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I’m curious…an EP needs to make a hole in one chamber to get to the other during an ablation. How is an iatrogenic hole different than a birth defect hole when one is using flecainide?

I don't think flecainide is relevant. The PFO from an ablation is relatively small and will usually close on its own fairly quickly compared to a congenital PFO. And the reason flecainide often works for people who've had ablations is because afib following the procedure isn't due to the PFO. It's due to them having afib. But people in the PFO group had afib as a complication of the surgery itself and flecainide apparently isn't effective at preventing afib from that cause.

I don't have actual knowledge or experience here, but I would think the hole left by a mere catheter would almost close up on its own, and then begin to heal like normal live tissue. The other defect would have a more gradual thinning and then a hole, perhaps as much as two-four mm in diameter, maybe even more in some cases. Think of what happens when you stick a wooden skewer into a loaf being baked and then remove it to see if any batter has stuck to the skewer indicating that more bake time is needed. When the skewer is withdrawn, the batter 'heals' itself quickly inside the loaf and you'll only see a hole where the outer portions had baked and the skewer leaves a permanent 'drill hole'. The defect, though, would have much wider margins.

When my MitraClip was inserted it required a significant septal puncture as it is the largest (they told me) device that is placed transcatheter. Subsequent ultrasounds showed that it took a long time to completely heal — over a year – but eventually it did heal. Neither the interventional cardiologist who placed it nor Natale (later) was concerned about this.