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The safety and efficiency of fluoroless site-specific transseptal puncture guided by three-dimensional intracardiac echocardiography. J Interv Card Electrophysiol 2022; 65:643-649. [PMID: 35804256 DOI: 10.1007/s10840-022-01298-7] [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: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although fluoroless transseptal puncture (TSP) guided by intracardiac echocardiography (ICE) has been used for many years, there are no reports of an accurate site-specific method for TSP in detail, especially about the safety and efficiency of the method. This study aimed to compare the efficacy and safety of TSP guided by three-dimensional ICE using a fluoroless site-specific method with that of the conventional fluoroless method in patients with atrial fibrillation (AF). METHODS This prospective study included 60 patients with AF scheduled for radiofrequency ablation who were assigned to undergo modified fluoroless site-specific TSP (SS-ICE group, n = 30) or conventional fluoroless TSP (C-ICE group, n = 30). TSP was guided by three-dimensional ICE in both study groups. RESULTS All fluoroless TSP were performed successfully in both groups. There were no significant differences in patient characteristics, Pre-TSP time (11.3 ± 1.7 min vs. 11.1 ± 1.6 min, P = 0.822) and TSP time (3.4 ± 0.9 min vs. 3.5 ± 1.1 min, P = 0.772) between the SS-ICE group and the C-ICE group. The distance between the actual traversing point and the presetting point in the fossa ovalis was less than 5 mm in 87% of patients (26/30, 3.1 ± 1.2 mm) in the SS-ICE group. There were no TSP-related complications in either group. CONCLUSION SS-ICE method is a simple, safe, and effective approach for fluoroless site-specific TSP.
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Intracardiac echocardiography techniques to identify ventricular arrhythmia substrate. Heart Rhythm O2 2022; 3:602-612. [DOI: 10.1016/j.hroo.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Fluoroless left atrial access for radiofrequency and cryoballoon ablations using a novel radiofrequency transseptal wire. J Interv Card Electrophysiol 2022; 64:183-190. [PMID: 35194727 PMCID: PMC9236982 DOI: 10.1007/s10840-022-01157-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/09/2022] [Indexed: 12/27/2022]
Abstract
Purpose Conventional catheter ablation for atrial fibrillation requires fluoroscopy, which has inherent risks of radiation exposure to patients and medical staff. Optimization of fluoroscopy parameters and use of three-dimensional electroanatomic mapping (EAM) and intracardiac echocardiography (ICE) have helped to reduce radiation exposure; however, despite growing evidence, there are still concerns about safety and added procedure time associated with fluoroless procedures, particularly in left-sided ablations, due to the potential risk of complications. Herein, we report our initial experience using a radiofrequency (RF) wire for completely fluoroless radiofrequency ablation (RFA) and cryoballoon ablation (CBA). Methods A retrospective analysis was conducted on ablation procedures for various cardiac arrhythmias performed non-fluoroscopically at two centers using the VersaCross RF wire transseptal system under EAM and ICE guidance. Results A total of 72 and 54 patients underwent RFA and CBA, respectively, successfully without any procedural complications. Transseptal access time for RFA was 14.5 ± 6.6 min from procedure start (including sheath and catheter placements ± right-sided ablation) or 2.8 ± 1.0 min from RF wire insertion into the femoral introducer. Transseptal access time for CBA was 19.2 ± 11.7 min from procedure start (including sheath and catheter placements ± right-sided ablation) or 3.5 ± 1.6 min from RF wire insertion into the femoral introducer. Average procedure time was 104.4 ± 38.0 min for RFA and 91.1 ± 22.1 min for CBA. Conclusions A RF wire can be used to achieve completely fluoroless transseptal puncture safely and effectively while improving procedural efficiency in both RFA and CBA.
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Kantenwein V, Telishevska M, Bourier F, Kottmaier M, Brkic A, Risse E, Popa M, Lengauer S, Kolb C, Deisenhofer I, Hessling G, Reents T. Feasibility and safety of left atrial access for ablation of atrial fibrillation in patients with persistent left superior vena cava. Pacing Clin Electrophysiol 2022; 45:357-364. [PMID: 35015906 DOI: 10.1111/pace.14446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 12/02/2021] [Accepted: 01/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients with persistent left superior vena cava (PLSVC) ablation procedures can be challenging. We sought to determine the feasibility and safety of left atrial ablations in patients with PLSVC, especially when PLSVC is unknown prior to the ablation procedure. METHODS AND RESULTS In this retrospective analysis 15 adult patients (mean age 64.6 ± 14.5 years, 53.3% male) with PLSVC undergoing 27 ablation procedures for atrial fibrillation or left atrial flutter were included. In 5 (33,3%) patients PLSVC was only discovered during the procedure. Transseptal puncture (TSP) was declared "difficult" by the ablating physician in 13 of 27 (48,2%) procedures and was not successfully completed in the first attempt in two patients with known PLSVC. Once TSP was successfully completed, all relevant structures were reached both during mapping and ablation in all procedures independent of whether PLSVC was known prior to the procedure. One major complication (3,7%) occurred in 27 procedures in a patient with known PLSVC. In the patients with unknown PLSVC no complication occurred. CONCLUSION In experienced hands, left atrial access and ablation in patients with PLSVC is feasible and safe, particularly with regard to patients in whom the PLSVC is unknown prior to the ablation procedure. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Verena Kantenwein
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Marta Telishevska
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Felix Bourier
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Marc Kottmaier
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Amir Brkic
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Elena Risse
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Miruna Popa
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Sarah Lengauer
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Christof Kolb
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Isabel Deisenhofer
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Gabriele Hessling
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
| | - Tilko Reents
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung Elektrophysiologie, Technische Universität München, Munich, Germany
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Tahin T, Riba A, Nemeth B, Arvai F, Lupkovics G, Szeplaki G, Geller L. Implementation of a zero fluoroscopic workflow using a simplified intracardiac echocardiography guided method for catheter ablation of atrial fibrillation, including repeat procedures. BMC Cardiovasc Disord 2021; 21:407. [PMID: 34433424 PMCID: PMC8390247 DOI: 10.1186/s12872-021-02219-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
Objective Pulmonary vein isolation (PVI) is the cornerstone of the interventional treatment of atrial fibrillation (AF). Traditionally, during these procedures the catheters are guided by fluoroscopy, which poses a risk to the patient and staff by ionizing radiation. Our aim was to describe our experience in the implementation of an intracardiac echocardiography (ICE) guided zero fluoroscopic (ZF) ablation approach to our routine clinical practice.
Methods We developed a simplified ICE guided technique to perform ablation procedures for AF, with the aid of a 3D electroanatomical mapping system. The workflow was implemented in two phases: (1) the Introductory phase, where the first 16 ZF PVIs were compared with 16 cases performed with fluoroscopy and (2) the Extension phase, where 71 consecutive patients (including repeat procedures) with ZF approach were included. Standard PVI (and redoPVI) procedures were performed, data on feasibility of the ZF approach, complications, acute and 1-year success rates were collected. Results In the Introductory phase, 94% of the procedures could be performed with complete ZF with a median procedure time of 77.5 (73.5–83) minutes. In one case fluoroscopy was used to guide the ICE catheter to the atrium. There was no difference in the complication, acute and 1-year success rates, compared with fluoroscopy guided procedures. In the Extension phase, 97% of the procedures could be completed with complete ZF. In one case fluoroscopy was used to guide the transseptal puncture and in another to position the ICE catheter. Acute success of PVI was achieved in all cases, 64.4% patients were arrhythmia free at 1-year. Acute major complications were observed in 4 cases, all of these occurred in the redo PVI group and consisted of 2 tamponades, 1 transient ischemic attack and 1 pseudoaneurysm at the puncture site. The procedures were carried out by all members of the electrophysiology unit in the Extension phase, including less experienced operators and electrophysiology fellows (3 physicians) under the supervision of the senior electrophysiologist. Consequently, procedure times became longer [90 (75–105) vs 77.5 (73.5–85) min, p = 0.014]. Conclusions According to our results, a ZF workflow of AF ablations can be successfully implemented into the routine practice of an electrophysiology laboratory, without compromising safety and effectivity.
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Affiliation(s)
- Tamas Tahin
- Department of Cardiology, Zala County St. Rafael Hospital, Zrinyi str. 1, Zalaegerszeg, 8900, Hungary.,Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Adam Riba
- Department of Cardiology, Zala County St. Rafael Hospital, Zrinyi str. 1, Zalaegerszeg, 8900, Hungary.
| | - Barnabas Nemeth
- Department of Cardiology, Zala County St. Rafael Hospital, Zrinyi str. 1, Zalaegerszeg, 8900, Hungary
| | - Ferenc Arvai
- Department of Cardiology, Zala County St. Rafael Hospital, Zrinyi str. 1, Zalaegerszeg, 8900, Hungary
| | - Geza Lupkovics
- Department of Cardiology, Zala County St. Rafael Hospital, Zrinyi str. 1, Zalaegerszeg, 8900, Hungary
| | - Gabor Szeplaki
- Heart and Vascular Centre, Mater Private Hospital, 72 Eccles Street, Dublin 7, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Laszlo Geller
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
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Kautzner J, Haskova J, Lehar F. Intracardiac Echocardiography to Guide Non-fluoroscopic Electrophysiology Procedures. Card Electrophysiol Clin 2021; 13:399-408. [PMID: 33990278 DOI: 10.1016/j.ccep.2021.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intracardiac echocardiography (ICE) is the most practical method for online imaging during electrophysiological procedures. It allows guiding of complex catheter ablation procedures together with electroanatomical mapping systems, either with minimal or with zero fluoroscopy exposure. Besides safe and reproducible transseptal puncture, ICE helps to assess location and contact of the tip of the ablation catheter relative to specific anatomical structures. Another option is visualization of the arrhythmogenic substrate in patients with ventricular arrhythmias. This article describes the clinical utility of ICE in non-fluoroscopic electrophysiology procedures more in detail.
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Affiliation(s)
- Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Palacky University Medical School, Olomouc, Czech Republic.
| | - Jana Haskova
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Frantisek Lehar
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Internal Medicine 1-Cardioangiology, St Anne's University Hospital, Brno, Czech Republic
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Desai M, Kahaly O, Aslam A, Saifa-Bonsu J, Usmani M, Okabe T, Afzal MR, Houmsse M. Comprehensive strategies to minimize radiation exposure during Interventional electrophysiology procedures: state-of-the-art review. Expert Rev Med Devices 2020; 17:1183-1192. [PMID: 32885677 DOI: 10.1080/17434440.2020.1819789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Cardiac electrophysiology (EP) procedures are frequently performed in patients with cardiac arrhythmias, chronic heart failure, and sudden cardiac death. Most EP procedures involve fluoroscopy, which results in radiation exposure to physicians, patients, and EP lab staff. Accumulated radiation exposure is a known health detriment to patients and physicians. AREA COVERED This review will summarize radiation exposure, dose metrics, complications of radiation exposure, factors affecting radiation exposure, minimizing radiation exposure, zero or near-zero fluoroscopy strategies, and up-to-date research in the area of reducing radiation exposure and best practices. EXPERT COMMENTARY Comprehensive strategies should be implemented in EP laboratories to minimize radiation exposure with standard fluoroscopy. There are routine techniques that can mitigate significant amounts of radiation exposure using standard equipment within the EP lab. The operators need to emphasize that EP practices routinely incorporate non-ionizing radiation sources for cardiac imaging (e.g. magnetic resonance imaging, advanced electroanatomical mapping systems, intracardiac ultrasonography) in addition to other novel technologies to mitigate radiation exposure to patients and physicians.
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Affiliation(s)
| | - Omar Kahaly
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Adil Aslam
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Jonnie Saifa-Bonsu
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Maham Usmani
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Muhammad R Afzal
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
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Troisi F, Quadrini F, Di Monaco A, Vitulano N, Caruso R, Guida P, Langialonga T, Grimaldi M. Electroanatomic guidance versus conventional fluoroscopy during transseptal puncture for atrial fibrillation ablation. J Cardiovasc Electrophysiol 2020; 31:2607-2613. [PMID: 32700436 DOI: 10.1111/jce.14683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/23/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Technological advancement in the setting of atrial fibrillation (AF) ablation has decreased radiation exposure and complications associated with the procedure. Yet, transseptal puncture (TSP) remains a challenging step that necessitates accurate guidance. We describe our experience performing TSP under electroanatomic (EA) guidance. METHODS AND RESULTS The analysis included 145 consecutive EA-guided ablation procedures performed between June 2018 and April 2019 and 145 consecutive standard ablations performed before June 2018. EA guidance utilized the CARTO 3 three-dimensional mapping system to reconstruct anatomic and electrical characteristics of the right atrium and fossa ovalis. Patients with a history of previous cardiac surgery were excluded. For EA-guided procedures, the mean patient age was 60 ± 10 years, 75.2% were male, and 69.0% had paroxysmal AF. Similarly, the mean age for conventional procedures was 60 ± 11 years, 71.0% were male, and 71.7% had paroxysmal AF. The fossa ovalis was detected as a region of low voltage, <0.75 mV. EA guidance yielded shorter fluoroscopy times (EA vs. conventional, 3.6 ± 2.5 vs. 13.5 ± 10.5 min; p < .001) and a lower dose area product than conventional guidance (13 ± 11 Gy* cm2 vs. 28 ± 27 Gy* cm2 ; p < .001). The total procedure duration was similar between groups (146 ± 48 vs. 148 ± 54 min). There were no significant complications related to TSP. CONCLUSION During AF ablation, TSP with EA guidance facilitated safe access to the left atrium while reducing radiation risk to both patients and operators.
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Affiliation(s)
- Federica Troisi
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Federico Quadrini
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Antonio Di Monaco
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Nicola Vitulano
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Rosa Caruso
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Pietro Guida
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Tommaso Langialonga
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Massimo Grimaldi
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
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Salam T, Wilson L, Bohannan S, Morin M. Safety and Effectiveness of a Novel Fluoroless Transseptal Puncture Technique for Lead-free Catheter Ablation: A Case Series. J Innov Card Rhythm Manag 2020; 11:4079-4085. [PMID: 32368383 PMCID: PMC7192152 DOI: 10.19102/icrm.2020.110405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/28/2019] [Indexed: 01/07/2023] Open
Abstract
Increasing awareness of the health risks associated with the exposure of patients and staff in the catheterization laboratory to radiation has encouraged the pursuit of efforts to reduce the use of fluoroscopy during catheter ablation procedures. Although nonfluoroscopic guidance of ablation catheters has been previously described, transseptal access is still perceived as the last remaining barrier to completely fluoroless ablations. This study examined the safety and effectiveness of transseptal puncture and radiofrequency (RF) catheter ablation using a completely fluoroless approach. Three hundred eighty-two consecutive cases that had undergone completely nonfluoroscopic RF catheter ablation were evaluated. Ablation procedures were performed for atrial fibrillation, atrial flutter, atrioventricular reentry tachycardia, and pulmonary vein complex/ventricular tachycardia. Transseptal puncture and RF ablation were conducted under three-dimensional electroanatomic mapping and intracardiac echocardiography image guidance. Fluoroless transseptal puncture and catheter ablation were completed successfully in all cases, with no intraoperative complications. One patient required minimal use of fluoroscopy to visualize sheath advancement through an existing inferior vena cava filter. Procedural time was approximately 2.2 hours from transvenous access until case conclusion; transseptal access was obtained within 28 minutes of procedure initiation. Arrhythmia was found to recur in 27% of cases on average three months after the procedure. We demonstrate the safety and effectiveness of a completely fluoroless transseptal puncture and RF ablation technique that eliminates radiation exposure and enables complex electrophysiology procedures to be performed in a lead-free environment.
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Affiliation(s)
- Tariq Salam
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
| | - Lane Wilson
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
| | - Sara Bohannan
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
| | - Michael Morin
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
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Koca S, Akdeniz C, Tuzcu V. Transseptal Puncture for Catheter Ablation in Children. Pediatr Cardiol 2019; 40:799-804. [PMID: 30729261 DOI: 10.1007/s00246-019-02069-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/31/2019] [Indexed: 11/25/2022]
Abstract
Transseptal puncture (TP) is used in pediatric patients to access the left atrium in left-sided arrhythmia catheter ablation. Performing this procedure can be difficult and risky, especially in small children. In this study, we aimed to evaluate the safety and feasibility of TPs in children ≤ 30 kg. Between April 2012 and April 2018, a retrospective evaluation was conducted of the clinical features, procedural outcomes, and follow-ups of ≤ 30 kg pediatric patients who required TPs for left-sided ablations at a pediatric electrophysiology center in which a three-dimensional mapping system was routinely used. A total of 45 pediatric patients who were ≤ 30 kg, underwent TPs: 10 patients ≤ 20 kg (Group 1) and 35 patients > 20 kg and ≤ 30 kg (Group 2). The TP success rate was 97.8%. The median procedure and fluoroscopy times were 120 min and 5.43 min, respectively. One patient developed self-limited pericardial effusion during the procedure; however, there were no incidences of cardiac tamponade. There was no significant difference between the two groups in terms of the procedure time and fluoroscopy time, and pericardial effusion was only observed in Group 2. TPs are safe and feasible in small children. These procedures can be performed with low complication rates in children weighing ≤ 30 kg.
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Affiliation(s)
- Serhat Koca
- Department of Pediatric Cardiology/Electrophysiology, Istanbul Medipol University Hospital, Istanbul, Turkey.
- Yuksek Ihtisas Hospital, Kizilay St. Nu 4 Sihhiye, Ankara, Turkey.
| | - Celal Akdeniz
- Department of Pediatric Cardiology/Electrophysiology, Istanbul Medipol University Hospital, Istanbul, Turkey
| | - Volkan Tuzcu
- Department of Pediatric Cardiology/Electrophysiology, Istanbul Medipol University Hospital, Istanbul, Turkey
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