The technique and safety of transseptal left heart catheterization: the Massachusetts General Hospital experience with 1,279 procedures

Transesophageal Echocardiography Improves Precision in Transseptal Puncture Compared to Fluoroscopy in Left Atrial Electrophysiological Procedures

Background: Complex arrhythmias often arise from the left side of the heart, necessitating established electrophysiological (EP) procedures like 3D-mapping-assisted radiofrequency (RF) ablations or pulmonary vein isolation (PVI). These procedures typically require transseptal access, emphasizing the critical role of achieving an optimal catheter position through a precise transseptal puncture (TSP). Commonly employed imaging methods for TSP guidance include fluoroscopy and interventional echocardiography. Despite their routine use, there is limited evidence on which imaging modality offers superior catheter positioning for EP procedures, and safety concerns regarding transseptal punctures with imaging remain underexplored. This study aims to systematically evaluate the feasibility, safety, and accuracy of echo-guided TSP compared to fluoroscopy-guided TSP. Methods: In this prospective study, 150 consecutive patients undergoing left atrial EP procedures were enrolled between October 2023 and February 2024 at the Ulm University Heart Center. Following optimal fluoroscopy-guided transseptal needle positioning at the interatrial septum, the catheter placement was further verified using transesophageal echocardiography (TEE). Adjustments were made in cases of suboptimal needle positioning observed in TEE. The fluoroscopically achieved septal positions were categorized based on TEE images as optimal, suboptimal, poor, or dangerous. Results: Among the 150 patients included (58.0% male), fluoroscopy achieved optimal, suboptimal, and poor/dangerous positions in 32.7%, 43.3%, and 24.0%, respectively. After TEE-guided adjustments, optimal and suboptimal positions were achieved in 59.3% and 40.7% of patients, respectively. No instances of poor or dangerous transseptal needle positions were observed under TEE guidance. Conclusions: TEE-guided TSP emerges as a feasible, more accurate, and safer imaging method for transseptal punctures in EP procedures.

A case report of atrial septal puncture "mistakenly" penetrated the aorta during left bypass radiofrequency ablation

INTRODUCTION

Transseptal punctures (TSPs) are widely used in left atrium and left ventricle surgery. Accidental puncture of the puncture needle into the aorta is a rare complication that is rarely reported but has serious consequences. The appropriate management of this complication remains unclear.

PATIENT CONCERNS

This report describes a case of a male with the chief complaint: paroxysmal palpitation for 1 year, aggravated for 1 month.

DIAGNOSIS

The electrophysiological diagnosis was atrioventricular reentrant tachycardia caused by left-side bypass.

INTERVENTIONS

Radiofrequency ablation of the heart was a necessary treatment and a TSP operation was needed, in which a puncture was mistakenly believed to have entered the aorta, a series of measures were taken urgently. Although the surgical procedure in this case was a false alarm, we still initiated a series of emergency plans. Emergency measures to address the complications were effectively implemented, and the emergency measures were promptly terminated after it was clear that complications had been misjudged.

OUTCOMES

At last, it was confirmed that the angiogram was a pulmonary artery image, not an aorta image. Then the atrial septal puncture operation was successfully completed, and under the guidance of the Carto system, the ablation was successfully completed. Postoperative fluoroscopy showed no complications, such as pericardial effusion. After 2 years of follow-up, there was no reoccurrence of tachycardia, and there were no complications. It is crucial that emergency procedures are terminated in a timely manner after a clear miscarriage of performance. Although accidental puncture into the aorta is urgent and serious, performing a blockage or even thoracotomy in an emergency if complications are not clearly confirmed can cause further damage to the patient and would be a definitively wrong strategy.

CONCLUSION

Strict and standardized TSP operations can avoid complications. Correct judgment of the authenticity of complications is crucial, and remedial measures that may cause further damage should not be blindly adopted. The retention of the aortic guide wire can provide convenient access for further differential diagnosis and remedial treatment.

Midterm follow-up after computed tomography angiography planned left atrial appendage closure

BACKGROUND

While studies have shown the advantages of computed tomography angiography (CTA) over transesophageal echocardiography (TEE) in left atrial appendage closure (LAAC) preprocedural planning for WATCHMAN™ legacy and FLX devices, there has been no reported long-term data for this approach.

OBJECTIVES

We sought to evaluate long-term outcomes using CTA-based preprocedural planning for LAAC using the WATCHMAN™ device.

METHODS

A prospective analysis of 231 consecutive patients who underwent LAAC in a single, large academic hospital in the United States was conducted over a 5-year period. CTA-guided preprocedural planning was performed in all. Procedural success, adverse events, length of procedure, number of devices used, and length of stay were evaluated. Rates of death, cerebral embolism, systemic embolism, and major and minor bleeding were recorded. Adjusted predicted stroke and major bleeding rates were derived from CHA2DS2-Vasc and HAS-BLED scores, respectively.

RESULTS

From January 26, 2017, to November 23, 2021, 231 patients underwent LAAC with CTA preprocedural planning by two operating physicians. The mean age of patients was 76.5 ± 8.4. 59.7% of patients were male. Mean CHA2DS2VASc and HAS-BLED scores were 4.5 ± 1.4 and 3.9 ± 0.9, respectively. All procedures were performed with intracardiac echo (100%). The procedural success rate was 99.1%. The CTA sizing strategy accurately predicted the implant size in 93.5% of patients. Mean number of devices used was 1.10 ± 0.3. Peri-procedural complication rate was 2.2%. 6 patients were lost to follow-up. Mean follow-up was 608.94 days with a total of 377.04 patient years. Median follow-up period of 368 days (interquartile range: 209-1067 days). There were 51 deaths from all causes (13.52 per 100 patient-years), 10 cases of cerebral embolism (2.65 per 100 patient-years), 2 cases of systemic embolism (0.53 per 100 patient-years), 17 cases of major bleeding (4.50 per 100 patient-years), and 31 cases of minor bleeding (8.2 per 100 patient-years). All-cause mortality at 1, 2, and 3 years was 12.7%, 20.9%, and 29.2%, respectively. CV event rates at 1, 2, and 3 years were 2.1%, 6.6%, and 10.5%, respectively.

CONCLUSIONS

CTA-based preprocedural planning is accurate in predicting device size for LAAC and associated with excellent clinical outcomes at 5 years.

VersaCross Transseptal System for Mitral Transcatheter Edge-To-Edge Repair With the PASCAL Repair Platform

Background

VersaCross is a novel radiofrequency transseptal solution that may improve the efficiency and workflow of transseptal puncture (TSP). The aim of this study was to compare the VersaCross transseptal system with mechanical needle systems during mitral transcatheter edge-to-edge repair (M-TEER) with the PASCAL device.

Methods

This is a single-center retrospective study of consecutive patients who underwent M-TEER with the PASCAL. Transseptal puncture was undertaken with either a mechanical needle or the VersaCross wire. The primary endpoints were success of TSP and successful delivery of the Edwards sheath on the chosen delivery wire. Secondary endpoints included number of wires used, tamponade rate, interval from femoral venous access to TSP and first PASCAL device deployment, procedural death, and stroke.

Results

Thirty-three consecutive patients (10 with mechanical needle, 23 with VersaCross) who underwent M-TEER with the Edwards PASCAL device were identified. All patients had successful TSP. In the mechanical needle group, the Edwards sheath was successfully delivered on the Superstiff Amplatz wire in all cases. In the VersaCross arm, the radiofrequency wire was used successfully for delivery of the sheath in all cases. There were no cases of pericardial effusion/tamponade in either arm. Interval from femoral venous access to TSP and to deployment of the first PASCAL device was shorter with the VersaCross system. Significantly fewer wires were used with VersaCross. There were no procedural deaths or strokes in either group.

Conclusions

VersaCross appears a safe and effective method of TSP and for delivery of the 22Fr sheath for M-TEER with PASCAL.

The feasibility and safety of combining atrial septal defect/patent foramen ovale and left atrial appendage closure: A systematic review and meta-analysis

Introduction

Atrial Septal Defect/Patent Foramen Ovale (ASD/PFO) occlusion is performed to prevent paradoxical embolism and reduce the risk of recurrent ischemic stroke. Left atrial appendage (LAA) closure is used as an alternative to medical therapy of non-valvular atrial fibrillation for prevention of stroke. Multiple studies have examined performing LAA and ASD/PFO occlusion. However, the feasibility and safety of combined occlusion of the left atrial appendage and ASD/PFO are not clear, furthermore, these studies are limited by their small sample sizes and retrospective analysis. In this study, we aimed to systematically review and meta-analyze the feasibility and safety of combining left atrial appendage and ASD/PFO closure.

Methods

PubMed, Web of Science, CNKI, Cochrane Library, Embase, and WanFang database were searched up to April 2022 to identify peer-reviewed human studies on assessing the feasibility, safety, and efficacy of combining left atrial appendage and ASD/PFO closure. The primary outcome was calculated: procedural feasibility outcome and procedural safety outcome.

Results

A total of 10 articles, including 340 patients from multiple countries, were included in the analysis. The principal findings of our study are: compared with single LAA closure, (i) combining PFO/ASD occlusion and LAA closure had similar procedural success proportion (98.43%, 95% CI: 96.67-100.00%), (ii) similar safety event incidences developed (1.67%, 95% CI: 0.24-3.92%), subgroup analyzed safety event incidences in death was 0.00 (95% CI: 0.00-0.33%), cardiac tamponade was 0.87% (95% CI: 0.00-2.77%), device embolization was 0.00 (95% CI: 0.00-0.60%), major bleeding was 0.00 (95% CI: 0.00-0.33%), stroke was 0.00 (95% CI: 0.00-0.02%).

Conclusion

Although this systematic review and meta-analysis demonstrate the technical feasibility and safety of combining closure of PFO/ASD and LAA, further studies of sufficient sample size, long-term follow-up, and rigor endpoint criteria are yet needed to fully evaluate this combination procedure for its role in clinical outcomes.

First experience with a transseptal puncture using a novel transseptal crossing device with integrated dilator and needle

BACKGROUND

This study aimed to evaluate the feasibility and safety of an innovative "all in one" integrated transseptal crossing device to achieve transseptal puncture (TSP).

METHODS

Twenty patients (10 males, mean age 65.65 ± 9.25 years), indicated to supraventricular left side tachyarrhythmia ablation, underwent TSP using a new-generation integrated crossing device, and a control cohort of twenty patients (10 males, mean age 65.5 ± 10.12 years) underwent TSP using the traditional TSP system.

RESULTS

In all the study patients, the novel TSP device led to a successful and safe access to the left atrium (LA). The mean transseptal time, defined as the time occurring between the groin puncture and the advancing of the guidewire into the left superior pulmonary vein (PV), was 3 min 33 s ± 44 s, 7 min 5 s ± 36 s in the control cohort. Additionally, we compared the cost of the two systems. No acute complications related to the TSP were noted in both cohorts.

CONCLUSIONS

TSP performed with the new integrated transseptal system is feasible and safe.

Intracardiac echocardiography from coronary sinus

Intracardiac echocardiography (ICE) has become an essential tool and is an integral part of percutaneous interventional and electrophysiology (EP) procedures. Intracardiac echocardiography offers real-time, high-quality, near-field evaluation of cardiac anatomy. Standard ICE imaging includes placing the catheter in the right atrium (RA), right ventricle (RV), or left atrium (LA, via the transeptal approach). Coronary sinus echocardiography (CSE) is another alternative, where the ICE catheter is positioned in the coronary sinus (CS). This approach offers better catheter stability and allows operators to visualize cardiac structure with particularly excellent views of the LA, LAA, left ventricle (LV), and mitral annulus. Additionally, CSE is an attractive alternative in cases with unfavorable interatrial septum or fossa ovalis anatomical features that could lead to difficulty advancing ICE catheter in left atrium. In this article focusing on CSE, we provide illustration-based guidance to help operators identify critical cardiac structures from CSE.

A new transseptal solution for enabling left atrial access of large delivery sheaths

BACKGROUND

Transseptal access for large sheaths may be encumbered by tissue resistance against the sheath-dilator stepped interface. The ExpanSure Large Access Transseptal Dilator (Baylis Medical) is designed as a single introducer and dilation device with a smooth sheath-dilator transition to support transseptal puncture. It may facilitate ease and efficiency of interatrial crossing.

METHODS

This study experimentally evaluated the crossing force of ExpanSure relative to a conventional 8.5 F Swartz SL1 transseptal sheath and dilator in a benchtop septum model. Its ability to reduce the subsequent crossing force of a 14 F WATCHMAN delivery sheath was also tested. The clinical use of ExpanSure, including procedure time, was then validated in a series of left atrial appendage closure (LAAC) procedures.

RESULTS

In a benchtop septum model (N = 12), less peak force (1.90 ± 0.08 N vs. 2.36 ± 0.09 N; p < .001) and overall work (17.3 ± 1.2 mJ vs. 28.0 ± 1.9 mJ; p < .001) were required to advance ExpanSure relative to a conventional SL1 transseptal sheath and dilator system. Peak force (2.34 ± 0.24 N vs. 2.65 ± 0.21 N; p < .003) and overall work (28.5 ± 3.9 mJ vs. 35.4 ± 2.1 mJ; p < .001) to advance a WATCHMAN sheath were also significantly lower after using ExpanSure than after using a conventional transseptal system. In 19 LAAC procedures, ExpanSure crossed the septum smoothly and integrated readily, which enabled efficient procedure completion (mean total procedure time 37.6 ± 13.5 min), with 100% success and no procedure-related complications.

CONCLUSION

Experimental force measurements, combined with early clinical experience using ExpanSure, suggest that the tapered design with smooth transition without dilator-sheath step-up and the larger diameter, both facilitated ease and efficiency of interatrial crossing.

Percutaneous occlusion of transseptal puncture-related free wall perforation at the coronary sinus with a ventricular septal occluder during left atrial appendage closure: A case report

Coronary sinus perforation is a life-threatening complication of transseptal puncture and needs to be repaired immediately. In this study, we report a case of a 74-year-old female patient with nonvalvular atrial fibrillation, who is a poor long-term anticoagulation candidate. During the manipulation of transseptal puncture, a perforation of the free right atrial wall at the coronary sinus ostium occurred, which was caused by the Brockenbrough needle and followed by the immediate advancement of an 8.5-French transseptal sheath. In consideration of the danger of cardiac tamponade after sheath removal, we decided to leave the 8.5-French sheath in the pericardial cavity. Then, we advanced a 6 mm ventricular septal occluder through the sheath. Finally, we achieved successful deployment of the device and closure of the perforation under the guidance of fluoroscopy and transthoracic echocardiography. Subsequently, the left atrial appendage orifice was occluded with a 21 mm Watchman device. This case illustrates that percutaneous device closure is feasible for inadvertent perforation of the free right atrial wall at the coronary sinus during transseptal puncture and should be considered as an alternative to surgery.

Inadvertent ascending aortic perforation after transseptal puncture: Successful treatment with an Amplatzer Duct Occluder II device

Transseptal puncture is a routine technique to access the left atrium during catheter ablation, but carries a small risk of perforation into the pericardium or aorta. When conservative management fails, surgical repair is usually needed. We report an 81-year-old male in whom aortic root perforation occurred after transseptal puncture and was treated successfully by percutaneous deployment of an Amplatzer Duct Occluder II device.

Transseptal Puncture for Catheter Ablation in Children

Transseptal puncture (TP) is used in pediatric patients to access the left atrium in left-sided arrhythmia catheter ablation. Performing this procedure can be difficult and risky, especially in small children. In this study, we aimed to evaluate the safety and feasibility of TPs in children ≤ 30 kg. Between April 2012 and April 2018, a retrospective evaluation was conducted of the clinical features, procedural outcomes, and follow-ups of ≤ 30 kg pediatric patients who required TPs for left-sided ablations at a pediatric electrophysiology center in which a three-dimensional mapping system was routinely used. A total of 45 pediatric patients who were ≤ 30 kg, underwent TPs: 10 patients ≤ 20 kg (Group 1) and 35 patients > 20 kg and ≤ 30 kg (Group 2). The TP success rate was 97.8%. The median procedure and fluoroscopy times were 120 min and 5.43 min, respectively. One patient developed self-limited pericardial effusion during the procedure; however, there were no incidences of cardiac tamponade. There was no significant difference between the two groups in terms of the procedure time and fluoroscopy time, and pericardial effusion was only observed in Group 2. TPs are safe and feasible in small children. These procedures can be performed with low complication rates in children weighing ≤ 30 kg.

Inadvertent transseptal puncture into the aortic root: the narrow edge between luck and catastrophe in interventional cardiology

Aims

Inadvertent puncture of the aortic root (AR) is a well-known complication of transseptal puncture (TSP). Strategies for handling of this potentially lethal complication have not been identified yet. In this study, we present typical anatomical locations and clinical management of aortic root puncture (ARP) due to TSP.

Methods and results

All patients with ARP were retrospectively collected from seven hospitals. Aortic root puncture was identified and classified regarding angiographical and intraoperative findings in cardiac surgery: (i) TSP from the right atrium (RA) to the non-coronary sinus (NCS), (ii) TSP from RA to the non-coronary sinutubular junction (STJ), and (iii) TSP from RA to the ascending aorta (AA). A total of 24 patients with inadvertent ARP were identified. In 19 patients, penetration of the aorta was accomplished by the inner dilator, in 5 patients by the complete sheath. Previous cardiac surgery had been performed in six patients. There were 13 RA-to-NCS punctures, 2 RA-to-STJ punctures, and 9 RA-to-AA punctures. No cardiac tamponade (CT) occurred in patients with RA-to-NCS and RA-to-STJ punctures. In 8 of 9 patients with RA-to-AA puncture, CT occurred immediately requiring urgent pericardiocentesis and surgical repair. Two patients died after surgical repair. In the 16 patients without surgical therapy, no shunt from the AR to the RA was observed 3 months after the procedure.

Conclusion

Aortic root puncture due to mislead TSP via NCS or STJ is usually not associated with a severe clinical course while ARP into the AA via the epicardial space generally leads to CT requiring surgical repair.

Demonstration of living anatomy clarifies the morphology of interatrial communications

Inferences made regarding the postnatal anatomy of the atrial septum still tend to be based on developmental evidence. Although atrial septation is a well-defined process, it is remarkably complex and remains poorly understood. It is now established, however, that the process involves the conjugation of several myocardial structures and mesenchymal tissues of both intracardiac and extracardiac origin. The resultant postnatal morphology is equally complex, evidenced by the fact that, in the normal heart, only the floor of the oval fossa, along with its anteroinferior muscular buttress, are true anatomical septums. In this regard, septums can be defined as partitions that can be removed without creating communications with the extracavitary space. The true septal components are surrounded by grooves, which themselves largely represent infolding of the atrial walls. These anatomical features can now accurately be revealed using virtual dissection of CT data sets. These images, when carefully reconstructed, demonstrated the anatomy with as much accuracy as when hearts are dissected in the autopsy room. Such virtual dissection, furthermore, shows the components as they are seen within the chest, thus facilitating understanding for those intending to undertake interventional therapeutic procedures. By preparing such images, we show the complexity of the normal atrial septum and its surrounds. We show that it is only defects within the oval fossa, or the much rarer vestibular defects, which can appropriately be illustrated in the context of a normally constructed heart.

Transseptal Access to the Left Atrium: Tips and Tricks to Keep it Safe Derived from Single Operator Experience and Review of the Literature

BACKGROUND

Transseptal puncture (TSP) remains a demanding procedural step in accessing the left atrium with inherent risks and safety concerns, mostly related to cardiac tamponade.

OBJECTIVE

Based on our own experience with 249 TSP procedures and in-depth literature review, we present our results and offer several tips and tricks that may render TSP successful and safe.

METHODS

This prospective study comprised 249 consecutive patients (146 men), aged 41.6±17.4 years, undergoing TSP by a single operator for ablation of a variety of arrhythmias, mostly related to left accessory pathways (n=145) or left atrial tachycardias (n=33) and more recently, atrial fibrillation (n=70). TSP was guided by fluoroscopy alone in all patients without the use of echocardiography imaging. In addition, an extensive literature review of TSP-related topics was carried out in PubMed, Scopus and Google Scholar.

RESULTS

Among 249 patients, 33 patients were children or young adolescents (aged 7-18 years); 14 patients were undergoing a repeat procedure. Patients with a manifest accessory pathway were the youngest (mean age 33.7±15.9) and patients with atrial fibrillation the oldest (mean age 56.0±10.8 years). A successful TSP was accomplished in 247 patients (99.2%). Two (0.8%) procedures were complicated by cardiac tamponade managed successfully with pericardiocentesis or surgical drainage. Review of the literature revealed no systematic reviews and meta-analyses of TSP studies; however, several patient series have documented that fluoroscopy-guided TSP, with various modifications in the technique employed in the present series, have been effective in 95-100% of the cases with a complication rate ranging from 0.0% to 6.7%, albeit with a mortality rate of 0.018%- 0.2%. Echo imaging techniques were employed in cases with difficult TSP.

CONCLUSION

Employing a standardized protocol with use of fluoroscopy alone minimized serious complications to 0.8% (2 patients) among 249 consecutive patients undergoing TSP for ablation of a variety of cardiac arrhythmias. Based on this single-operator experience and review of the literature, a list of practical tips and tricks is provided for a successful and safe procedure, reserving the more expensive and patient inconveniencing echo-imaging techniques for difficult or failed cases.

Transseptal Techniques for Emerging Structural Heart Interventions

The development of new transseptal transcatheter interventions for patients with structural heart disease is fueling increasing interest in transseptal puncture techniques. The authors review contemporary transseptal puncture indications and techniques and provide a step-by-step approach to challenging transseptal access and procedural complications.

Profuse and acute hemorrhagic gastroesophageal injury after cryotherapy in a cardiac surgery patient

Upper gastrointestinal injury associated with cryoablation and under placement of transesophageal echocardiography (TEE) during cardiac surgery is a rare complication but potentially fatal. During the cryoablation for the treatment of atrial fibrillation, delivered cryoenergy can adversely affect the esophagus, resulting in gastroesophageal ulceration. The TEE probe itself also can induce adverse effects like esophageal ulceration or perforation. In this case report, we describe a case of emergent gastroesophageal injury with massive bleeding that occurred after manipulation of a TEE probe during cryoablation therapy in a cardiac surgery patient.

Transseptal puncture for radiofrequency catheter ablations of left-sided arrhythmias in a paediatric population

Puncturing the atrial septum is frequently used in adults. In children, the transseptal puncture is less common, technically more demanding, and the rate of complications is not well described. We studied the feasibility and safety of this procedure in a retrospective analysis of 157 consecutive children undergoing transseptal puncture for radiofrequency catheter ablation of left atrial targets in two tertiary-care centres between 2005 and 2013. The median age of the patients at intervention was 12.5 years (1.1-18 years), with median weight of 42 kg (range 9.0-97.0 kg). Pre-excitation was found in 102 procedures, accessory pathway with exclusively retrograde conduction in 41, focal atrial tachycardia in nine, left-sided permanent junctional/reciprocating tachycardia-like accessory pathways in three, and atypical atrioventricular nodal re-entry tachycardia in two. All the procedures were guided by fluoroscopy. Additional imaging by transoesophageal echocardiography was used in three patients. Successful transseptal puncture was possible in 99.4% of the cases, ablation in 97.4%. The median time, including mapping and radiofrequency ablation, was 120 minutes (range 60-450), the median fluoroscopy time 10.8 minutes (range 1.8-75), and the median radiation dose 3 Gy cm2 (range 0.3-35). In total, five patients (3.2%) had a recurrent arrhythmia during the observation period of a median of 40 months (range 1-103). No complications associated with the transseptal puncture were observed. Transseptal puncture is a feasible and safe procedure in children. This access allows successful and efficient radiofrequency ablation of arrhythmia of the left atrium in the vast majority of the patients and might be considered as the first-line approach in this population.

Transseptal puncture - Review of anatomy, techniques, complications and challenges

In recent years, the transseptal puncture approach has enabled passage of increasingly large and complex devices into the left atrium. Traditional tools remain effective in creating and dilating the initial puncture, with an acceptable safety profile. Even for skilled operators, the procedure is technically demanding and requires sound understanding of atrial anatomy. Intracardiac echocardiography is useful in cases of previous septal repair, poorly defined fossa ovalis anatomy or when considering patent foramen ovale portal crossing. Iatrogenic atrial septal defect (iASD) is the most commonly encountered long-term complication and there is increasing evidence that larger devices are leading to symptomatic defects. The size of the sheath crossing the septum is the strongest predictor of iASD formation but other factors such as longer procedure times, significant catheter manipulation and high pulmonary pressures also contribute. Transcatheter mitral valve repair involves the use of large 22 Fr catheters which carry alarmingly high rates of defect persistence with precipitation of symptoms and possible influence on mortality. Long-term follow up data, particularly beyond the 12-month period are lacking and resultantly, evidence to guide management is sparse. Refinements of conventional instruments, as well as innovations to puncture the septum without mechanical pressure, herald a progressively safer future for the transseptal technique.

Modified Transseptal Puncture Technique in Challenging Septa: A Randomized Comparison to Conventional Technique

Background. Transseptal puncture (TSP) can be challenging. We compared safety and efficacy of a modified TSP technique (“mosquito” technique, MOSQ-TSP) to conventional TSP (CONV-TSP). Method. Patients undergoing AF ablation in whom first attempt of TSP did not result in left atrial (LA) pressure (failure to cross, FTC) were randomized to MOSQ-TSP (i.e., puncture of the fossa via a wafer-thin inner stylet) or CONV-TSP (i.e., additional punctures at different positions). Primary endpoint was LA access. Secondary endpoints were safety, time, fluoroscopic dose (dose-area product, DAP), and number of additional punctures from FTC to final LA access. Result. Of 384 patients, 68 had FTC (MOSQ-TSP, n = 34 versus CONV-TSP, n = 34). No complications were reported. In MOSQ-TSP, primary endpoint was 100% (versus 73.5%, p < 0.002), median time to LA access was 72 s [from 37 to 384 s] (versus 326 s [from 75 s to 1936 s], p < 0.002), mean DAP to LA access was 1778 ± 2315 mGy/cm² (versus 9347 ± 10690 mGy/cm², p < 0.002), and median number of additional punctures was 2 [1 to 3] (versus 0, p < 0.002). Conclusion. In AF patients in whom the first attempt of TSP fails, the “mosquito” technique allows effective, safe, and time sparing LA access. This approach might facilitate TSP in elastic, aneurysmatic, or fibrosed septa.

A simple and fast technique for radiofrequency-assisted perforation of the atrial septum in congenital heart disease

Radiofrequency (RF) assisted perforation of the atrial septum was performed successfully in three infants using a 0.035” RF wire deployed through a Williams right posterior catheter. Balloon atrial septoplasty was performed over the 0.035” RF wire in two of them, shortening the procedural time.

Feasibility and safety of transseptal puncture procedures for radiofrequency catheter ablation in small children weighing below 30 kg: single-centre experience

AIMS

Transseptal puncture (TSP) has become a common approach in catheter ablation of arrhythmia originating from the left atrium. In paediatric patients, however, TSP can be a challenge due to narrower access vessels and small left atrial size, and the safety of TSP in smaller children is yet to be understood. The purpose of this study was to retrospectively evaluate the feasibility and safety of TSP in children weighing below 30 kg.

METHODS AND RESULTS

Among 655 paediatric patients who underwent catheter ablation of arrhythmia between July 2009 and April 2015, 43 cases having structurally normal hearts, weighing <30 kg and requiring TSP were included in the study. Age, height, body weight, diagnosis, and complications during TSP and catheter ablation were evaluated. The median age, height, and body weight (range) were 7.0 years (0.3-11.1), 116.8 cm (54.0-138.4 cm) and 21.5 kg (4.3-29.6 kg), respectively. Diagnosis included manifest (n = 27; 62.8%) and concealed accessory pathway (n = 14; 32.6%) and atrial tachycardia (n = 2; 4.6%). In 10 cases (23.2%), TSP using radiofrequency energy was performed. None of the patients had major complications. Pericardial effusion was recorded as a minor complication in one patient (2.3%).

CONCLUSION

TSP was feasible, safe, and of low risk of complications in children weighing <30 kg.

Incidence, characteristics and functional implications of cerebral embolic lesions after the MitraClip procedure

AIMS

This study aimed to assess the incidence and impact of cerebral embolic events after the MitraClip procedure.

METHODS AND RESULTS

Twenty-seven high-risk patients (logistic EuroSCORE I 25±15%) underwent the MitraClip procedure and cerebral diffusion-weighted magnetic resonance imaging (MRI) in median two days before and three days after the procedure. On the same day, neurocognitive function was assessed using the Montreal Cognitive Assessment (MoCA) questionnaire and thorough clinical examination. Comparison of pre- and post-interventional MRI showed that 23 of 27 patients (85.7%) had newly acquired microembolic lesions with in median three (interquartile range 1-9) new lesions per patient. Of these, three patients (11.1%) had lesions with diameter >5 mm. Patients with >3 new cerebral embolic lesions (n=13, 48%) had a lower post-interventional MoCA score in comparison to patients with ≤3 embolic lesions (23.6±3.6 vs. 20.3±4.5; p=0.046) in univariate analysis. Multivariate stepwise regression analysis identified device time as an independent predictor of the number of post-procedural new lesions (p=0.003) and, for reduced post-interventional MoCA score, a low MoCA score at baseline (p<0.001).

CONCLUSIONS

The MitraClip procedure results in new ischaemic cerebral lesions in the vast majority of patients. Preliminary data suggest that these lesions are clinically without significant impact on global cognitive function. ClinicalTrials.gov: NCT01288976.

Targeted Transseptal Access for MitraClip Percutaneous Mitral Valve Repair

Targeted transseptal puncture remains the most critical initial part of the overall MitraClip procedure. Care and attention must be implemented for patient safety in choosing the optimal puncture site. A consistent and step-by-step methodical approach is recommended. As experienced operators are targeting more complex and nontraditional pathologic conditions, use of adjunctive tools and maneuvers (outlined in this review) are paramount to achieving successful targeted transseptal access and ultimately procedural success.

Atrial Septostomy: A Contemporary Review

Pulmonary arterial hypertension (PAH) is a rare disease, but it boasts significant morbidity and mortality. Although remarkable achievements have been made in the medical treatment of PAH, there is a role for invasive or surgical procedures in patients with progressive disease despite optimal medical therapy or with no access to such therapy. Atrial septostomy creates a right-to-left intracardiac shunt to decompress the overloaded right ventricle. Despite significant advances to validate and improve this palliative procedure, as well as recent reports of improved outcomes, it is only slowly being adopted. This article aims to detail the history, indications, contraindications, procedural techniques, and outcomes of atrial septostomy. We will also shed light on some of the newer interventions, inspired by the same physiological concept, that are being evaluated as potential palliative modalities in patients with PAH.

Transseptal access in pediatric and congenital electrophysiology procedures: defining risk

PURPOSE

Transseptal puncture (TSP) is commonly used to access the left heart for catheter ablation procedures. The specific complication risk of this procedure has not been determined. This study assesses the risk of TSP using a single standard technique during electrophysiology study (EPS) in pediatrics and congenital heart disease (CHD).

METHODS

Retrospective cohort study of patients undergoing TSP during EPS at the University of Michigan Congenital Heart Center between 1999 and 2011.

RESULTS

There were 373 left heart ablation procedures during the study period. Excluded were six adults without CHD, five procedures using an alternative imaging modality, five procedures using retrograde aortic access, one transhepatic access, and one where TSP was performed during a prior procedure. Included were 321 pediatric (≤18 years old without CHD) TSP procedures (median age 13 years) and 34 TSP procedures in patients with CHD (median age 28 years). There was one complication directly attributable to TSP: needle perforation of the left atrium without development of effusion in the pediatric group. Post-procedure echocardiograms were performed in 351 (99 %) cases, showing only trivial effusions in seven (1.9 %).

CONCLUSIONS

This single center experience over 12 years shows the risk of TSP in pediatric and CHD patients to be low, with a 0.3 % (95 % confidence interval (CI) 0, 0.9 %) risk for complications directly related to TSP using only single plane fluoroscopy for visualization.

Transseptal puncture to facilitate device closure of "long-tunnel" patent foramen ovale

BACKGROUND

Patent foramen ovale (PFO) is common and may predispose to paradoxical embolism. Transcatheter device closure of PFO can be challenging in certain cases of "long-tunnel" PFO morphology. We report our experience with device closure of long-tunnel PFO using transseptal puncture.

METHODS

We retrospectively reviewed all cases of PFO device closure using transseptal puncture at the Mayo Clinic from January 1, 2010 to September 30, 2013. We arbitrarily defined a PFO tunnel configuration as a tunnel length ≥ 12 mm as observed in intracardiac echocardiography (ICE) at the time of device closure.

RESULTS

Twelve patients (mean age 40.8 [range 15-67] years; 7 males [58%]) underwent PFO device closure with transseptal puncture. The most common indication for PFO closure was previous stroke (n = 7, 58%). Median tunnel length measured by ICE was 15 mm (12-20 mm). GORE® HELEX® Septal Occluder was used for closure in all but one patient. The only significant procedural complication was a minor perforation of the left atrial wall during attempted septal puncture, which resulted in a trivial pericardial effusion that resolved without intervention. At latest follow-up (mean 543 days, [range 170-1162]) one patient had a residual shunt and subsequently died due to complications during surgical PFO closure. No recurrent strokes or TIAs were reported.

CONCLUSION

Though not without risk, transseptal puncture can be a valuable tool for facilitating device closure of long-tunnel type PFOs. GORE® HELEX® Septal Occluder may be an effective option for facilitating device closure for patients with long-tunnel type PFO.

NRG™ RF powered transseptal needle: a useful technique for transcatheter atrial septostomy and Fontan fenestration: report of three cases

Transseptal puncture (TSP) is a frequently performed procedure for gaining access to the left atrium for catheter ablation, hemodynamic assessment of the left heart, left ventricular assist device implantation, percutaneous left atrial appendage closure or mitral valvuloplasty during childhood and adulthood. The standard technique for transseptal puncture applies mechanical pressure on the fossa ovalis with a Brockenbrough needle. However, this method is not feasible when the fossa ovalis is thick and aneurysmatic. In such patients, the radiofrequency ablation energy systems can be offered as a better alternative for TSP. Here, we aimed to demonstrate the outcome of transseptal puncture performed with an NRG™ RF powered transseptal needle in three patients.

Limiting left-sided catheter dwelling time using 3-D NavX to mark and reaccess the left atrium via prior transseptal puncture site

INTRODUCTION

Ablations requiring transseptal access to the left heart place patients at increased risk for stroke, bleeding, and post-procedural cognitive dysfunction and other complications. Diminishing left atrial catheter dwelling time may decrease these risks. 3-D NavX can be used to facilitate reaccess of transseptal puncture sites to allow catheter removal from the left atrium immediately after ablation, with reaccess through the prior transseptal site if required. Here, we describe the techniques employed and our experience using 3-D NavX to limit left atrial catheter dwelling time by marking and reaccess of the left atrium via the previously marked transseptal puncture site, a potentially radiation-free technique.

METHODS

With the use of 3-D NavX, a right atrial geometry is created. The patent foramen ovale is marked by using a standard EP catheter, or the transseptal puncture site is marked using 3-D NavX by creating a unipolar electrode on the transseptal needle at the time of puncture and at the time of catheter withdrawal of the ablation catheter from the left atrium. Marking the access site allows the catheter to be removed from the left side of the heart immediately after the ablation. If reaccess to the left atrium is required, the previously marked transseptal site is used to navigate the ablation catheter to reaccess the left atrium. All patients <30 years who had undergone this technique were evaluated. Data gathered included patient demographics, need for and success of transseptal reaccess, left atrial catheter dwelling time, and complications.

RESULTS

The transseptal site was marked by 3-D NavX in 54 patients. We were able to successfully reaccess the transseptal puncture site using 3-D guidance in all 10 patients where it was desired. In these 54 patients, the complication rate was low with one small post-procedural pulmonary embolism and one right bundle branch block. No other complications were noted. The median procedure time was 105 min (range 58-446 min), the median total fluoroscopic time for the entire procedure was 1.3 min (range 0.0-30.8 min), and the median left-sided catheter dwelling time was 21 min (range 6-112 min).

CONCLUSIONS

In our retrospective review, reaccess of transseptal puncture site was reproducible, and early removal of the catheter from the left side was without the need for repeat transseptal punctures. This technique decreases the time the catheter dwells in the left atrium, which could decrease risks such as clotting, bleeding, and cognitive dysfunction.

Randomized trial of conventional transseptal needle versus radiofrequency energy needle puncture for left atrial access (the TRAVERSE-LA study)

Background

Transseptal puncture is a critical step in achieving left atrial (LA) access for a variety of cardiac procedures. Although the mechanical Brockenbrough needle has historically been used for this procedure, a needle employing radiofrequency (RF) energy has more recently been approved for clinical use. We sought to investigate the comparative effectiveness of an RF versus conventional needle for transseptal LA access.

Methods and Results

In this prospective, single‐blinded, controlled trial, 72 patients were randomized in a 1:1 fashion to an RF versus conventional (BRK‐1) transseptal needle. In an intention‐to‐treat analysis, the primary outcome was time required for transseptal LA access. Secondary outcomes included failure of the assigned needle, visible plastic dilator shavings from needle introduction, and any procedural complication. The median transseptal puncture time was 68% shorter using the RF needle compared with the conventional needle (2.3 minutes [interquartile range {IQR}, 1.7 to 3.8 minutes] versus 7.3 minutes [IQR, 2.7 to 14.1 minutes], P=0.005). Failure to achieve transseptal LA access with the assigned needle was less common using the RF versus conventional needle (0/36 [0%] versus 10/36 [27.8%], P<0.001). Plastic shavings were grossly visible after needle advancement through the dilator and sheath in 0 (0%) RF needle cases and 12 (33.3%) conventional needle cases (P<0.001). There were no differences in procedural complications (1/36 [2.8%] versus 1/36 [2.8%]).

Conclusions

Use of an RF needle resulted in shorter time to transseptal LA access, less failure in achieving transseptal LA access, and fewer visible plastic shavings.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01209260.

Complications of transseptal catheterization for different cardiac procedures

BACKGROUND

Cardiac tamponade is the main complication of transseptal catheterization that is necessary for a variety of cardiac interventions and electrophysiology procedures.

METHODS

A retrospective assessment of all consecutive procedures that required transseptal puncture by the same experienced operator (with already >100 previous trans-septal procedures) during the period 2000-2012 was performed. We recorded any puncture-related complications of pericardial effusion and cardiac tamponade (acute or delayed).

RESULTS

A total of 393 procedures were retrieved: Group 1 [ablation of left-sided accessory pathways (n = 77), atrioventricular nodal reentry tachycardia-left septal access (AVNRT) (n = 12), and Inoue balloon mitral valvuloplasty (n = 27)], and Group 2 [atrial fibrillation (AF) ablation procedures: ostial pulmonary vein isolation (PVI) (including RF (n = 76) and cryo-balloon (n = 30)), circumferential PVI (n = 51), and combined procedures (n = 120)]. In total, 5 cases of tamponade were recorded, four of them were acute and one delayed (occurring 1h after the procedure). All tamponade cases occurred only during or after AF ablation procedures (cryo-balloon ablation = 1, circumferential PVI = 2, and combined procedures = 2). In one case emergency atrial repair following median sternotomy was necessary, and in another a surgical drainage through a limited thoracotomy was performed. The other three cases were treated with pericardiocentesis and drainage for 12h. No patient was on uninterrupted oral anticoagulation during the procedure.

CONCLUSIONS

AF ablation is associated with a higher incidence of tamponade compared to other procedures that require transseptal access. Such procedures should only be performed in hospitals with access to emergency surgical support.

Impact of transseptal puncture site on acute and mid-term outcomes during cryoballoon ablation: a comparison between anterior, medial and posterior transatrial access

BACKGROUND

Cryoballoon ablation (CBA) (Arctic Front, Medtronic, USA) has proven very effective in achieving pulmonary vein isolation (PVI). Different transseptal (TS) puncture sites might influence CBA procedure. The aim of the present study was to analyze the influence of different TS puncture sites (anterior, medial and posterior) on the acute and midterm outcomes of CBA in a series of patients undergoing PVI for drug resistant AF.

METHODS AND RESULTS

A total 103 patients (78 males, mean age: 57 ± 13 years) formed the study group. Transseptal punctures were performed in the anterior, medial and posterior portion of the FO in 41 (39.8%), 35 (34%) and 27 (26.2%) patients respectively. We found no statistical significant difference between the various sites of TS puncture in 1) the grade of PV occlusion (p = ns), the rate of PV isolation (p = ns), freedom from AF at a mean 12 month follow-up (p = ns) and complication rates (p = ns). Mean grade of occlusion was slightly lower in the RIPV when puncturing in the posterior FO but did not reach statistical significance. Mean procedural and fluoroscopy times were significantly lower when using the inner lumen mapping catheter (ILMC) (Achieve, Medtronic, USA) than the circular mapping catheter (CMC) (Lasso, Biosense Webster, California, USA) (107.24 mn vs 97.74 (p ≤ 0.001) and 25.7 mn vs 19.2 mn (p ≤ 0.001)).

CONCLUSION

Different sites of TS puncture on the horizontal axis of the FO (anterior, medial and posterior) did not influence grades of PV occlusion, rates of isolation, mid-term outcome and rates of complications during CB ablation.

Aortic intracardiac echocardiography-guided septal puncture during mitral valvuloplasty

AIMS

Transoesophageal echocardiography (TEE) and venous intracardiac echocardiography (ICE) are traditionally used to visualize the interatrial septum (IAS) and the tenting effect of the fossa ovalis in patients undergoing percutaneous balloon mitral valvuloplasty (PBMV). The aim of the present study was to assess the comparative efficacy and safety of arterial (intra-aortic) ICE and venous ICE, compared with TEE (traditional approach), in the patients undergoing PBMV.

METHODS AND RESULTS

TEE, aortic ICE, and venous ICE were consecutively performed in 50 patients (40 ± 9 years, 86% female). The images of intracardiac structures were obtained from both aortic and right atrial loci. The IAS was visualized using TEE, aortic ICE, and venous ICE. The mean mitral valve area was 1.14 ± 0.2 cm(2), and the mean left atrial volume index was 57.5 ± 12 mL/m(2). The mean size of the visualized septal length was 48 ± 5 mm by TEE, 51 ± 5 mm by aortic ICE, and 33 ± 6 mm by venous ICE. The Bland-Altman test indicated that the 95% limits of agreement for the measurement of septal diameter ranged from -11.0 to +5.9 mm (mean -2.5 mm) between TEE and aortic ICE, -2.8 to +33.5 mm (mean +15.3 mm) between TEE and venous ICE, and -36.6 to +0.8 mm (mean -17.9 mm) between venous and aortic ICE. Standard venous ICE generally tended to yield smaller values compared with TEE and aortic ICE for the measurement of septal length. Furthermore, the view of fossa ovalis and 'tenting effect' was optimal in 11 patients on venous ICE; however, the fossa ovalis and tip of the needle were well visualized in all patients on aortic ICE (P < 0.001). There were no major complications with the use of aortic ICE.

CONCLUSION

Aortic ICE is a superior alternative to venous ICE and facilitates trans-septal puncture in patients with mitral stenosis.

Invasive hemodynamic evaluation in patients with mechanical aortic valves

Invasive hemodynamic evaluation in the patient with a mechanical aortic valve has in the past required transseptal or apical left ventricular puncture in order to obtain left ventricular pressure measurements. Over the last few years, several case reports have described the feasibility of using a coronary pressure-sensing guidewire to cross mechanical prosthetic aortic valves. In the current manuscript, we report four cases in which the use of a pressure-sensing guidewire was utilized for invasive hemodynamic diagnostic evaluation in patients with mechanical aortic valves. Furthermore, we present a detailed description of the technical approach to this technique and the limitations of this approach.