The Electrophysiologist's Worst-Case Scenario

A 49-year-old woman undergoing pulsed-field ablation for symptomatic atrial fibrillation experienced a near-miss aortic entry during transseptal access. Despite apparently adequate fluoroscopic positioning, subtly rotated septal anatomy masked an anterior trajectory. Contrast injection through an NRG radiofrequency needle unexpectedly delineated the external aortic root before sheath advancement. Immediate transesophageal echocardiography and subsequent computed tomography confirmed the absence of structural injury. The ablation was safely completed 2 days later. This case illustrates how challenging septal orientation can limit the reliability of fluoroscopic cues, and it highlights the complementary safety value of contrast-capable radiofrequency needles and adjunctive imaging.