Transient ST-segment elevation during transseptal catheterization for atrial fibrillation ablation

For the treatment of refractory left atrial tachyarrhythmias, including atrial fibrillation, transseptal catheterization is often performed in order to achieve pulmonary vein isolation and left atrial substrate ablation. Herein, we report an unexpected ST-segment elevation in a 71-year-old man during a Brockenbrough transseptal catheterization procedure for atrial fibrillation ablation. The results of immediate coronary angiography were normal. The few reports of similar observations have not yielded a definite conclusion about the underlying pathophysiology of this electrocardiographic phenomenon. We reviewed the medical literature and hypothesize that manipulation of the intraseptal and left atrial ganglion plexuses by the transseptal needle and sheath causes an imbalance in autonomic innervation, which leads to coronary artery spasm and ST-segment elevation. Nonetheless, coronary artery air embolism during the transseptal approach should also be considered in the differential diagnosis. If the elevation is transient and there is no evidence of acute myocardial infarction, we believe that careful monitoring and evaluation are more appropriate than immediate termination of the ablation procedure.