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

Gregory M Marcus¹, Roderick Tung^{1

2}, Edward P Gerstenfeld¹, Trisha F Hue³, Feng Lin³, Jing Cheng⁴, J Peter Weiss², Wendy S Tzou⁵, Henry Hsia¹, Ashkan Ehdaie^{1

6}, Daniel H Cooper⁷, T Jared Bunch⁸, Jeffrey Arkles⁹, Babak Nazer¹⁰, Adam Lee¹, Alexios Hadjis¹¹, Duy T Nguyen¹², Mihail G Chelu¹³, Joshua Moss¹, Jonathan C Hsu¹⁴, Miguel Valderrábano¹⁵, Prashant D Bhave¹⁶, Andrew D Beaser¹⁷, Arvindh Kanagasundram¹⁸, Oussama Wazni¹⁹, Jason Bradfield²⁰, Grace Wall¹, Kathleen Chang¹, Michelle Yang¹, Gabrielle Montenegro¹, Sabrina Jarrott²¹, Joel H Kramer²¹, Anthony S Kim²¹, Yvonne M Morris²², William P Dillon²³

Affiliations

¹ Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
² Division of Cardiology, University of Arizona College of Medicine-Phoenix, Banner - University Medical Center (R.T., J.P.W.).
³ Department of Epidemiology and Biostatistics (T.F.H., F.L.), University of California, San Francisco.
⁴ Oral Epidemiology & Dental Public Health (J.C.), University of California, San Francisco.
⁵ Division of Cardiology, University of Colorado Anschutz Medical Center, Aurora (W.S.T.).
⁶ Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (A.E.).
⁷ Cardiovascular Division, Washington University School of Medicine, St. Louis (D.H.C.).
⁸ Division of Cardiovascular Medicine, University of Utah, Salt Lake City (T.J.B.).
⁹ Cardiovascular Division, University of Pennsylvania, Philadelphia (J.A.).
¹⁰ Division of Cardiology, University of Washington, Seattle (B.N.).
¹¹ Division of Cardiology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Canada (A.H.).
¹² Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.T.N.).
¹³ Department of Medicine-Cardiology, Cardiovascular Research Institute, Baylor College of Medicine and Texas Heart Institute at Baylor St. Luke's Medical Center, Houston (M.G.C.).
¹⁴ Division of Cardiology, University of California, San Diego (J.C.H.).
¹⁵ Department of Cardiology, Houston Methodist Hospital, TX (M.V.).
¹⁶ Department of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (P.D.B.).
¹⁷ Section of Cardiology, University of Chicago, IL (A.D.B.).
¹⁸ Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (A.K.).
¹⁹ Department of Cardiovascular Medicine, Cleveland Clinic, OH (O.W.).
²⁰ Cardiac Arrhythmia Center, University of California, Los Angeles (J.B.).
²¹ Department of Neurology (S.J., J.H.K., A.S.K.), University of California, San Francisco.
²² Patient Author (Y.M.M.), University of California, San Francisco.
²³ Department of Radiology and Biomedical Imaging (W.P.D.), University of California, San Francisco.

PMID: 39989365
PMCID: PMC12375378 (available on 2026-02-24)
DOI: 10.1161/CIRCULATIONAHA.124.071352

Randomized Controlled Trial

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

Gregory M Marcus et al. Circulation. 2025.

. 2025 Apr 15;151(15):1051-1059.

doi: 10.1161/CIRCULATIONAHA.124.071352. Epub 2025 Feb 24.

Authors

Affiliations

¹ Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
² Division of Cardiology, University of Arizona College of Medicine-Phoenix, Banner - University Medical Center (R.T., J.P.W.).
³ Department of Epidemiology and Biostatistics (T.F.H., F.L.), University of California, San Francisco.
⁴ Oral Epidemiology & Dental Public Health (J.C.), University of California, San Francisco.
⁵ Division of Cardiology, University of Colorado Anschutz Medical Center, Aurora (W.S.T.).
⁶ Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (A.E.).
⁷ Cardiovascular Division, Washington University School of Medicine, St. Louis (D.H.C.).
⁸ Division of Cardiovascular Medicine, University of Utah, Salt Lake City (T.J.B.).
⁹ Cardiovascular Division, University of Pennsylvania, Philadelphia (J.A.).
¹⁰ Division of Cardiology, University of Washington, Seattle (B.N.).
¹¹ Division of Cardiology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Canada (A.H.).
¹² Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.T.N.).
¹³ Department of Medicine-Cardiology, Cardiovascular Research Institute, Baylor College of Medicine and Texas Heart Institute at Baylor St. Luke's Medical Center, Houston (M.G.C.).
¹⁴ Division of Cardiology, University of California, San Diego (J.C.H.).
¹⁵ Department of Cardiology, Houston Methodist Hospital, TX (M.V.).
¹⁶ Department of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (P.D.B.).
¹⁷ Section of Cardiology, University of Chicago, IL (A.D.B.).
¹⁸ Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (A.K.).
¹⁹ Department of Cardiovascular Medicine, Cleveland Clinic, OH (O.W.).
²⁰ Cardiac Arrhythmia Center, University of California, Los Angeles (J.B.).
²¹ Department of Neurology (S.J., J.H.K., A.S.K.), University of California, San Francisco.
²² Patient Author (Y.M.M.), University of California, San Francisco.
²³ Department of Radiology and Biomedical Imaging (W.P.D.), University of California, San Francisco.

PMID: 39989365
PMCID: PMC12375378 (available on 2026-02-24)
DOI: 10.1161/CIRCULATIONAHA.124.071352

Abstract

Background: Catheter ablation of ventricular arrhythmias, one of the most rapidly growing procedures in cardiac electrophysiology, is associated with magnetic resonance imaging-detected brain lesions in more than half of cases. Although a retrograde aortic approach is conventional, modern tools enable entry through a transseptal approach that may avoid embolization of debris from the arterial system. We sought to test the hypothesis that a transseptal puncture would mitigate brain injury compared with a retrograde aortic approach.

Methods: The TRAVERSE trial (Transseptal Versus Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli) was a multicenter randomized controlled comparative effectiveness trial. Patients with left ventricular arrhythmias undergoing catheter ablation procedures were randomly assigned to a transseptal puncture approach compared (1:1) with a retrograde aortic approach. The primary outcome was the presence of an acute brain lesion detected by magnetic resonance imaging. Secondary outcomes included clinically manifest complications, procedural efficacy, and 6-month neurocognitive assessments.

Results: Among the 62 patients randomly assigned to a retrograde aortic approach with postoperative brain magnetic resonance imaging, 28 (45%) exhibited an acute brain lesion compared with 19 of the 69 (28%) of those randomized to a transseptal puncture (P=0.036). No differences in clinically manifest complications or procedural efficacy were observed. More patients in the retrograde aortic arm were categorized as having a high likelihood of cognitive impairment at 6 months (33% compared with 19% of those in the transseptal arm), but substantial loss to follow-up was present.

Conclusions: Among patients undergoing left ventricular catheter ablation procedures, a transseptal approach reduced the risk of acute brain lesions by nearly half compared with a retrograde aortic approach without sacrificing safety or efficacy. Given a likely embolic pathogenesis, the brain magnetic resonance imaging findings may reflect a propensity to other organ damage; these findings may extend to other procedures requiring left ventricular entry.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03946072.

Keywords: arrhythmias, cardiac; brain injuries; catheter ablation; electrophysiologic techniques, cardiac; embolism; follow-up studies; magnetic resonance imaging.

PubMed Disclaimer

Conflict of interest statement

Dr Tung has received speaking honoraria from Abbott, Medtronic, Biotronik, Biosense Webster, and Boston Scientific. Dr Tzou has received consulting fees, speaker honoraria, or grant funding or served on advisory board for Abbott, Biosense Webster, Boston Scientific, Biotronik, Kardium, and Medtronic. Dr Cooper reports serving as a consultant/advisory board member for Medtronic, Boston Scientific, and Volta Medical, and receiving honoraria for Fellow Education Lectures from Abbott Medical. Dr Nazer is a consultant to Siemens, Biosense Webster, and Boston Scientific and receives research support from Siemens. Dr Chelu reports grants from PCORI, grants and personal fees from Abbott, grants and personal fees from Impulse Dynamics, and personal fees from Biosense Webster. Dr Hsu reports receiving honoraria from Medtronic, Abbott, Boston Scientific, Biotronik, Janssen Pharmaceuticals, Bristol Myers Squibb, Pfizer, Sanofi, Altathera Pharmaceuticals, Milestone Pharmaceutical, Zoll Medical, iRhythm, Acutus Medical, Viz.ai, and Biosense Webster, and equity interest in Vektor Medical. The other authors report no conflicts.

Comment in

Assessing the Consequences of Retrograde and Transseptal Approaches to Ventricular Arrhythmia Ablation.
Nozica N, Tedrow U. Nozica N, et al. Circulation. 2025 Apr 15;151(15):1060-1062. doi: 10.1161/CIRCULATIONAHA.125.073626. Epub 2025 Apr 14. Circulation. 2025. PMID: 40228071 No abstract available.

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

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

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