 95%)and 14 patients (5%) received amiodarone only. Cardioversion was a planned procedure in the most of cases (97%). Sixty-seven patients (24%) had a transeophageal echocardiogram before procedure. There were no reported thromboembolic events. Conclusion These observational data of patients on apixaban undergoing cardiversion in everyday practice show no thromboembolic events on a follow-up of 30 days.

In atrial fibrillation (AF), the absence of a clear benefit of a rhythm-control strategy over a rate-control strategy seen in recent trials may be due to the fact that many of the usual antiarrhythmic strategy have significant weaknesses. Besides research efforts to improve the efficacy and safety of conventional antiarrhythmic agents, therapies directed 'upstream'of the electrical aspects of AF, towards the underlying anatomical substrate and atrial remodelling, have been proposed as new pharmacological therapeutic approaches. Potential upstream therapies for AF comprise a variety of agents such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), statins, N-3 polyunsaturated fatty acids and steroids. On the basis of experimental data, clinical studies have provided information on the potential of upstream therapy for the prevention of AF across a broad spectrum of cardiovascular patient groups. In patients with heart failure or hypertension, data are sufficient to support the use of ACEI or ARB as treatment that may decrease the risk of AF beyond their other beneficial effects. Similarly, it is highly possible that the use of statin in patients with a recognized indication may be associated with a benefit against AF. However, in most clinical settings, the evidence appears to be insufficient to drive changes in therapy management per se, and large-scale, randomized controlled trials with adequately defined endpoints are still needed. The results from these trials may help to understand the complex mechanisms that lead to AF, and may clarify the benefit-to-risk ratio of these new therapeutic approaches.

Objectives To improve the evaluation of the possible antiarrhythmic effect of statins, we performed a meta-analysis of randomized trials with statins on the end point of incidence or recurrence of atrial fibrillation (AF). Background The use of statins had been suggested to protect against AF in some clinical observational and experimental studies but has remained inadequately explored. Methods A systematic review of controlled trials with statins was performed. Eligible studies had to have been randomized controlled parallel-design human trials with use of statins that collected data on incidence or recurrence of AF. Results Six studies with 3,557 patients in sinus rhythm were included in the analysis. Three studies investigated the use of statins in patients with a history of paroxysmal AF (n = 1) or persistent AF undergoing electrical cardioversion (n = 2), and 3 investigated the use of statins in primary prevention of AF in patients undergoing cardiac surgery or after acute coronary syndrome. Incidence or recurrence of AF occurred in 386 patients. Overall, the use of statins was significantly associated with a decreased risk of AF compared with control (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.18 to 0.85, p = 0.02). Benefit of statin therapy seemed more marked in secondary prevention of AF (OR 0.33, 95% CI 0.10 to 1.03, p = 0.06) than for new-onset or postoperative AF (OR 0.60, 95% CI 0.27 to 1.37, p = 0.23). Conclusions Use of statins was significantly associated with a decreased risk of incidence or recurrence of AF in patients in sinus rhythm with a history of previous AF or undergoing cardiac surgery or after acute coronary syndrome.

Background Restoration of the mechanical and endocrine functions of the left atrium remains controversial after electrical cardioversion treatment for persistent atrial fibrillation. The objective of the prospective study was to describe the recovery of the endocrine and mechanical functions of the left atrium. Methods Evaluation of left atrium recovery after electrical cardioversion by the new speckle-tracking echocardiography technique and proANP measurement. Results Twenty patients suffering from persistent atrial fibrillation with no alteration of left ventricular ejection fraction were prospectively evaluated at baseline and then one month later by echocardiography, measuring left atrial volume and left atrial deformation (MPALS), as well as the proANP and BNP concentrations. One month after cardioversion 10 patients remained in sinus rhythm and 10 showed recurrent atrial fibrillation. No significant differences between the two groups in terms of clinical, echocardiographic and endocrine parameters were observed at baseline evaluation. We observed a significant reduction of left atrial volume only in the sinus group, whereas restoration of the left atrial deformation was only partial (18%) in that group. By contrast, we registered no significant changes in ANP concentration at one month in either the sinus or the atrial fibrillation groups. Conclusion These results suggest that restoration of left atrium mechanical function is only partial one month after treatment of persistent atrial fibrillation by electrical cardioversion, whereas a significant reduction of left atrial volume was noted, explaining the remaining high level of ANP in the sinus group.

Neurologic disorders represent the most severe complications of acute intermittent porphyria (AIP). Cognitive disturbances, bulbar and spinal weakness appear as the most critical neurological complications as they may lead to death or definitive motor weakness. A 38-year-old woman was admitted for an acute and painful tetra paresis occurring after a laparoscopy for an ovarian cyst. She also complained of abdominal pain treated with noramidopyrine, tachycardia, hypertension and hyponatremia. The electrophysiological examination showed a motor axonal neuropathy. The increase of Urine ALA at 268 micromol/l (N

In atrial fibrillation (AF), the absence of a clear benefit of a rhythm-control strategy over a rate-control strategy seen in recent trials may be due to the fact that many of the usual antiarrhythmic strategy have significant weaknesses. Besides research efforts to improve the efficacy and safety of conventional antiarrhythmic agents, therapies directed 'upstream'of the electrical aspects of AF, towards the underlying anatomical substrate and atrial remodelling, have been proposed as new pharmacological therapeutic approaches. Potential upstream therapies for AF comprise a variety of agents such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), statins, N-3 polyunsaturated fatty acids and steroids. On the basis of experimental data, clinical studies have provided information on the potential of upstream therapy for the prevention of AF across a broad spectrum of cardiovascular patient groups. In patients with heart failure or hypertension, data are sufficient to support the use of ACEI or ARB as treatment that may decrease the risk of AF beyond their other beneficial effects. Similarly, it is highly possible that the use of statin in patients with a recognized indication may be associated with a benefit against AF. However, in most clinical settings, the evidence appears to be insufficient to drive changes in therapy management per se, and large-scale, randomized controlled trials with adequately defined endpoints are still needed. The results from these trials may help to understand the complex mechanisms that lead to AF, and may clarify the benefit-to-risk ratio of these new therapeutic approaches.

ObjectivesThe purpose of this study was to evaluate the ventricular arrhythmias (VA) frequency in patients with unexplained syncope, ischemic or non-ischemic cardiac disease and left ventricular dysfunction (LVEF) and negative electrophysiological study (EP), implanted with cardioverter-defibrillator (ICD).BackgroundAccording to the current guidelines, EP is performed to evaluate syncope in patients with significant altered LVEF, mainly to guide treatment by ICD. Limited data concerning incidence of ventricular events in patients with no inducible arrhythmias is available.MethodsWe evaluated 58 consecutive patients with unexplained syncope who underwent EP. All patients had a depressed LVEF (< 45%). Sustained VA was only inducible in 28 patients (VF n = 8, SMVT n = 20). All patients were treated with ICD. We compared primary endpoint of severe VA in patients with negative and positive EP.ResultsBaseline characteristic were similar in the both groups. In the population (97% men), mean age was 67 ± 10 years, 67% had ischemic cardiopathy; mean LVEF was 30 ± 7% in non inducible group, 32 ± 9% in inducible group (p=0.16). During the follow-up (25 ± 22 months), 22 severe VA occurred; Kaplan-Meier analysis of time to first appropriate ICD therapy for non-inducible and inducible VA showed overlapping curves (p = 0.9), with 11 (37%) and 11 (39%) events in each group. Sub-group analysis according to LVEF and etiology of cardiopathy did not show significant difference.ConclusionsIn patients with unexplained syncope, ischemic or non-ischemic cardiopathy and left ventricular dysfunction, severe VA occurs in the follow-up at same rate whatever the result of EP. This study suggests that these patients should be treated with ICD without doing electrophysiological testing.

The atrial fibrillation is linked to an overmortality (x2), except in patients with lone atrial fibrillation. The severity of atrial fibrillation is due to the risk of thromboembolism event, especially stroke. This risk is very high in presence of rhumatismal mitral valve pathology or prosthetic valve. The annual risk of thromboembolism has been evaluated and the CHADS2 score defined from 0 to 6 In function of the CHADS2 score the risk of thromboembolism event is 1.9 to 18.2%/year. Other factors of thromboembolism accident are actually evaluated such as renal insufficiency, proteinuria. The main objective of atrial fibrillation treatment is the prevention of thromboembolism event. The antivitamin K agents proved their efficiency in term of mortality and morbidity justifying to identify the patients at risk of thromboembolism event.

The atrial fibrillation is linked to an overmortality (x2), except in patients with lone atrial fibrillation. The severity of atrial fibrillation is due to the risk of thromboembolism event, especially stroke. This risk is very high in presence of rhumatismal mitral valve pathology or prosthetic valve. The annual risk of thromboembolism has been evaluated and the CHADS2 score defined from 0 to 6 In function of the CHADS2 score the risk of thromboembolism event is 1.9 to 18.2%/year. Other factors of thromboembolism accident are actually evaluated such as renal insufficiency, proteinuria. The main objective of atrial fibrillation treatment is the prevention of thromboembolism event. The antivitamin K agents proved their efficiency in term of mortality and morbidity justifying to identify the patients at risk of thromboembolism event.

The physiology of cardiac muscle in thoracic veins is of interest as a source of ectopic activity which can lead to paroxystic atrial fibrillation (Haissaguerre et al. 1998 N Engl J Med 339: 659-666 ; Chen et al. 1999 Circulation 100:1879-1886). We have shown that noradrenalin can induce automatic ectopic activity in the pulmonary vein of the rat (Maupoil et al. 2007 Br J Pharmacol 150:899-905). Here we describe the effects of adrenergic agonists upon the resting membrane potential recorded with intracellular microelectrodes from cardiac muscle in the left atrium (LA), pulmonary veins (PV) and superior vena cava (SVC) of the rat. Isolated tissues were continuously perfused with Krebs-Heinseleit solution aerated with 95 % O2, 5 % CO2 and maintained at 36-37 °C. The quiescent resting membrane potentials were: LA −84±1 mV (n=14), SVC −74±1 mV (n=14), PV −69±1 mV (n=17). In each tissue noradrenalin (10-5M) induced a biphasic response with an initial hyperpolarisation (LA −3±1 mV, SVC −9±1 mV, PV −8±1 mV) followed by a depolarisation (LA +1±2 mV, SVC +15±2 mV, PV +34±1 mV). Only in PV did noradrenalin induce automatic electrical activity when the membrane potential reached ∼−50 mV. The α-adrenergic agonist cirazoline (10-6M) induced a monophasic depolarisation of the resting membrane potential in each tissue: to −80±2 mV in LA, to −49±1 mV in SVC and to −34±1 mV in PV. In no case did cirazoline induce automatic electrical activity. The β-adrenergic agonist isoprenaline (10-7M) induced a monophasic hyperpolarisation of the resting membrane potential in each tissue: to −87±1 mV in LA, to −79±2 mV in SVC and to −80±2 mV in PV. Conclusions 1. There are significant differences between the resting membrane potentials of the left atrium and both thoracic veins. 2. The responses of the resting membrane potential to adrenergic stimulation are qualitatively similar but quantitatively different with LA 3. Depolarisation is not sufficient to induce automatic electrical activity.

Objectives We aimed to determine whether mechanical dyssynchrony assessed by Equilibrium RadioNuclide Angiography (ERNA) may predict response to CRT. Methods 70 patients were consecutively enrolled. ERNA, echocardiography and electrocardiogram were performed before biventricular pacemaker implantation. Positive response to CRT was defined as an improvement in NYHA class in patients alive and not readmitted for HF within 6 months. Results Mean age was 65±9 years, 74 % of patients were men, 84 % were in NYHA class III or IV. Main HF aetiologies were ischemic (36 %) or dilated (50 %). ERNA left ventricular ejection fraction was 21±9 %, QRS duration was 161±34 ms. 96 % of patients received an ACE inhibitor or an angiotensin II receptor antagonist, 66 % a beta-blocker and 36 % an aldosterone antagonist. Non-response rate was 31.5 %. Interventricular delay assessed by ERNA was greater in non-responders versus responders in univariate analysis: respectively 92±39 ms and 57±46 ms, p = 0.005. QRS duration, interventricular and intraventricular delay assessed by echocardiography, intraventricular delay assessed by ERNA, were not significantly different between the two groups. In conclusion, by contrast to other methods, interventricular delay assessed by ERNA before implantation may help to identify responders and non-responders to CRT.

Neurologic disorders represent the most severe complications of acute intermittent porphyria (AIP). Cognitive disturbances, bulbar and spinal weakness appear as the most critical neurological complications as they may lead to death or definitive motor weakness. A 38-year-old woman was admitted for an acute and painful tetra paresis occurring after a laparoscopy for an ovarian cyst. She also complained of abdominal pain treated with noramidopyrine, tachycardia, hypertension and hyponatremia. The electrophysiological examination showed a motor axonal neuropathy. The increase of Urine ALA at 268 micromol/l (N38) and of at 235 micromol/l (N5) strongly suggested AIP that was further confirmed by PBG desaminase deficiency in red cells. Thanks to the prescription of heme arginate (HA) at the dose of 3 mg/kg/day for 4 days, pain resolved immediately and motor function began to improve since the second day of treatment concurrently to a dramatic decrease of both urine ALA and PBG concentrations. Motor recovery was complete after 12 months of evolution. This case illustrates the potential severity of acute porphyric neuropathy when precipitating factors (noramidopyrine, surgery) are present in previously undiagnosed AIP. Moreover, motor neuronal function improved while HA therapy was initiated 22 days after the clinical onset of weakness. This tempts us to propose HA therapy at any stage of acute porphyric neuropathy.

We report the case of an 18-year-old man with Danon disease, a genetic disorder inclunding a severe hypertrophic cardiomyopathy with very broad QRS, who had an implantable cardioverter defibrillator for primary prevention. Nine months after implantation, he received two inappropriate shocks due to R-wave double counting during sinus tachycardia. We discuss how to avoid such inappropriate therapy.

safety and efficacy of LA access with the NRG needle but without routine echo guidance. METHODS: This is a single-center, retrospective observational study. From September 2010 to March 2011, 104 patients underwent 105 LA catheter ablation procedures using the NRG needle for TSP access. A routine strategy of 2 separate TSP accesses was performed. Transseptal access was initially performed using the NRG needle within an 8.5 French SL-1 long sheath with fluoroscopy alone and without the use of routine echo (trans-esophageal or intracardiac) guidance. Left atrial access was confirmed with LA pressure monitoring and/or contrast injection. Intravenous heparin was infused after successful TSP access. Rates of successful TSP access with the NRG needle, need for RF energy delivery for TSP access, need for echo imaging guidance, and serious intra-procedural complications (death, tamponade, pericardial access) were recorded. RESULTS: Two hundred and nine TSP procedures were attempted in 105 procedures (104 patients). A single TSP access was performed in 1 patient who had a mechanical mitral valve. 41 patients (39%) had previous LA catheter ablation procedures. Echo guidance was performed in 2 cases (2.0%) to facilitate TSP access. The rates of successful LA access using the NRG needle without echo guidance was 96% (200 of 209 attempts). Radiofrequency energy was required to facilitate LA access in 62 attempts (31%). In the remaining successful TSP punctures, manual pressure with the NRG needle alone was sufficient to cross the atrial septum. One procedure (1%) was complicated by cardiac tamponade which occurred 78 minutes after TSP access, and was managed with percutaneous drainage. No death occurred in this study. CONCLUSIONS: In this study of patients undergoing left atrial catheter ablation, a high rate of transseptal access was achieved with the NRG needle and without routine echo guidance. The rates of serious intra-procedural complications and the need for “back-up” echo guidance were low. Performance of transseptal access with the NRG needle but without routine echo guidance appears to be a feasible strategy.