Leveraging a randomized trial to assess relationships between transeptal puncture, brain emboli, and migraine symptoms

Background Catheter ablation procedures with transseptal punctures (usually for atrial fibrillation) are often associated with migraine-related visual auras, but the mechanism remains unknown. Whether this phenomenon is mediated by the creation of an atrial septal defect from transseptal puncture or by silent acute brain emboli detected on magnetic resonance imaging related to the procedure remains to be investigated. Objective This study aimed to evaluate whether randomization to a transseptal puncture during catheter ablation for ventricular arrhythmias is associated with postprocedural visual auras and assess the relationship between occipital and parietal lobes acute brain emboli and migraine-related visual auras. Methods In the Transseptal Versus Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli trial, patients undergoing catheter ablation for ventricular arrhythmias were randomized to ventricular access via transseptal puncture vs a retrograde aortic approach. All had brain magnetic resonance imaging the day after their procedure and underwent a validated migraine assessment at 1 month. Results No differences in postablation visual auras were observed between transseptal (16% of 63) and retrograde aortic approaches (14% of 57; P =.78). However, more participants with acute brain emboli in the occipital or parietal lobes experienced migraine-related visual auras (38% vs 11%; P <.01). After multivariable adjustment, the presence of acute brain emboli was associated with 12-fold greater odds of visual auras. Conclusion Transseptal puncture was not associated with visual auras; however, acute brain emboli involving the visual cortex were associated with such symptoms. These data suggest that transseptal puncture is not causal in migraine-related visual auras and that postprocedure acute brain emboli are apparently not always clinically silent.