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Elagha A, Othman Y, Darweesh R, Awadein G, Hashad A. Characterization of the interatrial septum by high-field cardiac MRI: a comparison with multi-slice computed tomography. Egypt Heart J 2020; 72:81. [PMID: 33180202 PMCID: PMC7661592 DOI: 10.1186/s43044-020-00109-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/14/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Assessment of the interatrial septum (IAS) has become an attractive area of interest for a variety of important interventional procedures. Newer imaging modalities like multi-slice computed tomography (MSCT) and cardiac MRI (CMR) can provide higher resolution and wider field of view than echocardiography. Moreover, high-field (3-Tesla) CMR can even enhance spatial and temporal resolution.
The characteristics of the interatrial septum were retrospectively studied in 371 consecutive subjects (201 men, 31–73 years old) in whom MSCT was performed primarily for non-invasive evaluation of the coronary arteries. All subjects underwent both MSCT and MRI scans within 0–30 day’s interval. A 3D volume covering the whole heart was acquired across the heart with and without contrast enhancement. Also, patients underwent cardiac MSCT examinations using 64-row MSCT scanners.
Results
The mean scan time of MSCT was 10.4 ± 2.8 s and 9.7 ± 2.9 min for CMR. The mean length of IAS by CMR and CT was 39.65 ± 4.6 mm and 39.28 ± 4.7 mm, respectively. The mean maximal thickness of IAS by CMR and CT was 3.1 ± 0.97 mm and 3.15 ± 0.95 mm, respectively. The mean thickness of fossa ovalis by CMR and CT was 1.04 ± 0.36 mm and 1.04 ± 0.44 mm, respectively. The mean length of fossa ovalis by CMR and CT was 12.8 ± 3.7 mm and 12.8 ± 3.5 mm, respectively. Finally, the mean angle of IAS by CMR and CT was identical (155 ± 9.2°). Measurements of various morphological features of IAS showed no statistically significant difference between CMR and CT, with an excellent correlation and close relationship regarding IAS length, maximal IAS thickness, fossa ovalis thickness, fossa ovalis length, and IAS angle (r = 0.98, 0.98, 0.95, 0.96, and 0.92, respectively).
Conclusion
Whole-heart 3D acquisition at 3-T MRI using a free-breathing technique provides a valuable non-invasive imaging tool for excellent assessment of the interatrial septum—as compared to MSCT—that may have significant clinical implication for diagnostic purposes and therapeutic interventional procedures, as it may facilitate planning, improve outcome, and shorten its duration.
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Khan JM, Rogers T, Eng MH, Lederman RJ, Greenbaum AB. Guidewire electrosurgery-assisted trans-septal puncture. Catheter Cardiovasc Interv 2017; 91:1164-1170. [PMID: 28940991 DOI: 10.1002/ccd.27311] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/03/2017] [Accepted: 08/07/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Electrifying a coronary guidewire may be a simple escalation strategy when trans-septal needle puncture is unsuccessful. BACKGROUND Radiofrequency energy to facilitate trans-septal puncture through a dedicated device is costly and directly through a trans-septal needle may be less safe. Our technique overcomes these limitations. METHODS The technique was used in patients when trans-septal needle penetration failed despite excessive force or tenting of the atrial septum. A coronary guidewire, connected to an electrosurgery pencil, was advanced through the trans-septal needle, dilator, and sheath to perforate the interatrial septum during a short burst of radiofrequency energy. With the guidewire tip no longer "active," the dilator and sheath were advanced safely over the wire into the left atrium. In posthoc validation, radiofrequency assisted Brockenbrough needle and coronary guidewire punctures were made in freshly explanted pig hearts and compared under microscopy. RESULTS Eight patients who required trans-septal access for structural intervention were escalated to a guidewire electrosurgery strategy. Six patients had thickened fibrotic septum and two had prior surgical patch repair. Crossing was successful in all patients with no procedure related complications. The size of punctures (1.11 ± 0.40 mm vs 0.37 ± 0.08 mm, P = .009) and blanched penumbra (3.62 ± 1.23 mm vs 0.72 ± 0.29 mm, P = .003) in pig atrial septum were larger with an electrified needle than electrified guidewire. The hole generated by the electrified guidewire was smaller than by the nonelectrified needle. CONCLUSIONS When conventional trans-septal puncture fails, a coronary guidewire can be used to deliver brief radiofrequency energy safely and effectively. This technique is inexpensive and accessible to operators.
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Affiliation(s)
- Jaffar M Khan
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Toby Rogers
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marvin H Eng
- Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, Michigan
| | - Robert J Lederman
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Adam B Greenbaum
- Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, Michigan
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O'Brien B, Zafar H, De Freitas S, Sharif F. Transseptal puncture - Review of anatomy, techniques, complications and challenges. Int J Cardiol 2017; 233:12-22. [PMID: 28202256 DOI: 10.1016/j.ijcard.2017.02.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/22/2016] [Accepted: 02/01/2017] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Barry O'Brien
- Biomedical Engineering, School of Engineering & Informatics, National University of Ireland (NUI), Galway, Ireland
| | - Haroon Zafar
- Cardiovascular Research Centre Galway, School of Medicine, NUI, Galway, Ireland; School of Medicine, NUI, Galway, Ireland.
| | - Simon De Freitas
- Cardiovascular Research Centre Galway, School of Medicine, NUI, Galway, Ireland; School of Medicine, NUI, Galway, Ireland
| | - Faisal Sharif
- Cardiovascular Research Centre Galway, School of Medicine, NUI, Galway, Ireland; School of Medicine, NUI, Galway, Ireland; Department of Cardiology, University Hospital Galway, Ireland; BioInnovate, Ireland; CÚRAM, SFI Centre for Research in Medical Devices, Galway, Ireland
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Lien Nguyen B, Merino JL, Shachar Y, Estrada A, Doiny D, Castrejon S, Marx B, Johnson D, Marfori W, Gang ES. Non-Fluoroscopic Transseptal Catheterization During Electrophysiology Procedures using a Remote Magnetic Navigation System. J Atr Fibrillation 2013; 6:963. [PMID: 28496914 DOI: 10.4022/jafib.963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 12/04/2013] [Accepted: 12/04/2013] [Indexed: 11/10/2022]
Abstract
Transseptal punctures are commonly performed, and left atrial (LA) access is frequently lost during lengthy, complex electrophysiology (EP) procedures. We describe a new technique for non-fluoroscopic re-crossing the fossa ovalis using a new multielectrode transseptal sheath (TS) and a new remote magnetic catheter navigation system (RMNS) (CGCI System, Magnetecs) that uses 8 rapid external electromagnets for real-time navigation of a magnet-tipped electrode catheter across the initial transseptal puncture site in 5 patients undergoing left-sided ablation procedures. The three-dimensional (3D) position of a 8.5 Fr steerable TS with 5-ring 5-15-15-5-mm spaced distal electrodes (Agilis ES©, St Jude Medical), and site of fossal ovalis crossing were "shadowed landmarks" on a 3D electroanatomic mapping (EAM) system (EnSite/NavXTM, St Jude Medical). The TS-magnetic ablation catheter assembly was pulled-back to the inferior vena cava. EAM landmarks were used with RMNS-guided "manual" and "automated" catheter navigation modalities, until septal crossing was obtained. Transseptal re-crossing was successfully performed in all patients in 6.2±8.1 sec using the "automated" RMNS-guided technique and in 30.4±28.4 sec using the "manual" RMNS-guided technique (p=0.01) without complications. This new RMNS was safely and effectively used to perform non-fluoroscopic transseptal catheterization.
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Affiliation(s)
- Bich Lien Nguyen
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - Jose L Merino
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - Yehoshua Shachar
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - Alejandro Estrada
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - David Doiny
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - Sergio Castrejon
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - Bruce Marx
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - David Johnson
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - Wanda Marfori
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
| | - Eli S Gang
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center Los Angeles, California (B.L.N., E.S.G.); Electrophysiology Section, Heart and Great Vessels Department, Umberto I Hospital, Sapienza University of Rome, Italy (B.L.N.); Arrhythmia and Cardiac Electrophysiology Robotic Unit, La Paz University Hospital, Madrid, Spain (J.L.M., A.E., D.D., S.C.); Magnetecs, Corp., Inglewood, California (Y.S., B.M., D.J.); Department of Radiological Sciences, David Geffen School of Medicine at UCLA (W.M.)
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