Thrombosis Occurring During Trans-Septal Puncture with Electrocautery: A Case Report

Thrombosis Occurring During Trans-Septal Puncture with Electrocautery: A Case Report | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 3 July 2025 V1 Latest version Share on Thrombosis Occurring During Trans-Septal Puncture with Electrocautery: A Case Report Authors : Xiaohong Fu , Weiwei Sun , Zengfu Zhang , Jia Gao 0000-0002-5966-6312 , Guo Min , and Rui Wang 0000-0001-7855-0377 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175155875.53645948/v1 183 views 120 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction: Electrocautery-based trans-septal puncture (TSP) offers clinical advantages; however, we report a case of intra-procedural thrombosis, which raises important concerns regarding the safety and risk profile associated with electrocautery. Methods and Results: During radiofrequency ablation for atrial fibrillation, electrocautery TSP was performed on a patient with a thick interatrial septum. Left atrial access was achieved on the fourth attempt using electrocautery, and a new hyperechoic cord was observed in the right atrium, indicating acute thrombosis. The thrombus was resolved through heparin anticoagulation and blood withdrawal, allowing the procedure to resume. Conclusion: This case highlights the risks associated with electrocautery TSP and calls for further exploration of clinical solutions to address such challenges. Thrombosis Occurring During Trans-Septal Puncture with Electrocautery: A Case Report Xiaohong Fu 1# ,Weiwei Sun 1# , Zengfu Zhang 1 , Jia Gao 2 ,Min Guo 2 ,Rui Wang 2* 1. Shanxi Medical University, Taiyuan, Shanxi, China 2. Department of Cardiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China *Corresponding Author: Rui Wang, MD, PhD Department of Cardiology First Hospital of Shanxi Medical University Taiyuan, Shanxi 030001 Tel: +86 0351 4639633 Fax: +86 0351 4639633 E-mail: [email protected] #These authors contributed equally to this work ABSTRACT Introduction: Electrocautery-based trans-septal puncture (TSP) offers clinical advantages; however, we report a case of intra-procedural thrombosis, which raises important concerns regarding the safety and risk profile associated with electrocautery. Methods and Results: During radiofrequency ablation for atrial fibrillation, electrocautery TSP was performed on a patient with a thick interatrial septum. Left atrial access was achieved on the fourth attempt using electrocautery, and a new hyperechoic cord was observed in the right atrium, indicating acute thrombosis. The thrombus was resolved through heparin anticoagulation and blood withdrawal, allowing the procedure to resume. Conclusion: This case highlights the risks associated with electrocautery TSP and calls for further exploration of clinical solutions to address such challenges. Case Report Trans-septal puncture (TSP) is an essential procedure in radiofrequency ablation for atrial fibrillation (AF). Achieving safe and effective atrial septal puncture is critical to the successful outcome of the operation. One study demonstrated that, compared with conventional Brockenbrough (BRK) needle puncture, electrocautery puncture streamlines the procedural workflow, reduces the total duration of TSP, and does not increase the risk of intraoperative complications[1]. However, in an ex vivo porcine model, septal puncture performed using electrocautery was associated with elevated tissue temperatures and an expanded area of tissue charring, which may potentially increase the risk of thrombosis[2]. To date, no clinical case reports addressing this issue have been published in the literature. Herein, we report a case of thrombosis that occurred secondary to the use of electrocautery during TSP. A 51-year-old male patient with a one-year history of paroxysmal atrial fibrillation (AF) was admitted to the hospital due to heart failure. After a thorough discussion regarding the potential benefits and associated risks of radiofrequency ablation for AF, the patient provided informed consent and duly signed the consent form. Preoperatively, the CHA₂DS₂-VASc score was 1, and the HAS-BLED score was 0. Pulmonary vein and left atrial computed tomography (CT) scans were performed to exclude intracardiac thrombosis. The procedure was performed under general anesthesia. The right femoral vein was punctured to insert 7Fr, 10Fr, and 8Fr sheath tubes, and 2000 IU of heparin was administered for anticoagulation. The coronary sinus electrode was introduced through the 7Fr sheath tube, and the intracardiac echocardiography (ICE) was introduced through the 10Fr sheath tube. ICE was used to reconfirm that there was no thrombus in the cardiac cavity (Figure 1). The J-curve of the guidewire was introduced into the superior vena cava via an 8Fr sheath, and this sheath was subsequently replaced with an adjustable sheath (VIZIGO). Subsequently, the TSP was performed, and the catheter and guidewire assembly were positioned at the fossa ovalis under the guidance of ICE. Upon observing the “tenting sign,” the sheath tube was finely adjusted to reach the optimal puncture site. Thereafter, the “J” wire was exposed at the tip of the sheath tube. The electrocautery generator was set to electrocoagulation mode with a power output of 20 W. The tip of the cautery pen was subsequently brought into contact with the proximal portion of the guidewire to deliver energy, thereby effectively facilitating the TSP procedure. Energy delivery was limited to less than 2 seconds per application. As observed on the ICE, the atrial septum appeared thickened in this patient. Following the fourth energy delivery, the procedure was terminated, and the guidewire tip subsequently passed smoothly through the atrial septum. However, at this time, ICE identified a novel cord-like hyperechoic structure on the right atrial aspect of the atrial septum (Figure 2). Acute thrombosis was suspected, and the procedure was promptly terminated. To avoid the risk of pulmonary embolism caused by thrombus detachment, two measures were taken: Initially, based on the patient’s body weight, an immediate administration of 7,000 IU of heparin was delivered through the 7F sheath. Subsequently, blood was aspirated via the VIZIGO long sheath to remove the thrombus by suction. Approximately 2 minutes after the withdrawal of 100 mL of blood, the thrombus was observed to have disappeared under ICE (Figure 3). The patient’s vital signs remained stable, electrocardiogram (ECG) monitoring revealed no abnormalities, and blood oxygen saturation levels fluctuated between 97% and 98%. An ACT value of 216 was obtained 15 minutes after the administration of heparin, after which an additional 2,000 IU of heparin was administered. The withdrawn blood was subsequently filtered through gauze, and no clots were detected. Resolution of the thrombus was considered, and subsequent procedures were continued. A Pentaray electrode was used to construct the electroanatomical voltage map of the left atrium (LA) and pulmonary veins. Bilateral pulmonary vein isolation was performed during AF, and no pulmonary vein potentials were detected after a 30-minute observation period. The patient continued to receive rivaroxaban (20 mg/day) and amiodarone (200 mg/day) after surgery. At the 1-month follow-up assessment, the patient remained in sinus rhythm with no adverse events reported. Electrocautery-assisted TSP offers several distinct advantages over conventional BRK needle TSP. First, the J-shaped configuration of its head reduces the risk of atrial wall and aortic perforation during the procedure. Second, it simplifies the procedural workflow by eliminating the need for guidewire exchange, thereby reducing overall surgical costs. Notably, in complex anatomical cases—such as those involving a thickened or fibrosed septum or prior atrial septal defect closure—where traditional BRK needles may fail to traverse the septum, electrocautery demonstrates significant clinical utility[1, 3]. A study demonstrated that dedicated radiofrequency guidewires required less energy and achieved faster TSP compared to electrocautery[2]. However, their clinical application was limited by high costs, making electrocautery a considerably more cost-effective alternative. Thermal injury, destructive degeneration, and tissue charring caused by electrocautery are associated with an increased risk of thrombus formation[4, 5]; however, no clinical case had been reported before. This report presents the first documented case of thrombosis occurring during TSP using electrocautery. Notably, the patient exhibited a thickened septum, and the puncture was successfully performed only after four applications of electrocautery during the procedure. Repeated thermal injury may exacerbate local tissue charring and contribute to thrombus formation, highlighting an important clinical warning regarding procedural safety. First of all, regarding the anticoagulation strategy, current clinical practice involves administering an appropriate dose of heparin based on the patient’s body weight following successful TSP. Given the unique characteristics of the electrocautery technique, further clinical investigation is warranted to determine whether modifications to the standard heparin administration protocol are necessary—specifically, whether adequate anticoagulation should be achieved prior to the initiation of puncture in order to prevent thrombotic events. Additionally, in this case, the ACT was measured 15 minutes after heparin administration, which may have resulted in a monitoring gap. It is therefore recommended that ACT be monitored both before and after atrial septal puncture to ensure it remains within the optimal therapeutic range. This case clearly demonstrates the critical role of ICE in detecting thrombosis and enhancing procedural safety. During TSP, ICE should be positioned to provide clear visualization of the puncture site, enabling timely detection and intervention in the event of thrombotic complications. In conclusion, this is the first reported case of thrombus formation complicating the procedure of TSP by electrocautery, providing a risk warning for the clinical application of this technique. Acknowledgments This study was supported by the supporting funds for the “Introduction of Talents” doctoral program in the First Hospital of Shanxi Medical University from 2020 to 2021 (Grant No. 09686#); Basic Research Program of Shanxi Province (Grant No. 202203021222378); Project funded by China Postdoctoral Science Foundation (Grant No. 2023M732152). Data Availability Statement The data supporting the findings of this study are available from the corresponding authors (RW) upon reasonable request. 1. Cheng, H., et al., Intracardiac echocardiography guided electrified J-wire trans-septal puncture: A prospective randomized controlled trial. Pacing Clin Electrophysiol, 2024. 47 (3): p. 448-454.2. Knight, B.P., et al., Comparison of transseptal puncture using a dedicated RF wire versus a mechanical needle with and without electrification in an animal model. J Cardiovasc Electrophysiol, 2024. 35 (1): p. 16-24.3. Lee, C.C., et al., Case Report: A novel method of needle-free transseptal puncture. Front Cardiovasc Med, 2024. 11 : p. 1493240.4. Haines, D.E. and A.F. Verow, Observations on electrode-tissue interface temperature and effect on electrical impedance during radiofrequency ablation of ventricular myocardium. Circulation, 1990. 82 (3): p. 1034-8.5. Greenstein, E., et al., Incidence of tissue coring during transseptal catheterization when using electrocautery and a standard transseptal needle. Circ Arrhythm Electrophysiol, 2012. 5 (2): p. 341-4. Information & Authors Information Version history V1 Version 1 03 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keyword clinical: catheter ablation – atrial fibrillation Authors Affiliations Xiaohong Fu Shanxi Medical University View all articles by this author Weiwei Sun Shanxi Medical University View all articles by this author Zengfu Zhang Shanxi Medical University View all articles by this author Jia Gao 0000-0002-5966-6312 First Hospital of Shanxi Medical University View all articles by this author Guo Min First Hospital of Shanxi Medical University View all articles by this author Rui Wang 0000-0001-7855-0377 [email protected] First Hospital of Shanxi Medical University View all articles by this author Metrics & Citations Metrics Article Usage 183 views 120 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Xiaohong Fu, Weiwei Sun, Zengfu Zhang, et al. Thrombosis Occurring During Trans-Septal Puncture with Electrocautery: A Case Report. Authorea . 03 July 2025. 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