Transseptal left heart catheterization for cardiac ablation procedures

Transesophageal Echocardiography Improves Precision in Transseptal Puncture Compared to Fluoroscopy in Left Atrial Electrophysiological Procedures

Background: Complex arrhythmias often arise from the left side of the heart, necessitating established electrophysiological (EP) procedures like 3D-mapping-assisted radiofrequency (RF) ablations or pulmonary vein isolation (PVI). These procedures typically require transseptal access, emphasizing the critical role of achieving an optimal catheter position through a precise transseptal puncture (TSP). Commonly employed imaging methods for TSP guidance include fluoroscopy and interventional echocardiography. Despite their routine use, there is limited evidence on which imaging modality offers superior catheter positioning for EP procedures, and safety concerns regarding transseptal punctures with imaging remain underexplored. This study aims to systematically evaluate the feasibility, safety, and accuracy of echo-guided TSP compared to fluoroscopy-guided TSP. Methods: In this prospective study, 150 consecutive patients undergoing left atrial EP procedures were enrolled between October 2023 and February 2024 at the Ulm University Heart Center. Following optimal fluoroscopy-guided transseptal needle positioning at the interatrial septum, the catheter placement was further verified using transesophageal echocardiography (TEE). Adjustments were made in cases of suboptimal needle positioning observed in TEE. The fluoroscopically achieved septal positions were categorized based on TEE images as optimal, suboptimal, poor, or dangerous. Results: Among the 150 patients included (58.0% male), fluoroscopy achieved optimal, suboptimal, and poor/dangerous positions in 32.7%, 43.3%, and 24.0%, respectively. After TEE-guided adjustments, optimal and suboptimal positions were achieved in 59.3% and 40.7% of patients, respectively. No instances of poor or dangerous transseptal needle positions were observed under TEE guidance. Conclusions: TEE-guided TSP emerges as a feasible, more accurate, and safer imaging method for transseptal punctures in EP procedures.

First experience with a transseptal puncture using a novel transseptal crossing device with integrated dilator and needle

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.

The use of a novel nitinol guidewire to facilitate transseptal puncture and left atrial catheterization for catheter ablation procedures

AIMS

An increasing number of transseptal punctures (TSPs) are performed worldwide for atrial ablations. Transseptal punctures can be complex and can be associated with potentially life threatening complications. The purpose of the study was to evaluate the safety and efficacy of a novel transseptal guidewire (TSGW) designed to facilitate TSPs.

METHODS AND RESULTS

Transseptal punctures were performed using a SafeSept TSGW passed through a standard TSP apparatus. Transseptal punctures were performed by standard technique with additional use of a TSGW allowing probing of the interatrial septum without needle exposure and penetration of the fossa into the left atrium (LA). Transseptal puncture using the TSGW was performed in 210 patients. Left atrial access was achieved successfully in 205 of 210 patients (97.6%) and in 96.3% of patients undergoing repeat TSP. Left atrial access was achieved with the first pass in 81.2% (mean 1.4 ± 0.9 passes, range 1-6) using the TSGW. No serious complications were attributable to the use of the TSGW, even in cases of failed TSP.

CONCLUSIONS

The TSGW is associated with a high success rate for TSP and may be a useful alternative to transoesophageal or intracardiac echocardiogram-guided TSP.

Double transseptal puncture for catheter ablation of atrial fibrillation: safety of the technique and its use in the outpatient setting

Introduction. For pulmonary vein isolation in patients with atrial fibrillation (AF), some centers use the double transseptal puncture technique for catheter access in order to facilitate catheter manipulation within the left atrium. However, no safety data has so far been published using this approach. Method. 269 ablation procedures were performed in 243 patients (mean age 56.6 ± 9.3 years, 75% men) using the double transseptal puncture for catheter access in all cases. Patients were considered for ablation of paroxysmal (80%), persistent (19%), and permanent (1%) AF. 230 procedures were performed on an outpatient basis (85.5%), and 26 were repeat procedures (9.7%). Results. The double transseptal puncture catheter access was successfully achieved in all patients. The procedural success with the endpoint of pulmonary vein isolation was reached in 255 procedures (95%). A total of 1048 out of 1062 pulmonary veins (99%) were successfully isolated. Major complications occurred in eight patients (3.0%). Of these, seven patients (2.6%) had pericardial effusion requiring percutaneous drainage, and one patient (0.4%) suffered a minor reversible stroke. One patient (0.4%) had a minor air embolism with transient symptoms. Conclusion. The double transseptal puncture catheterization technique allows easy catheter manipulation within the left atrium to reach the goal of acute procedural success in AF ablation. Procedure-related complications are rare, and the technique can be used safely for AF ablation in the outpatient setting.

Interatrial septal puncture without the use of fluoroscopy-reducing ionizing radiation in left atrial ablation procedures

Ablation for atrial fibrillation is now widespread and may involve the delivery of relatively high doses of ionizing radiation to both patients and operators. Until now, atrial septal puncture has mandated the use of either fluoroscopy or additional expensive imaging modalities for its safe deployment. We describe a novel technique using the EnSite NavX three-dimensional imaging system for visualization of the transseptal needle throughout the puncture-without the need for either fluoroscopy or additional imaging. This may be important in reducing the need for fluoroscopy for left atrial ablation procedures.

Fossa ovalis radiofrequency perforation in a difficult case of conventional transseptal puncture for atrial fibrillation ablation

A 65-year-old man was referred for atrial fibrillation ablation to our center. Routine pre-procedure transthoracic and transoesophageal echocardiography and cardiac computed tomography examinations showed a normal interatrial septum and fossa ovalis anatomy. Access to left atrium was initially planned using a conventional transseptal needle puncture. During the procedure, several consecutive attempts in conjunction with intracardiac echocardiography support, failed to cross the septum. The procedure was then successfully carried out using a specifically designed radiofrequency transseptal catheter.

Safety of single transseptal puncture for ablation of atrial fibrillation: retrospective study from a large cohort of patients

INTRODUCTION

Transseptal puncture (TSP) is the conventional approach to assess the left atrial chamber. This technique has been widely used in interventional cardiology and, in the last years, this approach is mostly applied to electrophysiologic procedures. For atrial fibrillation (AF) ablation, two or more transseptal sheaths are often positioned in the left atrium in the majority of centers, therefore requiring two or more transseptal punctures. Theoretically, double puncture could bear additional risks or could increase the risk of persistence of septal defects. We reported the results of a retrospective analysis of a single transseptal puncture as a simplified approach for positioning multiple catheters in the left atrium during AF ablation.

METHODS

Between November 2003 and November 2005, 1,150 consecutive patients (mean age 54 +/- 8 years, 75% men) were considered for AF ablation and underwent single transseptal puncture for positioning multiple catheters in the left atrium.

RESULTS

In only 6 of 1,150 (0.5%) cases a second transseptal puncture was required to position the ablation catheter in the left atrium. Neither acute complications related to transseptal catheterization such as atrial or aortic perforations, pericardial tamponade, thrombotic formation, or air embolism, nor complications due to the attempts of crossing the septum with the ablation catheter were reported. In all cases, each mapping catheter was properly maneuvered at different sites in the left atrium and at the pulmonary veins. In no patient was a residual septal atrial defect after the transseptal maneuvers detected during a mean follow up of 14 +/- 2 months.

CONCLUSIONS

This retrospective study on a large cohort of patients shows that single transseptal puncture for positioning two or more catheters in the left atrium for AF ablation is a highly successful and safe maneuver with a very low morbidity in the majority of patients. This may avoid potential complications related to a second transseptal puncture.

Right atrial angiography facilitates transseptal puncture for complex ablation in patients with unusual anatomy

OBJECTIVE

The number of transseptal punctures performed worldwide has increased exponentially with the development of ablation therapies for atrial arrhythmias. Safe access into the left atrium in these procedures is often complicated by abnormal anatomy. We assessed the potential of right atrial angiography to facilitate transseptal puncture for atrial ablation.

METHODS AND RESULTS

We examined all transseptal punctures performed for complex left atrial ablation in our centre over a 29-month period. In cases where conventional transseptal techniques failed, we performed orthogonal right atrial angiography to define cardiac anatomy and orientation. During the study period, 255 transseptal procedures were performed. Of these, 16 cases were complicated by distorted atrial anatomy, extreme cardiac rotation or unexpected location of the atria in relation to the diaphragm, preventing left atrial access using conventional fluoroscopy. The application of right atrial angiography facilitated successful transseptal puncture in all patients when use of conventional mapping catheters and fluoroscopy proved unhelpful. There were no complications relating to right atrial angiography.

CONCLUSION

These cases highlight a number of difficulties encountered when performing transseptal punctures. Previously reported adjunctive techniques require specialised equipment, general anaesthesia or multiple catheters that may be unavailable or impede the procedure. Right atrial angiography is a simple and safe adjunct to conventional techniques to facilitate complex transseptal procedures.

A conservative approach to performing transseptal punctures without the use of intracardiac echocardiography: stepwise approach with real-time video clips

Atrial transseptal puncture as a means of accessing the left heart is a critical component of catheter ablation procedures for atrial fibrillation, left-sided accessory pathways, and access to the left ventricle in patients with certain types of prosthetic aortic valves. Although this technique has been performed successfully since the 1950s, severe and potentially life-threatening complications can still occur, including cardiac tamponade and/or death. Some have adopted the use of intracardiac echocardiography, but our laboratory and many others throughout the world have successfully relied on fluoroscopic imaging alone. The aim of this brief report is to describe in detail our technique for performing transseptal punctures during catheter ablation procedures for atrial fibrillation. We employ a similar approach when targeting left-sided accessory pathways, although only a single transseptal is performed in those cases. Utilizing a series of real-time video clips, we describe our technique of double transseptal puncture and illustrate in detail ways in which to avoid common pitfalls.

Cerebral air embolization in the Electrophysiology Laboratory during Transseptal Catheterization: Curative treatment of acute left hemiparesis with prompt hyperbaric oxygen therapy

We present a case of a 44 year-old man with medically refractory symptomatic paroxysmal atrial fibrillation in whom the initial attempt at left atrial catheter ablation was complicated by coronary and cerebral arterial air embolization during transseptal catheter exchange. The manifestations, management, and long term outcomes are detailed. Following the case report is a review of published reports and contemporary management strategies for treatment of acute air embolization. Dramatic clinical consequences can be aborted by prompt intervention including volume loading, oxygenation, lidocaine, and hyperbaric oxygen therapy.

Trans-septal catheterization in the electrophysiology laboratory: data from a multicenter survey spanning 12 years

OBJECTIVES

We report the data from the Italian Survey on trans-septal catheterization (TSP-C) for catheter ablation of arrhythmias in the left heart that covered 2003 and previous years.

BACKGROUND

Over the last decade the use of TSP-C in the electrophysiology laboratory has greatly increased. Recent data on number of procedures, accomplishment rate, and complications related to this procedure are lacking in a large cohort of patients.

METHODS

Thirty-three centers participated in the survey. The data collected retrospectively for 2003 included the number of procedures, indications, methods, and the number and reason for unaccomplished cases along with complications. Retrospective data collected for previous years included the annual number of procedures and cumulative data concerning indications, accomplishments, and complications.

RESULTS

Since 1992, 5,520 TSP-C procedures were used in arrhythmia ablation, with the peak increase in the use occurring in 2001. Trans-septal catheterization was performed for atrial fibrillation (AF) ablation in 78.3% of the procedures in 2003. The electrophysiologist independently performed the procedure in 29 of 33 centers. Trans-septal catheterization was successfully performed in 99.1% of the cases; the main reason for TSP-C not being performed was related to fossa ovalis/atrial septum anatomy. Complications were low both in 2003 and in the previous years (0.79% and 0.74%, respectively).

CONCLUSIONS

Trans-septal catheterization in the electrophysiology laboratory is associated with a high success and low complication rate. The use of TSP-C has progressively increased over the last decade and is currently used primarily for AF ablation. Although possible, severe complications were rare.

Immediate and late outcomes of patients undergoing transseptal left-sided heart catheterization for symptomatic valvular and arrhythmic diseases

BACKGROUND

The transseptal technique has been widely used for diagnostic and therapeutic left-sided heart catheterization. However, its differential immediate and late outcomes among patients with various valvular and arrhythmic diseases are not yet determined.

METHODS

Beginning from 1993, all patients undergoing transseptal procedures were screened and categorized into diagnosis, arrhythmia, and valvuloplasty groups according to the purposes of the catheterization. Incidences of transseptum-related acute major events (cardiac perforation, embolic stroke, and bradyarrhythmia during the procedure) and late complications (residual atrial septal defect [ASD], embolic stroke, bradyarrhythmia, and death up to 18 months) were analyzed and compared between groups.

RESULTS

From January 1993 to May 2003, a total of 176 patients underwent 184 transseptal procedures for diagnosis of valvular heart diseases (n = 8), catheter ablation of arrhythmogenic foci (n = 29), and mitral valvuloplasty (n = 147). The immediate outcome was similar among the 3 groups, with an overall acute complication incidence of 3.8%. At follow-up, the incidences of bradyarrhythmia, embolic stroke, and death were not different among the 3 groups. Patients undergoing valvuloplasty had a significantly higher prevalence of residual ASD, especially for those with more severe mitral stenosis and less valvuloplasty success. However, presence of ASD did not impose disadvantage over the 1.5-year prognosis.

CONCLUSION

Transseptal left-sided heart catheterization can be safely applied to patients with different categories of cardiac diseases with comparably good immediate and late outcomes. Although patients undergoing percutaneous valvuloplasty have a higher chance of permanent ASD creation, their prognosis is not influenced.

Rate control vs. pulmonary vein isolation

Atrial fibrillation (AF) is a frequent arrhythmia encountered in clinical practice. It can be asymptomatic in some patients but incapacitating in others. Regardless of symptoms, patients at increased risk of embolism need chronic anticoagulation. In patients with AF and a rapid ventricular response that cannot be controlled with drugs, interventional procedures are required. Radiofrequency catheter ablation of the atrioventricular junction with pacemaker implantation is an effective therapeutic approach that relieves the symptoms associated with a rapid and irregular rhythm. This approach can also improve left ventricular function in patients with tachycardia-induced cardiomyopathy. Due to the irreversible nature of this approach, it is more suitable for older patients and those with advanced left ventricular dysfunction. Many patients with a structurally normal heart have symptomatic paroxysmal AF refractory to antiarrhythmic agents. This form of AF is frequently initiated by premature atrial beats arising from the pulmonary veins. A catheter ablation technique is available to electrically isolate the pulmonary veins. This procedure can eliminate AF in many patients but can result in complications, including embolic events, pulmonary veins stenosis, and cardiac perforation.

Magnetic resonance image-guided trans-septal puncture in a swine heart

PURPOSE

To test the feasibility of performing magnetic resonance (MR)-guided trans-septal punctures in the swine heart.

MATERIALS AND METHODS

All procedures were performed in a 1.5-T MR scanner. A novel, active MR intravascular needle system was utilized for needle tracking and septal punctures. Trans-septal punctures were performed in five swine using electrocardiogram (ECG)-gated high resolution and non-ECG-gated, real-time MR imaging techniques. The intravascular needle was advanced over a guidewire from the femoral vein. Once the needle was in proper position, trans-septal punctures were made.

RESULTS

Active tracking of the needle traversing the septum was possible. The location of the catheter tip was confirmed using real time gradient recalled echo (GRE). After a confirmatory ventriculogram with gadolinium-DTPA, a 0.014-inch guidewire was advanced into the left atrium and left ventricle. All punctures were made with no change in cardiac rhythm or rate; postmortem analysis was performed on all animals and demonstrated that 18/19 (95%) punctures were directly through the fossa ovalis.

CONCLUSION

Using only MR guidance and a novel active intravascular needle system, we were able to repeatedly puncture the fossa ovalis in a swine heart from a transfemoral approach, with direct visualization of all components, including the needle, the atria, the fossa ovalis, and the surrounding vasculature.

Left Atrial Tachycardia Originating From the Mitral Annulus–Aorta Junction

Background— At the mitral annulus–aorta (MA-Ao) junction, the left atrium is continuous through the subaortic curtain with the musculature of the anterior mitral leaflet. Under experimental conditions, this region can generate abnormal electrical activity. In patients with left atrial tachycardia, we investigated whether this region could be the source of this arrhythmia.

Methods and Results— In 10 (28%) of 35 consecutive patients with left atrial tachycardia, the arrhythmia originated from the MA-Ao junction. Sustained, self-limited episodes of atrial tachycardia (cycle length, 340±56 ms; duration, 125±69 seconds) were repeatedly induced. Prematurity of the extrastimulus and time to first atrial tachycardia complex were directly correlated ( R =0.66; P <0.001). During tachycardia, bipolar electrograms at the earliest site preceded onset of the P wave by 44±14 ms and were of longer duration and lower amplitude than those recorded from nearby left atrial sites (52±8 versus 24±4 ms, P <0.001; and 0.53±0.08 versus 3.45±0.96 mV, respectively; P <0.001). Ablation eliminated the tachycardia with no recurrence after a mean follow-up of 24±19 months. A comparative study in mouse embryos demonstrated the presence of the developing specialized conduction system in the MA-Ao region starting at embryonic age 11.5.

Conclusions— The MA-Ao junction can be a frequent source of left atrial tachycardia. This previously unrecognized site of origin may explain why catheter ablation has been less successful in eliminating left versus right atrial tachycardias. Remnants of the developing specialized conduction system could be the underlying substrate of this arrhythmia.

Technique and Results of Pulmonary Vein Angiography in Patients Undergoing Catheter Ablation of Atrial Fibrillation

INTRODUCTION

Delineation of pulmonary vein (PV) anatomy is an integral part of the PV isolation procedure. The aims of the present study were to (1) describe the technique of selective PV angiography, (2) show the typical fluoroscopic locations and appearance of the PVs, and (3) compare the ostial diameters of PVs measured by angiography and magnetic resonance imaging (MRI).

METHODS AND RESULTS

Twenty consecutive patients undergoing a PV isolation procedure underwent selective PV angiography using a deflectable 8-French lumened catheter (Naviport, Cardima). The left superior PV (LSPV) runs upward and away from the spine in the right anterior oblique (RAO) projection and upward and toward the spine in the left anterior oblique (LAO) projection. The opposite is true for the right superior PV (RSPV). The left inferior PV (LIPV) has a bull's-eye appearance in the RAO projection, and the right inferior PV (RIPV) has a bull's-eye appearance in the LAO projection due to their end-on trajectories. The LIPV in the LAO projection and the RIPV in the RAO projection run horizontally toward the spine. An excellent correlation was noted in PV ostial size as assessed by angiography and MRI (r(2) < 0.90, P < 0.0001).

CONCLUSION

This study describes the technique and results of PV angiography and fluoroscopy. The study also demonstrates good correlation of PV ostial diameters by contrast venography and MRI. PV angiography can be used as an alternate to MRI or computed tomographic imaging, particularly when these tests are unavailable or are contraindicated in the patient.

Shifting of Puncture Site in the Fossa Ovalis During Radiofrequency Catheter Ablation: Intracardiac Echocardiography-guided Transseptal Left Heart Catheterization

Intracardiac echocardiography (ICE) serves as an adjunct to fluoroscopy for electrophysiological procedures by identifying critical anatomic landmarks and confirming catheter-endocardial contact. In the present study, we investigated the usefulness of ICE for radiofrequency catheter ablation. ICE was utilized to guide transseptal puncture in 19 patients undergoing radiofrequency catheter ablation. The fossa ovalis, which was one critical anatomic landmark, had an average vertical diameter of 18.5 +/- 6.9 mm and an average horizontal diameter of 10.0 +/- 2.4 mm, as measured by ICE and fluoroscopy. Although there was only a small shift of the puncture site in the horizontal direction, the puncture site shifted towards the upper edge of the fossa ovalis for 17 patients (89%). Furthermore, we could verify that the distance between the apex of the tent-shape formed by the pressure of the puncture needle in the fossa ovalis and the left atrial wall opposing it was sufficient to carry out the procedure safely. Confirming the puncture site using ICE is useful in carrying out transseptal left heart catheterization safely.

Demonstration of a left atrial input to the atrioventricular node in humans

BACKGROUND

During right atrial stimulation, the anterior and posterior approaches provide inputs to the atrioventricular (AV) node. The purpose of the present study was to determine how activation proceeding from the left atrium reaches the AV node.

METHODS AND RESULTS

We studied AV nodal conduction during right and left atrial (coronary sinus) stimulation in 46 patients (27 women and 19 men; mean age, 46+/-4 years) who had structurally normal hearts. At an identical cycle length (600 ms), left atrial stimulation resulted in shorter A-H intervals than right atrial stimulation (73+/-3 ms versus 99+/-3 ms; P<0.05). In addition, atrial electrograms recorded close to the His bundle changed from near to far field potentials when stimulation was shifted to the left atrium. The A-H interval prolonged as the site of pacing was progressively moved from the distal to the proximal coronary sinus. During constant pacing from the distal coronary sinus, atrial activation close to the His bundle could be advanced by late extrastimuli delivered at the anterior and posterior approaches (up to 11+/-2 ms and 9+/-1 ms, respectively), without altering His bundle activation time. In contrast, late extrastimuli delivered at the inferoparaseptal mitral annulus advanced both the A and H electrograms in 19 of 20 patients, which is consistent with a left-sided input to the AV node. Right and left atrial stimulation resulted in similar AV nodal function.

CONCLUSION

The mitral annulus provides a left atrial input to the human AV node.