A 74-year-old female with long-standing persistent nonvalvular atrial fibrillation (CHA₂DS₂-VASc 5, HAS-BLED 4), hypertension, and congestive heart failure (LVEF 45%) was scheduled for LAA closure. Recurrent subcutaneous hematomas from chronic rivaroxaban therapy necessitated a strategy to minimize procedural anticoagulation. Pre-procedural transesophageal echocardiography (TEE) revealed significant left atrial enlargement (49 × 54 mm), displacing the interatrial septum and obscuring standard fluoroscopic landmarks. This anatomy increased the difficulty and perforation risk of a traditional transseptal approach. Under synchronized fluoroscopy and 2D intracardiac echocardiography (ICE) guidance (Johnson & Johnson, SNDSTR10), the Accusafe guidewire was advanced through an 8Fr sheath (Johnson & Johnson) positioned at the optimal tenting site (Figures 1C,D). Real-time ICE allowed millimeter-scale adjustment to a posterior-inferior puncture trajectory (Figure 1A), achieving first-pass (single-attempt) septal penetration (Figure 1B). The guidewire's shape-memory U-tip prevented overshooting, mitigating risk of injury to adjacent structures. The ASP step itself was performed without the use of contrast agent. Post-puncture, ICE confirmed stable wire co-axiality with the LAA ostium, facilitating single-pass deployment of a LAMAX device (Figures 1E,F). The total procedure time was 38 min under local anesthesia, with only 2.1 min of fluoroscopy. Final ICE and angiography confirmed optimal device position without leak. Immediate post-procedural assessment showed no hemodynamically significant residual atrial septal defect. The patient resumed aspirin on postoperative day 1 and was discharged on day 3 without bleeding or thromboembolic events, demonstrating the technique's potential to mitigate bleeding risks while effectively preventing stroke. Longer-term follow-up data are being collected.

Traditional ASP using a Brockenbrough (BRK) needle carries risks related to limited control and operator dependence. Our approach integrates the Accusafe guidewire—a nitinol device with a sharp, steerable tip and U-shaped memory retention.

This case demonstrates that the Accusafe guidewire under dual ICE/fluoroscopy guidance can facilitate safe and precise ASP in general anatomy, achieving successful first-pass puncture and LAA closure with a short procedure time and no complications. Its integrated design may enhance safety by mitigating overshoot risk and eliminating device exchange. This initial experience in a patient with complex anatomy confirms the technique's feasibility and suggests potential advantages for a broad range of cardiologists performing left atrial interventions, including in electrophysiology and structural heart procedures. Further studies are warranted to establish its broader applicability and safety profile.