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Blockhaus C, Waibler H, Guelker J, Klues H, Bufe A, Seyfarth M, Koektuerk B, Shin D. Transesophageal echocardiography guided transseptal puncture and nadir temperatures in cryoballoon pulmonary vein isolation. J Arrhythm 2022; 38:238-244. [PMID: 35387133 PMCID: PMC8977571 DOI: 10.1002/joa3.12679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/27/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Cryoballoon (CB) guided pulmonary vein isolation (PVI) is an established procedure in the treatment of atrial fibrillation (AF). Transseptal access is an indispensable step during PVI and may be associated with severe complications. For specific interventions, specific puncture sites of the fossa ovalis are advantageous. Here, we analyzed the potential impact of a transesophageal echocardiography (TOE) guided transseptal puncture on nadir temperatures in CB PVI. Methods and Results We retrospectively analyzed 209 patients undergoing CB PVI in our hospital. The use of TOE had been at the operator’s discretion. No TOE‐related complications such as perforation of the pharynx or esophagus or loss of teeth were noted. Concerning the applied freezes, we found significantly lower nadir temperatures in all PVs in the TOE group than in the non‐TOE group. Procedure time and fluoroscopy time and complications were similar in both groups. Conclusion TOE‐guided TSP in CB PVI is safe and feasible. Our study found significantly lower nadir temperatures of CB freezes after TOE‐guided TSP which potentially underscores the value of a more infero‐anterior puncture site.
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Affiliation(s)
- Christian Blockhaus
- Department of Cardiology Heart Centre Niederrhein Helios Clinic Krefeld Germany
- Witten‐Herdecke University Witten Germany
| | - Hans‐Peter Waibler
- Department of Cardiology Heart Centre Niederrhein Helios Clinic Krefeld Germany
| | - Jan‐Erik Guelker
- Witten‐Herdecke University Witten Germany
- Department of Cardiology Petrus Hospital Wuppertal Germany
| | - Heinrich Klues
- Department of Cardiology Heart Centre Niederrhein Helios Clinic Krefeld Germany
| | - Alexander Bufe
- Department of Cardiology Heart Centre Niederrhein Helios Clinic Krefeld Germany
- Witten‐Herdecke University Witten Germany
| | - Melchior Seyfarth
- Witten‐Herdecke University Witten Germany
- Department of Cardiology Helios University Hospital Wuppertal Germany
| | - Buelent Koektuerk
- Department of Cardiology Heart Centre Niederrhein Helios Clinic Krefeld Germany
- Witten‐Herdecke University Witten Germany
| | - Dong‐In Shin
- Department of Cardiology Heart Centre Niederrhein Helios Clinic Krefeld Germany
- Witten‐Herdecke University Witten Germany
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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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Abstract
BACKGROUND Transseptal puncture for left heart interventions became a routine procedure guided by fluoroscopy and echocardiography. The use of intracardiac potentials derived from the sheath-transseptal-needle/guidewire-combination may provide helpful information to increase safety of this procedure. METHODS AND RESULTS We recorded the intracardiac potentials from the sheath-transseptal-needle/guidewire-combination during the transseptal puncture procedure in 31 consecutive patients (mean age 67.2±8.2years; 21 in sinus rhythm, 10 in atrial fibrillation) designated for ablation of atrial fibrillation by the Cryo-balloon ® technique (Medtronic, Minnesota, USA). The EP-Navigator ® 3-D-image integration tool (Philips Healthcare, Hamburg, Germany) was used for visualization of the device position in relation to the cardiac structures. Typical and reproducible potentials could be derived in all patients for the different device localizations at transseptal puncture procedure. Especially the transition from the muscular interatrial septum into the fossa ovalis could be easily depicted by the changes of both morphology and magnitude of the atrial signal (6.1±2.3mV in sinus rhythm [SR]/3.5±0.9mV in atrial fibrillation [AF] at the muscular interatrial septum and 0.5±0.2mV in SR/0.5±0.1mV in AF in the fossa ovalis). CONCLUSIONS The crucial steps of a transseptal procedure can be verified by typical changes (morphology and amplitude) of the intracardiac signals derived from the sheath-transseptal-needle/guidewire-combination in patients with sinus rhythm as well as in atrial fibrillation.
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Afzal S, Veulemans V, Balzer J, Rassaf T, Hellhammer K, Polzin A, Kelm M, Zeus T. Safety and efficacy of transseptal puncture guided by real-time fusion of echocardiography and fluoroscopy. Neth Heart J 2016; 25:131-136. [PMID: 27966185 PMCID: PMC5260626 DOI: 10.1007/s12471-016-0937-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aims Visual guidance through echocardiography and fluoroscopy is crucial for a successful transseptal puncture (TSP) in a prespecified region of the fossa ovalis. The novel EchoNavigator system Release II (EchoNav II, Philips Healthcare, Andover, Massachusetts, USA) enables the real-time fusion of fluoroscopic and echocardiographic images. We evaluated this new imaging method in respect to safety and efficacy of TSP during MitraClip implantation and left atrial appendage closure. Methods Forty-four patients before (−EchoNav) and 44 patients after (+EchoNav) the introduction of real-time fusion were included in our retrospective, single-centre study. The primary endpoint was the occurrence of adverse events due to TSP. Secondary endpoints were successful puncture at the prespecified region and time until TSP (min). Results In both groups TSP was performed successfully in the prespecified region and no adverse events occurred during or due to the accomplishment of TSP. Time until TSP was significantly reduced in the +EchoNav group in comparison with the EchoNav group (18.48 ± 5.62 min vs. 23.20 ± 9.61 min, p = 0.006). Conclusions Real-time fusion of echocardiography and fluoroscopy proved to be as safe and successful as standard best practice for TSP. Moreover, efficacy was improved through significant reduction of time until TSP.
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Affiliation(s)
- S Afzal
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany.
| | - V Veulemans
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - J Balzer
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - T Rassaf
- Department of Cardiology, University Hospital Essen, Westgerman Heart-and Vascular Centre, Essen, Germany
| | - K Hellhammer
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - A Polzin
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - M Kelm
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - T Zeus
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
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Erden İ, Erden EÇ, Golcuk E, Aksu T, Yalin K, Güler TE, Özcan KS, Turan B. Impact of transesophageal echocardiography during transseptal puncture on atrial fibrillation ablation. J Arrhythm 2016; 32:170-5. [PMID: 27354860 PMCID: PMC4913159 DOI: 10.1016/j.joa.2015.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/25/2015] [Accepted: 12/16/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of our study was to demonstrate the added value of routine transesophageal echocardiography (TEE) for correctly positioning the transseptal system in the fossa ovalis (FO), thus potentially preventing complications during fluoroscopy-guided transseptal puncture (TP), and for assessing the optimal puncture site within the FO according to the expected procedure type. METHODS Ninety-one patients undergoing pulmonary vein isolation (PVI) procedures by cryoballoon technique for drug-resistant paroxysmal or persistent atrial fibrillation (AF) were prospectively included. In 57 patients, the TP procedure was performed under fluoroscopic guidance and septal localization was confirmed by contrast injection through the needle and demonstration of septal tenting in both the anteroposterior and left lateral fluoroscopic projections. In 34 patients, TP was performed under TEE guidance and positioning was targeted to perform the TP procedure in the more anterior and inferior locations of the FO. Two patient groups were compared according to the incidence of complications directly attributable to transseptal catheterization, thromboembolic complications, recurrence rates after the ablation procedure, total procedural time, and fluoroscopy time. RESULTS Fluoroscopy time (p<0.001), total cryoablation time (p=0.002), and total procedural time (p<0.001) were shorter in the TEE-guided group. Left inferior pulmonary vein (LIPV) cryoablation time (p=0.007) and right inferior pulmonary vein (RIPV) cryoablation time (p=0.004) were significantly shorter and the number of applications to the LIPV (p=0.007) and RIPV (p=0.005) were significantly fewer in the TEE-guided group. Although there was a trend toward higher complication rates (20.6% vs. 31.6%, p=0.37) and recurrence rates (11.8% vs. 20.1%, p=0.26) in the fluoroscopy-guided group, the differences between the groups were not statistically significant. CONCLUSIONS TEE-guided TP for AF ablation is associated with shorter fluoroscopy time, shorter total cryoablation time, and shorter total procedural time. Importantly, TEE-guided TP facilitates cryoablation of the inferior pulmonary veins.
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Affiliation(s)
- İsmail Erden
- Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey
| | - Emine Çakcak Erden
- Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey
| | - Ebru Golcuk
- Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey
| | - Tolga Aksu
- Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey
| | - Kıvanç Yalin
- Bursa State Hospital, Cardiology, Clinic, Hasta Yurdu Cd., No. 31, PK 16040 Tophane, Bursa, Turkey
| | - Tümer Erdem Güler
- Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey
| | - Kazım Serhan Özcan
- Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey
| | - Burak Turan
- Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey
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HOWARD STEPHENA, QUALLICH STEPHENG, BENSCOTER MARKA, HOLMGREN BRYCEC, ROLFES CHRISTOPHERD, IAIZZO PAULA. Tissue Properties of the Fossa Ovalis as They Relate to Transseptal Punctures
: A Translational Approach. J Interv Cardiol 2015; 28:98-108. [DOI: 10.1111/joic.12174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- STEPHEN A. HOWARD
- Department of Biomedical Engineering; University of Minnesota; Minneapolis Minnesota
- Medtronic, Inc.; Mounds View Minnesota
| | - STEPHEN G. QUALLICH
- Department of Biomedical Engineering; University of Minnesota; Minneapolis Minnesota
- Department of Surgery; University of Minnesota; Minneapolis Minnesota
| | - MARK A. BENSCOTER
- Department of Biomedical Engineering; University of Minnesota; Minneapolis Minnesota
- Medtronic, Inc.; Mounds View Minnesota
| | - BRYCE C. HOLMGREN
- Department of Biomedical Engineering; University of Minnesota; Minneapolis Minnesota
- Department of Surgery; University of Minnesota; Minneapolis Minnesota
| | - CHRISTOPHER D. ROLFES
- Department of Biomedical Engineering; University of Minnesota; Minneapolis Minnesota
- Department of Surgery; University of Minnesota; Minneapolis Minnesota
| | - PAUL A. IAIZZO
- Department of Biomedical Engineering; University of Minnesota; Minneapolis Minnesota
- Department of Surgery; University of Minnesota; Minneapolis Minnesota
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