A Novel Low Right Atrial-approach Transseptal Puncture Technique for Large-bore Deflectable Sheaths: Enhancing Control, Precision, and Safety.

The conventional transseptal puncture (TSP) technique, developed in the 1960s, remains a procedural standard but offers limited control when applied to contemporary large-bore deflectable sheaths. The objective of this study is to describe a novel low right atrial (RA)-approach TSP technique designed to optimize control, precision, and safety when using large-bore deflectable systems. This technique eliminates the need for superior vena cava (SVC) positioning and instead advances the deflectable sheath-dilator assembly from the low RA toward the interatrial septum under imaging guidance. The deflectable capabilities of the sheath, protected by the spiral or J-tip wire, enable atraumatic manipulation and precise targeting before puncture. This method was used in 63 consecutive procedures, including pulsed field ablation, left atrial appendage occlusion, and concomitant cases. All punctures were completed successfully without complications. The average time from inferior vena cava advancement to septal crossing was 2-3 min. This new low RA-approach TSP technique provides superior sheath control and maneuvering of large-bore deflectable systems, offering competitive safety and efficiency as an excellent alternative to conventional SVC-based approaches.