Complication prevention in ablation procedures: How to perform transseptal puncture safely in case of atrial septum aneurysm

Interatrial septum dissection and closure from transseptal puncture during mitral transcatheter edge-to-edge repair: a case report

Background

An 85-year-old woman was referred for mitral valve transcatheter edge-to-edge repair (TEER) following multiple heart failure hospitalizations related to her severe functional mitral regurgitation. In addition to previous transcatheter aortic valve replacement for aortic stenosis, her past medical history was significant for chronic steroid use related to microscopic polyangiitis leading to renal transplantation.

Case summary

Her procedure was complicated by an interatrial septum dissection with associated haemopericardium originating from the transseptal puncture site. To our knowledge, our case demonstrates the first use of an Amplatzer occluder device to manage this complication by preventing ongoing flow into the pericardial space. This complication occurred in the setting of a single, successful transseptal puncture in the typical location for a mitral valve TEER procedure, raising the consideration that chronic steroid use may be an underappreciated risk factor for iatrogenic interatrial septal damage.

Discussion

Transoesophageal echocardiography is integral to identifying and risk stratifying this complication, and imagers should have a low threshold to screen for it, particularly in the setting of haemodynamic compromise. The decision to deploy a closure device should be made on a case-by-case basis considering the risks and benefits of doing so compared with conservative management.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

The transseptal puncture experience: Safety insights from FDA MAUDE database

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.