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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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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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A novel and easy approach to difficult transseptal puncture during atrial fibrillation ablation. J Interv Card Electrophysiol 2020; 62:269-276. [PMID: 33034794 DOI: 10.1007/s10840-020-00891-y] [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: 03/26/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
AIMS Transseptal passage is sometimes difficult to obtain. This study evaluates the feasibility and safety of a novel and easy transseptal puncture (TSP) technique named 2D2G (using two dilators and two guidewires) in patients with difficult TSP. METHODS AND RESULTS Forty-four paroxysmal atrial fibrillation patients with difficult TSP were enrolled in this study. They were allocated to the 2D2G group or the conventional group in a 1:1 fashion. The primary endpoint in both groups was successful TSP without changing the puncture site or using auxiliary tools. The secondary endpoints were the safety, total transseptal puncture time, and ablation time. There were no differences in baseline demographic or clinical characteristics between the two groups. Successful LA access in the 2D2G group was 100% (vs. 64%, P < 0.05). The total TSP time (10 ± 3 min vs. 5 ± 1 min, P < 0.05) and ablation time (42 ± 19 min vs. 58 ± 22 min, P < 0.05) in the conventional group were significantly longer than those in the 2D2G group. No major complications occurred in either group, and all the patients underwent successful circumferential pulmonary vein isolation (CPVI). CONCLUSION In AF patients with difficult TSP, the 2D2G technique is safe, feasible, and time-saving.
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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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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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Alkhouli M, Rihal CS, Holmes DR. Transseptal Techniques for Emerging Structural Heart Interventions. JACC Cardiovasc Interv 2017; 9:2465-2480. [PMID: 28007198 DOI: 10.1016/j.jcin.2016.10.035] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/25/2016] [Accepted: 10/06/2016] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Mohamad Alkhouli
- Divisions of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Charanjit S Rihal
- Divisions of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - David R Holmes
- Divisions of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.
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Raphael CE, Alkhouli M, Maor E, Panaich SS, Alli O, Coylewright M, Reeder GS, Sandhu G, Holmes DR, Nishimura R, Malouf J, Cabalka A, Eleid MF, Rihal CS. Building Blocks of Structural Intervention. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005686. [DOI: 10.1161/circinterventions.117.005686] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Claire E. Raphael
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Mohamad Alkhouli
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Elad Maor
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Sidakpal S. Panaich
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Oluseun Alli
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Megan Coylewright
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Guy S. Reeder
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Gurpreet Sandhu
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - David R. Holmes
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Rick Nishimura
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Joseph Malouf
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Allison Cabalka
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Mackram F. Eleid
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
| | - Charanjit S. Rihal
- From the Departments of Cardiovascular Medicine (C.E.R., E.M., S.S.P., G.S.R., G.S., D.R.H., R.N., J.M., M.F.E., C.S.R.) and Pediatrics (A.C.), Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown (M.A.); Division of Cardiology, Department of Medicine, Novant Heart and Vascular Institute, Charlotte, NC (O.A.); and Department of Cardiology, Dartmouth-Hitchcock Heart and Vascular Center, Lebanon, NH (M.C.)
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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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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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12
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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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ARKLES JEFFREY, ZADO ERICA, SUPPLE GREGORY, FRANKEL DAVIDS, CALLANS DAVID, MARCHLINSKI FRANCIS, DIXIT SANJAY. Feasibility of Transseptal Access in Patients With Previously Scarred or Repaired Interatrial Septum. J Cardiovasc Electrophysiol 2015; 26:963-968. [DOI: 10.1111/jce.12730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 05/09/2015] [Accepted: 05/18/2015] [Indexed: 12/18/2022]
Affiliation(s)
- JEFFREY ARKLES
- Electrophysiology Section; Cardiovascular Division, Temple University Hospital; Philadelphia Pennsylvania USA
| | - ERICA ZADO
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - GREGORY SUPPLE
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - DAVID S. FRANKEL
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - DAVID CALLANS
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - FRANCIS MARCHLINSKI
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - SANJAY DIXIT
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
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Comparison of a Radiofrequency Powered Flexible Needle with a Classic Rigid Brockenbrough Needle for Transseptal Punctures in Terms of Safety and Efficacy. Heart Lung Circ 2015; 24:173-8. [DOI: 10.1016/j.hlc.2014.07.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/29/2014] [Accepted: 07/28/2014] [Indexed: 12/26/2022]
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15
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Yao Y, Ding L, Chen W, Guo J, Bao J, Shi R, Huang W, Zhang S, Wong T. The training and learning process of transseptal puncture using a modified technique. Europace 2013; 15:1784-90. [DOI: 10.1093/europace/eut078] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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16
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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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17
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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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Fromentin S, Sarrazin JF, Champagne J, Nault I, Philippon F, Molin F, Blier L, O’Hara G. Prospective comparison between conventional transseptal puncture and transseptal needle puncture with radiofrequency energy. J Interv Card Electrophysiol 2011; 31:237-42. [DOI: 10.1007/s10840-011-9564-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
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SY RAYMONDW, KLEIN GEORGEJ, LEONG-SIT PETER, GULA LORNEJ, YEE RAYMOND, KRAHN ANDREWD, SKANES ALLANC. Troubleshooting Difficult Transseptal Catheterization. J Cardiovasc Electrophysiol 2011; 22:723-7. [DOI: 10.1111/j.1540-8167.2010.01987.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Transseptal puncture using minimally invasive echocardiography during atrial fibrillation ablation. Europace 2010; 12:1435-8. [DOI: 10.1093/europace/euq297] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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21
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De Ponti R. Transseptal catheterization for ablation in the left heart: what to do when the door is locked up tight? Europace 2010; 12:604-5. [PMID: 20382969 DOI: 10.1093/europace/euq099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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