- Email: [email protected]
A Guide to Transseptal Access
Accepted Manuscript A guide to transseptal access Enes Gul, MD, Adrian Baranchuk, MD, Benedict M. Glover, MD PII:
S0828-282X(16)31023-6
DOI:
10.1016/j.cjca.2016.10.014
Reference:
CJCA 2280
To appear in:
Canadian Journal of Cardiology
Received Date: 4 May 2016 Revised Date:
21 September 2016
Accepted Date: 2 October 2016
Please cite this article as: Gul E, Baranchuk A, Glover BM, A guide to transseptal access, Canadian Journal of Cardiology (2016), doi: 10.1016/j.cjca.2016.10.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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ACCEPTED MANUSCRIPT
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A guide to transseptal access
AC C
EP
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Enes Gul MD, Adrian Baranchuk MD, Benedict M Glover MD Cardiac Electrophysiology, Queens University, Kingston, Ontario Corresponding Author: Dr Benedict M Glover: [email protected] Word count: 1585
ACCEPTED MANUSCRIPT Abstract
Transseptal access is commonly performed for any procedure which requires access to the left side of the heart such as catheter ablation of atrial fibrillation, left atrial tachycardia, left sided accessory pathways, ventricular tachycardia, left atrial
RI PT
appendage closure, percutaneous mitral valvuloplasty and mitral valve repair. In order to perform this in a safe and effective manner it is important that the operator has a detailed knowledge of the relevant anatomy, the technique required, the ability to deal with difficult cases and complications. The aim of this article is to provide a
SC
detailed description of the anatomy, techniques, potential complications and difficulties associated with performing this procedure.
M AN U
Summary
Transseptal access is an important skill for all cardiologists who perform electrophysiological and interventional procedures on the left side of the heart. This
AC C
EP
TE D
article aims to summarize the anatomy and technique required for this procedure.
ACCEPTED MANUSCRIPT Introduction
Transseptal (TS) access is commonly performed for the catheter ablation of atrial fibrillation (AF), left atrial (LA) tachycardia, left sided accessory pathways (AP’s), (VT),
LA appendage
valvuloplasty and mitral valve repair.
closure,
percutaneous
mitral
The aim of this article is to provide a
RI PT
ventricular tachycardia
comprehensive overview of the relevant anatomy, techniques, difficulties and the potential risks associated with this procedure.
SC
Anatomy
The fossa ovalis (FO) is an oval shaped predominantly fibrous indentation in the
M AN U
lower posterior interatrial septum (Figure 1) measuring approximately 0.49 – 2.43 cm in the anterior-posterior projection and 0.38 – 2.69 cm in the cranio-caudal projection. [1] The floor of the FO is formed by the septum primum while the surrounding limbus is formed by the septum secundum antero-inferiorly. The superior, antero-superior and posterior components of the limbus are formed by infoldings of the right atrial
TE D
(RA) and LA walls and are predominantly adipose tissue. Only the floor of the FO and the antero-inferior limbus share a wall directly with the LA and this is often referred to as the ‘true’ interatrial septum. Puncture in any other region of the atrial septum will lead to exit from the heart. Although a patent foramen ovale (PFO) is
EP
present in approximately 25 percent of individuals (most commonly in the anterosuperior region of the FO), access through a PFO may make many left sided
AC C
procedures more difficult as the catheter may be poorly aligned and therefore TS puncture is generally still preferred. [1] Several important structures are closely associated with the FO. Anterior and superior to the interatrial septum is the non-coronary sinus of valsalva, posterior is a double folding of pericardium covering both the right atrium (RA) and the LA where puncture may result in a pericardial effusion. The coronary sinus (CS) is inferior and anterior.
ACCEPTED MANUSCRIPT TS technique
This is generally performed under fluoroscopic guidance with the additional use of either transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE). Contrast may be injected and pressure monitoring may be performed through
RI PT
the TS needle. TS needles are available in different lengths and angulations.. TS sheaths also vary in length and angulation and may have either a fixed or deflectable distal end.
In order to help delineate the anatomy on fluoroscopy a catheter may be positioned in
SC
the CS which approximates the lateral wall of the LA as well as the general direction in which to advance the needle and the proximal His, which identifies the central fibrous body at the most inferior aspect of the noncoronary aortic cusp. The most
M AN U
useful fluoroscopic views are left anterior oblique (LAO), right anterior oblique (RAO) and left lateral (LL) as shown in Figure 2..
The steps which we take in performing TS access are as follows:
Flush the sheath, dilator and TS needle with heparinized saline in order to
eliminate all air. Some operators keep the stylet in place in order to prevent shearing
TE D
of the inside of the dilator.
Position the introducing wire into the superior vena cava (SVC) or the right
subclavian vein and advance the sheath and dilator over the wire.. Remove the wire and aspirate and flush the apparatus with heparinized saline.
Connect the proximal end of the TS needle to pressure monitoring and
EP
contrast if required. Advance the TS needle to within approximately 3cm inside the
AC C
distal end of the dilator.
The sheath with the dilator and TS needle are positioned between 4 to 6 o’
clock (using the arrow at the proximal end of the TS needle) and withdrawn from the SVC into the RA using an LAO projection. The use of TEE and ICE has shown that a range of angles may be required in order to engage the FO and the adjunctive use of these technologies may assist the operator in directing the TS needle.
Two jumps should be seen as the apparatus is withdrawn (media image,
supplemental data). The first as it deflects from the descending aorta and enters from the SVC into RA, Further withdrawal results in a second jump as the apparatus engages the FO.
ACCEPTED MANUSCRIPT
In the LAO projection the tip of the dilator should be parallel and superior to
the CS. In the RAO projection the FO is seen from a frontal view and the apparatus should be posterior to the His catheter. In the LL position the needle should be pointing to 1 o’clock on fluoroscopy.
The needle is advanced out of the dilator with pressure monitoring. There is
by checking the pressure and injecting contrast.
RI PT
usually a jump as the needle crosses the septum. Confirmation should be performed
The sheath and dilator can then be advanced over the TS needle. The TS
needle is then removed and the apparatus is advanced over the introducing wire into
SC
one of the pulmonary veins (usually the upper). The wire and dilator are removed and the sheath is flushed with heparinized saline and connected to a continuous infusion of heparinized saline.
Heparin may be given prior to TS access or immediately after. Survey data
M AN U
from 78 centres in Europe has shown that in 69% of centres heparin is administered after TS access, 18% before, and the remaining 13% partly before and partly afterwards in patients undergoing AF ablation. [2]
TE D
Troubleshooting the difficult case
1. Thickened interatrial septum
EP
This is often fibrotic in patients who have undergone several prior procedures. In such a case either a TS needle with a larger angle (allowing more horizontal transmission
AC C
of forward pressure) or an RF NRG (Baylis Medical, Montreal, Canada) needle may be used. The additional use of TEE or ICE is generally important in such cases. Following access with the needle the interatrial septum may require dilatation over a wire with the sheath and dilator and double wiring a single puncture.
2. Aneurysmal interatrial septum
This may result in difficulty with engagement of the FO, an unpredictable trajectory of the TS needle resulting in either LA perforation or puncture of the aortic root and the potential for thrombus. Imaging with either TEE or ICE is helpful in these cases.
ACCEPTED MANUSCRIPT A change in the angulation of the needle or the use of an NRG ((Baylis Medical, Montreal, Canada) needle may also be useful.
3. Enlarged LA
RI PT
This may result in bulging of the interatrial septum towards the RA with deviation of the TS needle either anterior towards the aortic root or posterior towards the pericardium. Imaging with TEE or ICE may help visualize the TS needle position in
SC
such cases. A larger angulated needle may also help reach the FO.
4. Dilated aortic root
M AN U
This may result in an exaggeration of the aorto-septal groove, a more posterior alignment of the FO and an increased the risk of aortic puncture. Using a larger angle needle and the use of TEE or ICE is generally considered helpful in these cases.
Interatrial septal patches
TE D
5.
TS access can still be gained in the presence of pericardial and prosthetic patches and has been reported at the inferoposterior border of atrial septal defect closure devices.
EP
[3] The additional use of ICE or TEE is extremely helpful in these cases.
AC C
Complications
Several potential complications may occur. Early recognition of these is important in order to prevent a potentially catastrophic outcome. Most of these can be prevented and managed with good technique.
1. Cardiac tamponade
This may occur as a result of the TS apparatus entering the pericardial space. The accumulation of a significant pericardial effusion is generally associated with an increase in heart rate (although occasionally transient bradycardia and hypotension) preceding a drop in blood pressure (although an increase in sympathetic drive may
ACCEPTED MANUSCRIPT initially result in an increase in the blood pressure). On echocardiographic assessment fluid accumulation is generally noted around chambers with the lowest pressures first; the RA followed by the RV, LA and finally the LV although it may also be localized. In an LAO fluoroscopic projection a reduction in the left lateral wall excursion may occur. [4] Immediate pericardiocentesis is required for treatment of cardiac tamponed
RI PT
along with fluid resuscitation. Cardiac surgery may be required if bleeding continues.
2. Aortic puncture
SC
Aortic puncture with the TS needle can be successfully managed in the majority of cases provided it is recognised when only the needle has entered the aorta. The use of TEE and ICE should significantly minimise this risk from occurring. The cautious
M AN U
monitoring of pressure through the TS needle as well as the injection of contrast through the TS prior to advancing the sheath and dilator should prevent an adverse outcome. Provided only the needle has entered the aorta this can be retracted and the patient can be monitored. If the dilator enters the aortic root surgical intervention will
3. Air embolism
TE D
likely be required.
Air may embolize from the equipment to the coronary arteries resulting in an acute
EP
myocardial infarction, the cerebral circulation resulting in cerebral ischemia or indeed any component of the systemic circulation. Treatment of this is limited to dealing
AC C
with any potential complications which may occur as a result of ischemia although this may not always be possible.
4. Iatrogenic atrial septal defect (IASD).
Although these are common immediately post procedure the majority resolve within 6 months. [5] The majority which persist are small (< 3mm on TEE) and uncommonly require closure.
ACCEPTED MANUSCRIPT Conclusions
A thorough understanding of the relevant anatomy, equipment, imaging, technique, and troubleshooting for more complex cases should result in safe TS access in the majority of cases. Close monitoring should be performed in order to prevent serious
AC C
EP
TE D
M AN U
SC
RI PT
complications.
ACCEPTED MANUSCRIPT References
1.
Klimek-Piotrowska W, Holda MK, Koziej M, et al. Anatomy of the true
interatrial septum for transseptal access to the left atrium. Ann Anat 2016; 205: 60-4 2.
Chen J, Todd DM, Hocini M, et al. Current periprocedural management of
RI PT
ablation for atrial fibrillation in Europe: results of the European Heart Rhythm Association survey.Europace 2014;16:378–81 3.
El-Said HG, Ing FF, Grifka RG, et al. 18-year experience with transseptal
procedures through baffles, conduits, and other intra-atrial patches. Catheterization
tamponade. Heart Rhythm 2005; 2:1224-30
SC
Cardiovasc Interventions 2000; 50:434–439
5.
PS,
4.
Nanthakumar K, Kay GN, Plumb VJ et al. Decrease in fluoroscopic cardiac
Singh
SM,
M AN U
silhouette excursion precedes hemodynamic compromise in intraprocedural
Douglas
Reddy
VY.
The incidence and longterm clinical outcome of iatrogenic atrial septal defects second ary to transseptalcatheterization with
AC C
EP
TE D
Electrophysiol 2011 4: 166-71
a 12F transseptal sheath.
Circ
Arrhythm
ACCEPTED MANUSCRIPT Figure legends
Figure 1 Anatomy of the FO. A TS sheath is rotated into the 4 o’clock position and engages the FO. This is surrounded by a rim of tissue called the limbus. The aortic root is anterior to the FO and runs anterior to the superior vena cava as the ascending
RI PT
aorta. Also seen in this image are the right ventricle and the right ventricular outflow tract.
Figure 2 Fluoroscopic and echocardiographic images involved in TS access. Image A
SC
shows an RAO view in which the sheath and dilator are posterior to the His catheter. Image B shows an LAO view showing that the dilator is parallel and superior to the CS catheter. This view delineates the lateral wall of the LA. In image C the left lateral
M AN U
view demonstrates that the tip of the sheath is pointing posterior to the His and is positioned in a 1 o’clock orientation. An ICE image is shown in image D in which the RA is at the superior aspect of the image and the LA at the inferior aspect with tenting of the FO. A 2 dimensional TEE shows tenting of the FO with the aortic valve anterior. A 3 dimensional TEE in image F shows a clear view of the FO and the
TE D
limbus with the aorta anteriorly and the SVC superior and posterior. This image shows the optimal locations for puncture of the FO for catheter ablation of AF (red arrow) which generally requires a posterior approach with one puncture superior and the other inferior, LA appendage closure (blue arrow) which is best performed
EP
through an inferoposterior approach,. mitral valve repair (yellow arrow) is best performed through a posterior and superior approach, catheter ablation for VT (purple
AC C
arrow) may be performed through either a posterior or anterior approach although posterior may be preferable and left sided accessory pathways (green arrow) are generally performed through an anterior approach.
ACCEPTED MANUSCRIPT Video legend
Video 1 LAO fluoroscopic image showing the TS sheath, dilator and needle being withdrawn from the SVC to the RA (first jump) and then engagement with the FO (second jump). Following confirmation on TEE the needle is advanced and crosses
RI PT
the atrial septum. This is confirmed with a LA pressure tracing. The CS catheter helps to guide the TS access and the direction of the needle when crossing the atrial septum
AC C
EP
TE D
M AN U
SC
is superior and parallel to the CS catheter.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0828-282X(16)31023-6
DOI:
10.1016/j.cjca.2016.10.014
Reference:
CJCA 2280
To appear in:
Canadian Journal of Cardiology
Received Date: 4 May 2016 Revised Date:
21 September 2016
Accepted Date: 2 October 2016
Please cite this article as: Gul E, Baranchuk A, Glover BM, A guide to transseptal access, Canadian Journal of Cardiology (2016), doi: 10.1016/j.cjca.2016.10.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
SC
RI PT
ACCEPTED MANUSCRIPT
M AN U
A guide to transseptal access
AC C
EP
TE D
Enes Gul MD, Adrian Baranchuk MD, Benedict M Glover MD Cardiac Electrophysiology, Queens University, Kingston, Ontario Corresponding Author: Dr Benedict M Glover: [email protected] Word count: 1585
ACCEPTED MANUSCRIPT Abstract
Transseptal access is commonly performed for any procedure which requires access to the left side of the heart such as catheter ablation of atrial fibrillation, left atrial tachycardia, left sided accessory pathways, ventricular tachycardia, left atrial
RI PT
appendage closure, percutaneous mitral valvuloplasty and mitral valve repair. In order to perform this in a safe and effective manner it is important that the operator has a detailed knowledge of the relevant anatomy, the technique required, the ability to deal with difficult cases and complications. The aim of this article is to provide a
SC
detailed description of the anatomy, techniques, potential complications and difficulties associated with performing this procedure.
M AN U
Summary
Transseptal access is an important skill for all cardiologists who perform electrophysiological and interventional procedures on the left side of the heart. This
AC C
EP
TE D
article aims to summarize the anatomy and technique required for this procedure.
ACCEPTED MANUSCRIPT Introduction
Transseptal (TS) access is commonly performed for the catheter ablation of atrial fibrillation (AF), left atrial (LA) tachycardia, left sided accessory pathways (AP’s), (VT),
LA appendage
valvuloplasty and mitral valve repair.
closure,
percutaneous
mitral
The aim of this article is to provide a
RI PT
ventricular tachycardia
comprehensive overview of the relevant anatomy, techniques, difficulties and the potential risks associated with this procedure.
SC
Anatomy
The fossa ovalis (FO) is an oval shaped predominantly fibrous indentation in the
M AN U
lower posterior interatrial septum (Figure 1) measuring approximately 0.49 – 2.43 cm in the anterior-posterior projection and 0.38 – 2.69 cm in the cranio-caudal projection. [1] The floor of the FO is formed by the septum primum while the surrounding limbus is formed by the septum secundum antero-inferiorly. The superior, antero-superior and posterior components of the limbus are formed by infoldings of the right atrial
TE D
(RA) and LA walls and are predominantly adipose tissue. Only the floor of the FO and the antero-inferior limbus share a wall directly with the LA and this is often referred to as the ‘true’ interatrial septum. Puncture in any other region of the atrial septum will lead to exit from the heart. Although a patent foramen ovale (PFO) is
EP
present in approximately 25 percent of individuals (most commonly in the anterosuperior region of the FO), access through a PFO may make many left sided
AC C
procedures more difficult as the catheter may be poorly aligned and therefore TS puncture is generally still preferred. [1] Several important structures are closely associated with the FO. Anterior and superior to the interatrial septum is the non-coronary sinus of valsalva, posterior is a double folding of pericardium covering both the right atrium (RA) and the LA where puncture may result in a pericardial effusion. The coronary sinus (CS) is inferior and anterior.
ACCEPTED MANUSCRIPT TS technique
This is generally performed under fluoroscopic guidance with the additional use of either transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE). Contrast may be injected and pressure monitoring may be performed through
RI PT
the TS needle. TS needles are available in different lengths and angulations.. TS sheaths also vary in length and angulation and may have either a fixed or deflectable distal end.
In order to help delineate the anatomy on fluoroscopy a catheter may be positioned in
SC
the CS which approximates the lateral wall of the LA as well as the general direction in which to advance the needle and the proximal His, which identifies the central fibrous body at the most inferior aspect of the noncoronary aortic cusp. The most
M AN U
useful fluoroscopic views are left anterior oblique (LAO), right anterior oblique (RAO) and left lateral (LL) as shown in Figure 2..
The steps which we take in performing TS access are as follows:
Flush the sheath, dilator and TS needle with heparinized saline in order to
eliminate all air. Some operators keep the stylet in place in order to prevent shearing
TE D
of the inside of the dilator.
Position the introducing wire into the superior vena cava (SVC) or the right
subclavian vein and advance the sheath and dilator over the wire.. Remove the wire and aspirate and flush the apparatus with heparinized saline.
Connect the proximal end of the TS needle to pressure monitoring and
EP
contrast if required. Advance the TS needle to within approximately 3cm inside the
AC C
distal end of the dilator.
The sheath with the dilator and TS needle are positioned between 4 to 6 o’
clock (using the arrow at the proximal end of the TS needle) and withdrawn from the SVC into the RA using an LAO projection. The use of TEE and ICE has shown that a range of angles may be required in order to engage the FO and the adjunctive use of these technologies may assist the operator in directing the TS needle.
Two jumps should be seen as the apparatus is withdrawn (media image,
supplemental data). The first as it deflects from the descending aorta and enters from the SVC into RA, Further withdrawal results in a second jump as the apparatus engages the FO.
ACCEPTED MANUSCRIPT
In the LAO projection the tip of the dilator should be parallel and superior to
the CS. In the RAO projection the FO is seen from a frontal view and the apparatus should be posterior to the His catheter. In the LL position the needle should be pointing to 1 o’clock on fluoroscopy.
The needle is advanced out of the dilator with pressure monitoring. There is
by checking the pressure and injecting contrast.
RI PT
usually a jump as the needle crosses the septum. Confirmation should be performed
The sheath and dilator can then be advanced over the TS needle. The TS
needle is then removed and the apparatus is advanced over the introducing wire into
SC
one of the pulmonary veins (usually the upper). The wire and dilator are removed and the sheath is flushed with heparinized saline and connected to a continuous infusion of heparinized saline.
Heparin may be given prior to TS access or immediately after. Survey data
M AN U
from 78 centres in Europe has shown that in 69% of centres heparin is administered after TS access, 18% before, and the remaining 13% partly before and partly afterwards in patients undergoing AF ablation. [2]
TE D
Troubleshooting the difficult case
1. Thickened interatrial septum
EP
This is often fibrotic in patients who have undergone several prior procedures. In such a case either a TS needle with a larger angle (allowing more horizontal transmission
AC C
of forward pressure) or an RF NRG (Baylis Medical, Montreal, Canada) needle may be used. The additional use of TEE or ICE is generally important in such cases. Following access with the needle the interatrial septum may require dilatation over a wire with the sheath and dilator and double wiring a single puncture.
2. Aneurysmal interatrial septum
This may result in difficulty with engagement of the FO, an unpredictable trajectory of the TS needle resulting in either LA perforation or puncture of the aortic root and the potential for thrombus. Imaging with either TEE or ICE is helpful in these cases.
ACCEPTED MANUSCRIPT A change in the angulation of the needle or the use of an NRG ((Baylis Medical, Montreal, Canada) needle may also be useful.
3. Enlarged LA
RI PT
This may result in bulging of the interatrial septum towards the RA with deviation of the TS needle either anterior towards the aortic root or posterior towards the pericardium. Imaging with TEE or ICE may help visualize the TS needle position in
SC
such cases. A larger angulated needle may also help reach the FO.
4. Dilated aortic root
M AN U
This may result in an exaggeration of the aorto-septal groove, a more posterior alignment of the FO and an increased the risk of aortic puncture. Using a larger angle needle and the use of TEE or ICE is generally considered helpful in these cases.
Interatrial septal patches
TE D
5.
TS access can still be gained in the presence of pericardial and prosthetic patches and has been reported at the inferoposterior border of atrial septal defect closure devices.
EP
[3] The additional use of ICE or TEE is extremely helpful in these cases.
AC C
Complications
Several potential complications may occur. Early recognition of these is important in order to prevent a potentially catastrophic outcome. Most of these can be prevented and managed with good technique.
1. Cardiac tamponade
This may occur as a result of the TS apparatus entering the pericardial space. The accumulation of a significant pericardial effusion is generally associated with an increase in heart rate (although occasionally transient bradycardia and hypotension) preceding a drop in blood pressure (although an increase in sympathetic drive may
ACCEPTED MANUSCRIPT initially result in an increase in the blood pressure). On echocardiographic assessment fluid accumulation is generally noted around chambers with the lowest pressures first; the RA followed by the RV, LA and finally the LV although it may also be localized. In an LAO fluoroscopic projection a reduction in the left lateral wall excursion may occur. [4] Immediate pericardiocentesis is required for treatment of cardiac tamponed
RI PT
along with fluid resuscitation. Cardiac surgery may be required if bleeding continues.
2. Aortic puncture
SC
Aortic puncture with the TS needle can be successfully managed in the majority of cases provided it is recognised when only the needle has entered the aorta. The use of TEE and ICE should significantly minimise this risk from occurring. The cautious
M AN U
monitoring of pressure through the TS needle as well as the injection of contrast through the TS prior to advancing the sheath and dilator should prevent an adverse outcome. Provided only the needle has entered the aorta this can be retracted and the patient can be monitored. If the dilator enters the aortic root surgical intervention will
3. Air embolism
TE D
likely be required.
Air may embolize from the equipment to the coronary arteries resulting in an acute
EP
myocardial infarction, the cerebral circulation resulting in cerebral ischemia or indeed any component of the systemic circulation. Treatment of this is limited to dealing
AC C
with any potential complications which may occur as a result of ischemia although this may not always be possible.
4. Iatrogenic atrial septal defect (IASD).
Although these are common immediately post procedure the majority resolve within 6 months. [5] The majority which persist are small (< 3mm on TEE) and uncommonly require closure.
ACCEPTED MANUSCRIPT Conclusions
A thorough understanding of the relevant anatomy, equipment, imaging, technique, and troubleshooting for more complex cases should result in safe TS access in the majority of cases. Close monitoring should be performed in order to prevent serious
AC C
EP
TE D
M AN U
SC
RI PT
complications.
ACCEPTED MANUSCRIPT References
1.
Klimek-Piotrowska W, Holda MK, Koziej M, et al. Anatomy of the true
interatrial septum for transseptal access to the left atrium. Ann Anat 2016; 205: 60-4 2.
Chen J, Todd DM, Hocini M, et al. Current periprocedural management of
RI PT
ablation for atrial fibrillation in Europe: results of the European Heart Rhythm Association survey.Europace 2014;16:378–81 3.
El-Said HG, Ing FF, Grifka RG, et al. 18-year experience with transseptal
procedures through baffles, conduits, and other intra-atrial patches. Catheterization
tamponade. Heart Rhythm 2005; 2:1224-30
SC
Cardiovasc Interventions 2000; 50:434–439
5.
PS,
4.
Nanthakumar K, Kay GN, Plumb VJ et al. Decrease in fluoroscopic cardiac
Singh
SM,
M AN U
silhouette excursion precedes hemodynamic compromise in intraprocedural
Douglas
Reddy
VY.
The incidence and longterm clinical outcome of iatrogenic atrial septal defects second ary to transseptalcatheterization with
AC C
EP
TE D
Electrophysiol 2011 4: 166-71
a 12F transseptal sheath.
Circ
Arrhythm
ACCEPTED MANUSCRIPT Figure legends
Figure 1 Anatomy of the FO. A TS sheath is rotated into the 4 o’clock position and engages the FO. This is surrounded by a rim of tissue called the limbus. The aortic root is anterior to the FO and runs anterior to the superior vena cava as the ascending
RI PT
aorta. Also seen in this image are the right ventricle and the right ventricular outflow tract.
Figure 2 Fluoroscopic and echocardiographic images involved in TS access. Image A
SC
shows an RAO view in which the sheath and dilator are posterior to the His catheter. Image B shows an LAO view showing that the dilator is parallel and superior to the CS catheter. This view delineates the lateral wall of the LA. In image C the left lateral
M AN U
view demonstrates that the tip of the sheath is pointing posterior to the His and is positioned in a 1 o’clock orientation. An ICE image is shown in image D in which the RA is at the superior aspect of the image and the LA at the inferior aspect with tenting of the FO. A 2 dimensional TEE shows tenting of the FO with the aortic valve anterior. A 3 dimensional TEE in image F shows a clear view of the FO and the
TE D
limbus with the aorta anteriorly and the SVC superior and posterior. This image shows the optimal locations for puncture of the FO for catheter ablation of AF (red arrow) which generally requires a posterior approach with one puncture superior and the other inferior, LA appendage closure (blue arrow) which is best performed
EP
through an inferoposterior approach,. mitral valve repair (yellow arrow) is best performed through a posterior and superior approach, catheter ablation for VT (purple
AC C
arrow) may be performed through either a posterior or anterior approach although posterior may be preferable and left sided accessory pathways (green arrow) are generally performed through an anterior approach.
ACCEPTED MANUSCRIPT Video legend
Video 1 LAO fluoroscopic image showing the TS sheath, dilator and needle being withdrawn from the SVC to the RA (first jump) and then engagement with the FO (second jump). Following confirmation on TEE the needle is advanced and crosses
RI PT
the atrial septum. This is confirmed with a LA pressure tracing. The CS catheter helps to guide the TS access and the direction of the needle when crossing the atrial septum
AC C
EP
TE D
M AN U
SC
is superior and parallel to the CS catheter.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT