Assessing the Feasibility of Radiofrequency Wire-Based Transseptal Puncture in Fluoroscopy-Only Pulsed Field Ablation Workflows.

INTRODUCTION: Safe and effective left atrial (LA) access is a critical step in catheter ablation procedures. While radiofrequency wire (RFW)-based transseptal puncture (TSP) offers advantages over mechanical needle (MN) techniques, adoption in Europe has been limited due to concerns about the need for costly adjunctive imaging. This study evaluated the feasibility of using RFW-based TSP within fluoroscopy-only pulsed field ablation (PFA) procedures. METHODS: A retrospective, single-center chart review of consecutive PFA cases was conducted. TSP was performed using either an MN or RFW, with MN serving as a feasibility benchmark. All procedures used the pentaspline PFA system under standard-of-care protocols, with fluoroscopy as the primary imaging modality. RESULTS: A total of 617 PFA procedures were analyzed (435 RFW, 182 MN). Baseline characteristics were similar. LA access was successful in all RFW cases, with no significant difference in complication rates. Notably, no RFW cases required adjunctive echocardiography, compared to three in the MN group (0% vs. 1.6%, p < 0.01). Procedural times and fluoroscopy exposure were comparable. In patients with prior TSP, RFW enabled significantly faster and more consistent access than MN (8.1 ± 3.9 min vs. 11.1 ± 5.8 min, p < 0.01). CONCLUSION: Purpose-built RFW systems demonstrated comparable safety and efficacy to MN-based devices in fluoroscopy-only PFA workflows, with added efficiency and predictability in complex anatomies. These findings suggest that the benefits of RFW can be realized without reliance on costly imaging modalities.