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Knight BP, Wasserlauf J, Al-Dujaili S, Al-Ahmad A. Comparison of transseptal puncture using a dedicated RF wire versus a mechanical needle with and without electrification in an animal model. J Cardiovasc Electrophysiol 2024; 35:16-24. [PMID: 37890041 DOI: 10.1111/jce.16111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Mechanical force to achieve transseptal puncture (TSP) using a standard needle may lead to overshooting and injury, and can potentially be avoided using a radiofrequency (RF)-powered needle or wire. Applying electrocautery to needles and guidewires as an alternative to purpose-built RF systems has been associated with safety risks, such as tissue coring and thermal damage. The commercially available AcQCross needle-dilator system (Medtronic) features a sharp open-ended needle for mechanical puncture, as well as a built-in connector to enable energy delivery for RF puncture. This investigation compares the safety and efficacy of the AcQCross needle to the dedicated VersaCross RF wire system and generator (Baylis Medical/Boston Scientific). METHODS In an ex vivo porcine model, VersaCross wire punctures were performed using 1 s, constant mode (approx. 10 W) with maximum two attempts. AcQCross punctures were performed by applying energy for 2 s using a standard electrosurgical generator at 10 W (max. five attempts), 20 W (max. two attempts), and 30 W (max. two attempts). Efficacy was assessed in terms of puncture success and a number of energy applications required for TSP. Safety was assessed quantitatively as force required for TSP, energy required to puncture, and incidence of tissue coring, as well as by qualitative assessment of puncture sites. Additional qualitative observation of tissue cores and debris were obtained from TSP performed in live swine. RESULTS RF TSP was 100% successful using the VersaCross wire with 1.0 ± 0.0 attempts. When power was used with the AcQCross needle, it failed to puncture at low (10 and 20 W) power settings; TSP was achieved with 30 W of energy with 91% success using 1.53 ± 0.51 attempts (p < .05 vs. VC) with greater variability (F1,33 = 9223.5, p < .0001). Compared to RF puncture using the VersaCross system, mechanical puncture, alone, using the AcQcross needle required six times more force (8 mm additional forward device displacement) to perforate the septum. Qualitative assessment of puncture sites revealed larger defects and more tissue charring with the AcQCross needle at 30 W compared to punctures with VersaCross wire. Tissue coring with the open-ended AcQCross needle was observed in vivo and measured to occur in 57% of punctures using the ex vivo model; no coring was observed with the closed-tip VersaCross wire. CONCLUSIONS The AcQCross needle frequently required higher energy of 30 W to achieve RF TSP and was associated with tissue coring and charring, which have been, previously, reported when electrifying a standard open-ended mechanical needle or guidewire. These findings may limit safety and effectiveness compared to the VersaCross system.
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Affiliation(s)
- Bradley P Knight
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jeremiah Wasserlauf
- Cardiovascular Institute, North Shore University Health System, Evanston, Illinois, USA
| | - Saja Al-Dujaili
- Department of Scientific Affairs, Boston Scientific Corporation, Mississauga, Ontario, Canada
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
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Asfour IK, Elchouemi M, Gianni C, Helmy R, Tschopp DR, Horton RP, Natale A, Al-Ahmad A. Novel streamlined technique for left atrial appendage closure using a radiofrequency wire-based large access system. J Cardiovasc Electrophysiol 2023; 34:1690-1697. [PMID: 37417961 DOI: 10.1111/jce.15995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/17/2023] [Accepted: 06/26/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Transseptal puncture (TSP) to allow for large delivery sheath left atrial (LA) access remains a challenging aspect of LA appendage closure (LAAC) in patients with prior history of TSP, thick or lipomatous septum, atrial septal aneurysms, or other complex cardiac anatomies. This study investigates the use of the VersaCross large access (VLA) system (Baylis Medical/Boston Scientific) to improve procedural efficiency of LAAC compared to the standard needle workflow. METHODS AND RESULTS Fifty LAAC procedures using WATCHMAN FLX between November 2021 and September 2022 were retrospectively analyzed comparing the VLA workflow (n = 25) to the standard needle workflow (n = 25). Study primary endpoint was time to procedural efficiency, and secondary endpoints included TSP time, acute LAAC success, fluoroscopy use, device recaptures, and periprocedural complications. Acute LAAC was successfully completed in all cases with no intraprocedural complications. TSP time was faster, but not significant, using the VLA workflow compared to the standard RF needle workflow (2.6 ± 1.1 min vs. 3.0 ± 1.8 min, p = 0.38). Time to WATCHMAN sheath in LA from TSP was 27% faster (1.5 ± 0.8 min vs. 2.1 ± 0.9 min; p = 0.03), and time to WATCHMAN release from TSP was 19% faster (10.5. ± 2.5 min vs. 13.0 ± 3.7 min; p = 0.01) with the VLA workflow. Overall procedure time was 15% faster (30.4 ± 5.1 min vs. 36.0 ± 6.6 min; p = 0.003) using VLA. Fluoroscopy time was 25% lower (4.0 ± 2.2 min vs. 5.5 ± 2.3 min; p = 0.003) and fluoroscopy dose was 60% lower (97.0 ± 91.7 mGy vs. 241.8 ± 240.6 mGy; p = 0.01) and more consistent [F-test, p ˂ 0.0001] using the VLA workflow compared to the needle workflow. CONCLUSION The VLA system streamlines LAAC procedures, improving LAAC efficiency and reducing fluoroscopy use by allowing for de novo dilation of the septum for large-bore delivery sheaths, and reducing device exchanges and delivery sheath manipulation.
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Affiliation(s)
- Issa K Asfour
- Department of Medicine, East Tennessee University, Johnson City, Tennessee, USA
| | - Mohanad Elchouemi
- College of Natural Sciences, University of Texas, Austin, Texas, USA
| | - Carola Gianni
- Texas Cardiac Arrythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Rami Helmy
- College of Natural Sciences, University of Texas, Austin, Texas, USA
| | - David R Tschopp
- Texas Cardiac Arrythmia Institute, St. David's Medical Center, Austin, Texas, USA
- Austin Heart Hospital, Austin, Texas, USA
| | - Rodney P Horton
- Texas Cardiac Arrythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Andrea Natale
- Texas Cardiac Arrythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrythmia Institute, St. David's Medical Center, Austin, Texas, USA
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Whitler C, McClellan B, Patel H, Rajpurohit D, Kalaba F, Kado H, David S, Shah D. Improved left atrial appendage closure procedural efficiency using radiofrequency transseptal wire system. Catheter Cardiovasc Interv 2023; 101:460-467. [PMID: 36626294 DOI: 10.1002/ccd.30550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/16/2022] [Accepted: 12/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The radiofrequency (RF) needle has been shown to improve transseptal puncture efficiency and safety compared to mechanical needles. This study aimed to investigate the use of VersaCross RF transseptal wire system (Baylis Medical) to improve procedural efficiency of left atrial appendage closure (LAAC) compared to the standard RF needle-based workflow. METHODS Eighty-one LAAC procedures using WATCHMAN FLX were retrospectively analyzed comparing the standard RF needle-based workflow to a RF wire-based workflow. Study primary endpoint was time to WATCHMAN device release, and secondary endpoints were transseptal puncture time, LAAC success, fluoroscopy use, and procedural complications. RESULTS Twenty-five cases using standard RF needle-based workflow were compared to 56 cases using the RF wire-based workflow. Baseline patient characteristics were similar between both groups. LAAC was successful in all patients with no differences in intraprocedural complication rates (p = 0.40). Transseptal puncture time was 1.3 min faster using the RF wire-based workflow compared to the standard RF needle-based workflow (6.5 ± 2.3 vs. 7.8 ± 2.3 min, p = 0.02). Overall, time to final WATCHMAN device release was 4.5 min faster with the RF wire-based workflow compared to the RF needle-based workflow (24.6 ± 5.6 vs. 29.1 ± 9.6 min, p = 0.01). Fluoroscopy time was 21% lower using the RF wire-based workflow (7.6 ± 2.8 vs. 9.6 ± 4.4 min; p = 0.05) and fluoroscopy dose was 67% lower (47.1 ± 35.3 vs. 144.9 ± 156.9 mGy, p = 0.04) and more consistent (F-test, p ˂ 0.0001). CONCLUSIONS The RF wire-based workflow streamlines LAAC procedures, improving LAAC efficiency and safety by reducing fluoroscopy, device exchanges, and delivery sheath manipulation.
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Affiliation(s)
- Cameron Whitler
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Brittni McClellan
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Harshil Patel
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Dhruv Rajpurohit
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Frank Kalaba
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Herman Kado
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Shukri David
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Dipak Shah
- Cardiology Department, Ascension Providence Hospital, Southfield, Michigan, USA
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Rizzi S, Pannone L, Monaco C, Bisignani A, Miraglia V, Gauthey A, Bala G, Al Housari M, Lipartiti F, Mojica J, Del Monte A, Mouram S, Sieira J, Ströker E, Almorad A, Iacopino S, Chierchia GB, De Asmundis C. First experience with a transseptal puncture using a novel transseptal crossing device with integrated dilator and needle. J Interv Card Electrophysiol 2022; 65:731-737. [PMID: 35945310 DOI: 10.1007/s10840-022-01329-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Sergio Rizzi
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Cinzia Monaco
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Antonio Bisignani
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Vincenzo Miraglia
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Anais Gauthey
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Gezim Bala
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Maysam Al Housari
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Felicia Lipartiti
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Joerelle Mojica
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Alvise Del Monte
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Sahar Mouram
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Juan Sieira
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Erwin Ströker
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Alexandre Almorad
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Saverio Iacopino
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Gian Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Carlo De Asmundis
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
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Wasserlauf J, Knight BP. Comparing the safety and effectiveness of dedicated radiofrequency transseptal wires to electrified metal guidewires. J Cardiovasc Electrophysiol 2022; 33:371-379. [PMID: 34978365 PMCID: PMC9303383 DOI: 10.1111/jce.15341] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/10/2021] [Accepted: 12/06/2021] [Indexed: 12/04/2022]
Abstract
Background Application of electrocautery to a metal guidewire is used by some operators to perform transseptal puncture (TSP). Commercially available dedicated radiofrequency (RF) guidewires may represent a better alternative. This study compares the safety and effectiveness of electrified guidewires to a dedicated RF wire. Methods TSP was performed on freshly excised porcine hearts using an electrified 0.014″ or 0.032″ guidewire under various power settings and was compared to TSP using a dedicated RF wire with 5 W power (0.035″ VersaCross RF System, Baylis Medical). The primary endpoint was the number of attempts required to achieve TSP. Secondary endpoints included the rate of TSP failure, TSP consistency, the effect of the distance between the tip of the guidewire and the tip of the dilator, and effect of RF power output level. Qualitative secondary endpoints included tissue puncture defect appearance, thermal damage to the TSP guidewire or dilator, and tissue temperature using thermal imaging. Results The RF wire required on average 1.10 ± 0.47 attempts to cross the septum. The 0.014″ electrified guidewire required an overall mean of 2.17 ± 2.36 attempts (2.0 times as many as the RF wire; p < .01), and the 0.032″ electrified guidewire required an overall mean of 3.90 ± 2.93 attempts (3.5 times as many as the RF wire; p < .01). Electrified guidewires had a higher rate of TSP failure, and caused larger defects and more tissue charring than the RF wire. Thermal analysis showed higher temperatures and a larger area of tissue heating with electrified guidewires than the RF wire. Conclusion Fewer RF applications were required to achieve TSP using a dedicated RF wire compared to an electrified guidewire. Smaller defects and lower tissue temperatures were also observed using the RF wire. Electrified guidewires required greater energy delivery and were associated with equipment damage and tissue charring, which may present a risk of thrombus, thermal injury, or scarring.
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Affiliation(s)
- Jeremiah Wasserlauf
- Department of Internal Medicine, Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Bradley P Knight
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Andrade JG, Macle L, Bennett MT, Hawkins NM, Essebag V, Champagne J, Roux JF, Makanjee B, Tang A, Skanes A, Khaykin Y, Morillo C, Jolly U, Lockwood E, Amit G, Angaran P, Sapp J, Wardell S, Wells GA, Verma A, Deyell MW. Randomized trial of conventional versus radiofrequency needle transseptal puncture for cryoballoon ablation: the CRYO-LATS trial. J Interv Card Electrophysiol 2022; 65:481-489. [PMID: 35739438 PMCID: PMC9640463 DOI: 10.1007/s10840-022-01277-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Transseptal puncture to achieve left atrial access is necessary for many cardiac procedures, including atrial fibrillation ablation. More recently, there has been an increasing need for left atrial access using large caliber sheaths, which increases risk of perforation associated with the initial advancement into the left atrium. We compared the effectiveness of a radiofrequency needle-based transseptal system versus conventional needle for transseptal access. METHODS This prospective controlled trial randomized 161 patients with symptomatic paroxysmal atrial fibrillation undergoing cryoballoon pulmonary vein isolation to transseptal access with a commercially available transseptal system (radiofrequency needle plus stiff pigtail wire; RF + Pigtail group) versus conventional transseptal access (standard group). The primary outcome was time required for left atrial access. Secondary outcomes included failure of the assigned transseptal system, radiation exposure, and complications. RESULTS The median transseptal puncture time was significantly shorter using the radiofrequency needle plus stiff pigtail wire transseptal system compared with conventional transseptal (840 ± 323 vs. 956 ± 407 s, P = 0.0489). Compared to conventional transseptal puncture, fewer transseptal attempts were required (1.0 ± 0.5 RF applications vs. 1.3 ± 0.8 mechanical punctures, P = 0.0123) and the fluoroscopy time was significantly shorter (72.0 [IQR 48.0, 129.0] vs. 93.0 [IQR 60.0, 171.0] s, P = 0.0490) with the radiofrequency needle plus stiff pigtail wire transseptal system. Failure to achieve transseptal LA access with the assigned system was rarely observed (1.3% vs. 5.7%, P = 0.2192). There were no procedural complications observed with either system. CONCLUSIONS The use of a radiofrequency needle plus stiff pigtail wire resulted in shorter time to left atrial access and reduced fluoroscopy time compared to left atrial access using conventional transseptal equipment. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT03199703.
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Affiliation(s)
- Jason G. Andrade
- University of British Columbia, Vancouver, Canada ,Center for Cardiovascular Innovation, 2775 Laurel St, Vancouver, BC V5Z 1M9 Canada ,Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Nathaniel M. Hawkins
- University of British Columbia, Vancouver, Canada ,Center for Cardiovascular Innovation, 2775 Laurel St, Vancouver, BC V5Z 1M9 Canada
| | - Vidal Essebag
- McGill University Health Centre, Montreal, Canada ,Hôpital Sacré-Coeur de Montréal, Montreal, Canada
| | | | | | | | | | | | | | - Carlos Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | | | | | - Guy Amit
- McMaster University, Hamilton, Canada
| | - Paul Angaran
- St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - John Sapp
- Dalhousie University, Halifax, Canada
| | | | | | - Atul Verma
- McGill University Health Centre, Montreal, Canada
| | - Marc W. Deyell
- University of British Columbia, Vancouver, Canada ,Center for Cardiovascular Innovation, 2775 Laurel St, Vancouver, BC V5Z 1M9 Canada
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Guarguagli S, Nagarajan VD, Marinelli A, Cazzoli I, Sawhney V, Ezzat V, Ernst S. Transseptal puncture via a superior access as an alternative to the conventional femoral route. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Morcos R, Megaly M, Desai A, Alkhouli M, Saad M, Luna M, Garcia S, Khalili H, Maini B. The transseptal puncture experience: Safety insights from FDA MAUDE database. Catheter Cardiovasc Interv 2021; 98:E855-E861. [PMID: 33932271 DOI: 10.1002/ccd.29746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is a paucity of literature on safety and efficacy of various transseptal puncture (TSP) needles. OBJECTIVES To assess the reported mechanisms of failure, complications, and outcomes among the most frequently used transseptal needles in the United States. METHODS We queried the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database between January 2011 and January 2021 for reports on the most commonly used transseptal needles: NRG (Baylis Medical, Montreal, Canada), and BRK (St. Jude, Saint Paul, MN)]. The primary outcome was the mechanism of failure. Secondary outcomes included clinical consequences of device failure. RESULTS The final analysis included 306 reports of failure/complication with TSP needles (NRG n = 70, BRK n = 236). The most commonly reported mode of failure was detachment of the needle component (i.e., clip, hub, stopcock, shaft, spring, or needle tip) (14.7% overall; 17.8% BRK; and 4.3% NRG). Among these reports, cardiac perforation was the most common complication (69.9% overall; 69.1% for BRK; and 72.9% for NRG). Pericardiocentesis was the second most commonly reported complication (45.1% overall; 48.3% for BRK; and 34.3% for NRG). The procedure was successfully completed in 33.3% of all cases (36.4% for BRK and 22.9% for NRG), while surgical conversion was needed in (13.4% overall; 14% for BRK and 11.4% for NRG) of the reports. Death occurred in 3.9% of all cases overall (3.4% for BRK and 5.7% for NRG). CONCLUSIONS Needle detachment was the most common mode of failure, and cardiac perforation was the most common complication reported with TSP needles. Future efforts should focus on innovative TSP needle design, best practice guidelines, including role of imaging guidance, and increased TSP training.
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Affiliation(s)
- Ramez Morcos
- Division of Cardiology, Florida Atlantic University, Boca Raton, Florida, USA
| | - Michael Megaly
- Division of Cardiology, Banner University Medical Center/ University of Arizona, Phoenix, Arizona, USA
| | - Anand Desai
- Division of Cardiology, Florida Atlantic University, Boca Raton, Florida, USA
| | | | - Marwan Saad
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michael Luna
- School of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Santiago Garcia
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Houman Khalili
- Division of Cardiology, Florida Atlantic University, Boca Raton, Florida, USA
| | - Brijeshwar Maini
- Division of Cardiology, Florida Atlantic University, Boca Raton, Florida, USA
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Hu X, Wu S, Qin M, Jiang W, Liu X. Radiofrequency ablation for paroxysmal atrial fibrillation in a patient with dextrocardia and interruption of the inferior vena cava: a case report. Eur Heart J Case Rep 2021; 5:ytab191. [PMID: 34268479 PMCID: PMC8276615 DOI: 10.1093/ehjcr/ytab191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/13/2021] [Accepted: 04/22/2021] [Indexed: 11/23/2022]
Abstract
Background Dextrocardia with interruption of the inferior vena cava (I-IVC) is a very rare
anatomical variant. Catheter ablation of atrial fibrillation (AF) in patients with this
anatomical variant is challenging for electrophysiologists. This case report presents a
safe, effective, and radiation-free approach for high-power ablation of AF via a
superior transseptal approach in patients with dextrocardia and I-IVC. Case summary A 57-year-old man with paroxysmal AF with dextrocardia and I-IVC with azygos
continuation was referred to our hospital for radiofrequency (RF) ablation. It was
evident that transseptal puncture and pulmonary vein isolation (PVI) would be impossible
using an IVC approach via the femoral vein. Therefore, we decided to perform left atrium
(LA) ablation via the superior vena cava approach. A phased array intracardiac
echocardiography (ICE) catheter was inserted in the right femoral vein.
Three-dimensional (3D) anatomical reconstruction of LA, right atrium (RA), and coronary
sinus (CS) ostium were performed using ICE with azygos vein and RA imaging.
Navigation-enabled electrodes were inserted into annotated CS on cardiac 3D ICE image.
The left internal jugular vein was accessed using an SL1 transseptal sheath and
Brockenbrough needle. Transseptal puncture was performed under ICE with an RF-assisted
approach. We accomplished ablation index guided high-power pulmonary vein isolation
using a bi-directional guiding sheath with visualization capabilities and a surround
flow contact force-sensing catheter. No complications occurred during or after the
procedure. Discussion With the application of multitude of newer technologies, we can accomplish safe,
effective, and fluoroscopy-free RF ablation of AF using the superior approach in
patients with complex anomaly.
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Affiliation(s)
- Xiaofeng Hu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Shaohui Wu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Weifeng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Xuhui District, Shanghai 200030, China
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10
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Yagi N, Nakagami T, Yamaguchi S, Hamaoka T, Fukai K. Novel method for endovascular fenestration using radiofrequency transseptal needle for aortic dissection with malperfusion syndrome. Radiol Case Rep 2020; 15:1437-1441. [PMID: 32642013 PMCID: PMC7334550 DOI: 10.1016/j.radcr.2020.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/04/2020] [Accepted: 06/04/2020] [Indexed: 12/02/2022] Open
Abstract
Malperfusion syndrome is considered one of the most significant adverse events in aortic dissection disease and often requires invasive strategies to improve ischemia. We report the case of a patient who was presented with worsening claudication and leg rest pain due to malperfusion syndrome of type B aortic dissection. We successfully performed endovascular fenestration therapy to relieve the symptom by using a NRG radiofrequency transseptal needle (Baylis Medical, Montreal, Canada). We suggest that this novel method would be available for the patients with malperfusion syndrome of aortic dissection
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Affiliation(s)
- N Yagi
- Department of Cardiovascular Medicine, University Hospital, Kyoto Prefectural University of Medicine, 465 Kaji-cho, Kamigyo-ku, Kyoto-shi, Kyoto, 602-8566, Japan.,Department of Cardiovascular Medicine, Omihachiman Community Medical Center, 1379 Tsuchidacho, Omihachiman, Shiga, 523-0082, Japan
| | - T Nakagami
- Department of Cardiovascular Medicine, Omihachiman Community Medical Center, 1379 Tsuchidacho, Omihachiman, Shiga, 523-0082, Japan
| | - S Yamaguchi
- Department of Cardiovascular Medicine, Omihachiman Community Medical Center, 1379 Tsuchidacho, Omihachiman, Shiga, 523-0082, Japan
| | - T Hamaoka
- Department of Cardiovascular Medicine, Omihachiman Community Medical Center, 1379 Tsuchidacho, Omihachiman, Shiga, 523-0082, Japan
| | - K Fukai
- Department of Cardiovascular Medicine, Omihachiman Community Medical Center, 1379 Tsuchidacho, Omihachiman, Shiga, 523-0082, Japan
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11
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Sanchez JM, Shah R, Kouassi Y, Chronowic M, Wilson L, Marcus GM. A cost‐effectiveness analysis comparing a conventional mechanical needle to a radiofrequency device for transseptal punctures. J Cardiovasc Electrophysiol 2020; 31:1672-1677. [DOI: 10.1111/jce.14500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/27/2022]
Affiliation(s)
- José M. Sanchez
- Section of Cardiac Electrophysiology, Division of Cardiology University of California San Francisco California
| | - Rahil Shah
- Department of Clinical Pharmacy University of California San Francisco California
| | - Yao Kouassi
- Department of Clinical Pharmacy University of California San Francisco California
| | | | - Leslie Wilson
- Department of Clinical Pharmacy University of California San Francisco California
| | - Gregory M. Marcus
- Section of Cardiac Electrophysiology, Division of Cardiology University of California San Francisco California
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12
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Imnadze G, Ajaj T, Bante H, Sohns C, Sommer P. Transseptal puncture without fluoroscopy using a radiofrequency needle: A case series. Cardiol J 2020; 28:655-662. [PMID: 32037502 DOI: 10.5603/cj.a2020.0008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/21/2020] [Accepted: 12/24/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The non-fluoroscopy approach with the use of a three-dimensional (3D) navigation system is increasingly recognized as a future technology in the treatment of arrhythmias. However, there are a limited number of articles published concerning transseptal puncture without the use of fluoroscopy. METHODS Presented in this paper is the first series of patients (n = 10) that have undergone transseptal puncture without the use of fluoroscopy under transesophageal echocardiography control using a radiofrequency transseptal needle and a 3D navigation system. RESULTS All patients were treated without complications. In 6 patients, re-pulmonary vein isolation was performed. In 5 cases, linear ablation of the left atrium for treatment of left atrial macro re-entry tachycardia was provided. In 2 patients, focal atrial tachycardia was treated, 1 patient underwent cavo tricuspidal isthmus (CTI) ablation and 1 patient, re-CTI ablation. The ablation of complex fragmented atrial electrograms was done in 2 patients. In 1 case, right atrial macro re-entry tachycardia was treated. CONCLUSIONS Transseptal puncture without using fluoroscopy is safe and effective when using a radiofrequency needle, a 3D navigation system and transesophageal echocardiography.
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Affiliation(s)
- Guram Imnadze
- Arrhythmia Department, Klinikum Osnabrueck, Germany. .,Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany.
| | - Tarek Ajaj
- Arrhythmia Department, Klinikum Osnabrueck, Germany
| | | | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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13
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Meier D, Antiochos P, Herrera-Siklody C, Eeckhout E, Delabays A, Tzimas G, Fournier S, Pascale P, Muller O, Monney P. Interatrial septum dissection and atrial wall hematoma following transseptal puncture: A systematic review of the literature. Catheter Cardiovasc Interv 2019; 96:424-431. [PMID: 31642609 DOI: 10.1002/ccd.28554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/08/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Interatrial septum (IAS) dissection due to transseptal puncture (TSP) is a rare, underreported complication of the procedure. Data on the mechanism, diagnosis, and management of this complication are lacking. METHODS We conducted a systematic review of all reported cases of IAS dissection with or without associated LA hematoma due to TSP, by thoroughly searching MEDLINE and EMBASE through May 2019. RESULTS After screening of n = 882 studies, eight studies with a total of 19 patients addressed the complication of IAS dissection and/or LA hematoma secondary to TSP. Median age was 63 years with a 1:1 male to female ratio. Ablation of atrial fibrillation was the most frequently reported procedure (84%). Diagnosis was established using fluoroscopy with contrast injection (58%), TEE (32%) or intracardiac echocardiography (5%). The mechanism identified involved puncture of the septum secundum portion of the IAS, leading to transient needle passage into the extracardiac space. In the majority of patients, the hematoma remained localized in the IAS and management was conservative with progressive resolution of the hematoma during follow-up (95%). Two patients (11%) required further intervention by either pericardiocentesis or surgical drainage due to hemodynamic instability. CONCLUSIONS IAS dissection with or without hematoma after TSP remains an underdiagnosed entity. The main mechanism involves lesion to the septum secundum portion of the IAS, resulting in needle passage into the extracardiac space and local bleeding. Although conservative management may be sufficient in the majority of cases, interventional cardiologists should be familiar with this complication and its diagnosis.
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Affiliation(s)
- David Meier
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Panagiotis Antiochos
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | | | - Eric Eeckhout
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alain Delabays
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Georgios Tzimas
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Stephane Fournier
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy
| | - Patrizio Pascale
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Olivier Muller
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Pierre Monney
- Division of Cardiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
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14
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15
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Gul EE, Abuelatta R, Haseeb S, Melhem M, Al Amoudi O. Venoplasty of a chronic venous occlusion with 'diathermy' for cardiac device lead placement. Indian Pacing Electrophysiol J 2018; 19:27-29. [PMID: 30367925 PMCID: PMC6354209 DOI: 10.1016/j.ipej.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/16/2018] [Accepted: 10/23/2018] [Indexed: 10/28/2022] Open
Abstract
Venous revascularization is an approach used in patients with total venous occlusion requiring venous access for cardiac device lead placement. Several percutaneous approaches to venous revascularization have been proposed. For the first time, we describe the case of a 69-year-old male with total venous occlusion who was successfully revascularized using a 'diathermy' technique.
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Affiliation(s)
- Enes Elvin Gul
- Division of Cardiac Electrophysiology, Department of Cardiology, Madinah Cardiac Centre, Madinah, Saudi Arabia.
| | - Reda Abuelatta
- Division of Cardiac Electrophysiology, Department of Cardiology, Madinah Cardiac Centre, Madinah, Saudi Arabia
| | - Sohaib Haseeb
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Mohammad Melhem
- Division of Cardiac Electrophysiology, Department of Cardiology, Madinah Cardiac Centre, Madinah, Saudi Arabia
| | - Osama Al Amoudi
- Division of Cardiac Electrophysiology, Department of Cardiology, Madinah Cardiac Centre, Madinah, Saudi Arabia
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16
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Bailout Atrial Balloon Septoplasty to Overcome Challenging Left Atrial Transseptal Access for Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol 2018; 4:1011-1019. [DOI: 10.1016/j.jacep.2018.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/26/2018] [Accepted: 04/05/2018] [Indexed: 11/17/2022]
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17
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Tokuda M, Yamashita S, Matsuo S, Kato M, Sato H, Oseto H, Okajima E, Ikewaki H, Isogai R, Tokutake K, Yokoyama K, Narui R, Tanigawa SI, Inada K, Yoshimura M, Yamane T. Radiofrequency needle for transseptal puncture is associated with lower incidence of thromboembolism during catheter ablation of atrial fibrillation: propensity score-matched analysis. Heart Vessels 2018; 33:1238-1244. [DOI: 10.1007/s00380-018-1159-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/30/2018] [Indexed: 11/24/2022]
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18
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Salghetti F, Sieira J, Chierchia GB, Curnis A, de Asmundis C. Recognizing and reacting to complications of trans-septal puncture. Expert Rev Cardiovasc Ther 2017; 15:905-912. [PMID: 29161923 DOI: 10.1080/14779072.2017.1408411] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The transseptal puncture (TSP) enables access to the left heart, through the fossa ovalis (FO), both in electrophysiology and in cardiac interventional procedures. TSP is usually safe in experienced hands. Sometimes TSP can be technically demanding and carries the risk of severe complications in approximately 1%. While performing a TSP, every effort should be taken in order to avoid complications. In the event of complications, prompt recognition and reaction are essential and a combined 'heart-team' management may be the most effective approach. Areas covered: Main TSP-related complications are cardiac tamponade, aortic root puncture, embolic stroke, transient ST elevation of inferior leads and iatrogenic atrial septal defect. A challenging TSP may be expected in presence of difficult IAS-FO anatomies, previous TSP, IAS occluder device and previous IAS surgical repair. Use of echo imaging and special needles (ie., radiofrequency needle and J-shaped guidewire) may avoid TSP-related complications in difficult settings. Expert commentary: Some tools are available to help minimize the risks of TSP. However, their availability might be limited. To increase safety of TSP, an adequate training of physicians, identification of patients in whom it might be difficult and a prompt recognition of complications seem to be the most important background.
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Affiliation(s)
- Francesca Salghetti
- a Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing , Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium.,b Division of Cardiology , Spedali Civili Hospital, Università degli Studi di Brescia , Brescia , Italy
| | - Juan Sieira
- a Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing , Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
| | - Gian-Battista Chierchia
- a Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing , Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
| | - Antonio Curnis
- b Division of Cardiology , Spedali Civili Hospital, Università degli Studi di Brescia , Brescia , Italy
| | - Carlo de Asmundis
- a Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing , Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
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19
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Wong RH, Yu PS, Kwok MW, Chow SC, Ho JY, Underwood MJ, Yu SC. Endovascular Fenestration for Distal Aortic Sealing After Frozen Elephant Trunk With Thoraflex. Ann Thorac Surg 2017; 103:e479-e482. [DOI: 10.1016/j.athoracsur.2016.12.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/06/2016] [Accepted: 12/18/2016] [Indexed: 10/19/2022]
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20
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Radinovic A, Mazzone P, Landoni G, Agricola E, Regazzoli D, Della-Bella P. Different transseptal puncture for different procedures: Optimization of left atrial catheterization guided by transesophageal echocardiography. Ann Card Anaesth 2017; 19:589-593. [PMID: 27716687 PMCID: PMC5070316 DOI: 10.4103/0971-9784.191548] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Left atrial catheterization through transseptal puncture is frequently performed in cardiac catheterization procedures. Appropriate transseptal puncture is critical to achieve procedural success. Aims: The aim of the study is to evaluate the feasibility of selective transseptal punctures, using a modified radiofrequency (RF) transseptal needle and transesophageal echocardiography (TEE), in different types of procedures that require specific sites of left atrial catheterization. Setting and Design: This was an observational trial in a cardiac catheterization laboratory of a teaching hospital. Materials and Methods: Patients undergoing different percutaneous procedures requiring atrial transseptal puncture such as atrial fibrillation (AF) ablation, left atrial appendage (LAA) occlusion, and mitral valve repair were included in the study. All procedures were guided by TEE and an RF transseptal needle targeting a specific region of the septum to perform the puncture. Statistical Analysis: The statistical analysis was descriptive only. Results: RF-assisted transseptal punctures were performed in six consecutive patients who underwent AF ablation (two patients), LAA closure (two patients), and mitral valve repair (two patients). In all patients, transseptal punctures were performed successfully at the desired site. No adverse events or complications were observed. Conclusions: Selective transseptal puncture, using TEE and an RF needle, is a feasible technique that can be used in multiple approaches requiring a precise site of access for left atrial catheterization.
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Affiliation(s)
- Andrea Radinovic
- Department of Arrhythmology and Cardiac Pacing Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizio Mazzone
- Department of Arrhythmology and Cardiac Pacing Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy
| | - Eustachio Agricola
- Department of Arrhythmology and Cardiac Pacing Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Damiano Regazzoli
- Department of Arrhythmology and Cardiac Pacing Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della-Bella
- Department of Arrhythmology and Cardiac Pacing Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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21
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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: 43] [Impact Index Per Article: 6.1] [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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22
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Morais P, Vilaça JL, Ector J, D'hooge J, Tavares JMRS. Novel Solutions Applied in Transseptal Puncture: A Systematic Review. J Med Device 2017. [DOI: 10.1115/1.4035374] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Access to the left atrium is required for several minimally invasive cardiac interventions in the left heart. For this purpose, transseptal puncture (TSP) technique is often performed, perforating the atrial septum under fluoroscopic or/and ultrasound imaging guidance. Although this approach has been used for many years, complications/failures are not uncommon mainly in patients with abnormal atrial anatomy and repeated TSP. Thus, this study presents an overview of methods and techniques that have been proposed to increase the safety and feasibility of the TSP. A systematic review of literature was conducted through the analysis of the articles published between 2008 and 2015. The search was performed in PubMed, Scopus, and ISI Web of Knowledge using the expression “transseptal puncture.” A total of 354 articles were retrieved from the databases, and 64 articles were selected for this review. Moreover, these 64 articles were divided into four categories, namely: (1) incidence studies, (2) intraprocedural guidance techniques, (3) preprocedural planning methods, and (4) surgical instruments. A total of 36 articles focused on incidence studies, 24 articles suggested novel intraprocedural guidance techniques, 5 works focused on preprocedural planning strategies, and 21 works proposed surgical instruments. The novel 3D guidance techniques, radio-frequency surgical instruments, and pre-interventional planning approaches showed potential to overcome the main procedural limitations/complications, through the reduction of the intervention time, radiation, number of failures, and complications.
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Affiliation(s)
- Pedro Morais
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães 4710-057, Portugal
- Lab on Cardiovascular Imaging and Dynamics, KU Leuven, Leuven 3000, Belgium
- Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Faculdade de Engenharia, Universidade do Porto, Porto, Portugal
| | - João L. Vilaça
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães 4710-057, Portugal
- DIGARC—Polytechnic Institute of Cávado and Ave, Vila Frescainha S. Martinho Barcelos 4750-810, Portugal
| | - Joris Ector
- Lab on Cardiovascular Imaging & Dynamics, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Jan D'hooge
- Lab on Cardiovascular Imaging & Dynamics, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - João Manuel R. S. Tavares
- Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Departamento de Engenharia Mecânica, Faculdade de Engenharia, Universidade do Porto, Rua Dr. Roberto Frias, s/n, Porto 4200-465, Portugal e-mail:
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23
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Sharma G, Singh GD, Smith TW, Fan D, Low RI, Rogers JH. Accuracy and procedural characteristics of standard needle compared with radiofrequency needle transseptal puncture for structural heart interventions. Catheter Cardiovasc Interv 2016; 89:E200-E206. [DOI: 10.1002/ccd.26608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 04/13/2016] [Accepted: 05/02/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Gaurav Sharma
- Division of Cardiovascular Medicine; University of California Davis Medical Center; Sacramento California
| | - Gagan D. Singh
- Division of Cardiovascular Medicine; University of California Davis Medical Center; Sacramento California
| | - Thomas W. Smith
- Division of Cardiovascular Medicine; University of California Davis Medical Center; Sacramento California
| | - Dali Fan
- Division of Cardiovascular Medicine; University of California Davis Medical Center; Sacramento California
| | - Reginald I. Low
- Division of Cardiovascular Medicine; University of California Davis Medical Center; Sacramento California
| | - Jason H. Rogers
- Division of Cardiovascular Medicine; University of California Davis Medical Center; Sacramento California
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24
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Karagöz T, Akın A, Aykan HH. NRG™ RF powered transseptal needle: a useful technique for transcatheter atrial septostomy and Fontan fenestration: report of three cases. Bosn J Basic Med Sci 2014; 14:259-62. [PMID: 25428681 DOI: 10.17305/bjbms.2014.4.60] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 09/28/2014] [Accepted: 09/28/2014] [Indexed: 11/16/2022] Open
Abstract
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.
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25
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Maisano F, La Canna G, Latib A, Godino C, Denti P, Buzzatti N, Taramasso M, Cioni M, Giacomini A, Colombo A, Alfieri O. Transseptal access for MitraClip® procedures using surgical diathermy under echocardiographic guidance. EUROINTERVENTION 2012; 8:579-86. [DOI: 10.4244/eijv8i5a89] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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26
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Greenstein E, Passman R, Lin AC, Knight BP. Incidence of tissue coring during transseptal catheterization when using electrocautery and a standard transseptal needle. Circ Arrhythm Electrophysiol 2012; 5:341-4. [PMID: 22331817 DOI: 10.1161/circep.111.968040] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The application of radiofrequency electrocautery to a standard, open-ended transseptal needle has been used to facilitate transseptal puncture (TSP). The purpose of this study was to determine the incidence of cardiac tissue coring when this technique is used. METHODS AND RESULTS A model using excised swine hearts submerged in a saline-filled basin was developed to simulate TSP with electrocautery and a standard transseptal needle. Punctures were performed without the use of electrocautery and by delivering radiofrequency energy to the transseptal needle using a standard electrocautery pen at 3 target sites (fossa ovalis, non-fossa ovalis septum, and aorta). The tissue of the submerged heart was gently tented, and the needle was advanced on delivery of radiofrequency. The devices were retracted, and the needle was flushed in a collection basin. None of the TSPs without cautery caused tissue coring. For TSPs using electrocautery, the frequency of coring was at least 21% for any puncture permutation used in the study and averaged 37% at septal sites (P<0.001 compared with punctures without cautery). Tissue coring occurred in 33 of 96 (35%) punctures through the fossa ovalis and in 38 of 96 (40%) punctures through non-fossa ovalis septum. The frequency of tissue coring at aortic sites was 62 of 96 (65%), which was significantly higher than at the septal sites (P<0.001). CONCLUSIONS In an animal preparation, TSP at the level of the fossa ovalis using electrocautery and a standard open-ended Brockenbrough needle resulted in coring of the septal tissue in 35% of cases (33 of 96 punctures).
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Affiliation(s)
- Eugene Greenstein
- Division of Cardiology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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