Download Legend for supplemental videos and images

Legend for supplemental videos and images.
Background
These images were recorded from a patient who underwent an
electrophysiological study followed by ablation of a left sided accessory
pathway. The radiofrequency ablation catheter was delivered to the mitral
valve annulus via a transeptal sheath. This series of videos demonstrates the
important stages of the transeptal puncture that is described in the main
article. All videos and figures are taken at 30° in the left anterior oblique
projection except video 1 which is posterior-anterior and video 3 which is at
40°in the right anterior oblique projection.
Image 1: intra cardiac catheters
This fluoroscopic image shows diagnostic electrophysiology catheters with
four electrodes (quadripolar) positioned on the Bundle of His (His) and at the
apex of the right ventricle (RVA). A decapolar catheter is in the coronary sinus
(CS) which runs along the epicardial aspect of the mitral valve annulus. The
transeptal assembly (TS) is seen on the superior aspect of the intra atrial
septum in the right atrium.
Video 1: position sheath in superior vena cava
The electrophysiology intra cardiac catheters are already in place. A 135cm
0.032” J tipped guide wire has been advanced from the right femoral vein up
to the superior vena cava (SVC). In the video the sheath and dilator are
advanced over the guide wire into the SVC.
Video 2: pull transeptal assembly down to the intra atrial septum
The Brockenbrough needle has been inserted inside the transeptal dilator with
its tip 2cm inside the distal end of the dilator. The whole assembly is
withdrawn smoothly towards the patient’s feet while observing the catheter
movement on X-ray, demonstrated in this video. The first lateral movement
seen is the catheter falling into the right atrium from the SVC and then a
second more subtle movement is looked for as the catheter falls from the
thicker muscular intra atrial septum into the fossa ovalis. The assembly is then
gently advanced to try and catch the lip of the fossa, however in this video it
does not and the assembly rides superiorly over the intra atrial septum.
Video 3: checking needle position in RAO
The His catheter is a surrogate marker for the aortic root. The tip of the
transeptal assembly is seen posterior to this, and also the mouth of the
coronary sinus (marked by the decapolar catheter). In addition the direction of
the transeptal needle is approximately parallel with the coronary sinus
catheter. If the needle is advanced in this position there is no danger of
puncturing the aortic root.
Video 4: transeptal puncture
Using the right hand the needle is advanced into the transeptal sheath which
is held steady with the left hand. This is observed on X-ray as the needle
emerges out of the transeptal dilator. Often a small jump is seen as the
tension of the fossa ovalis is released however this is not seen here.
Video 5: dye check
In this example the position of the transeptal needle appeared to be more
superior than expected. As there was doubt the pressure line was removed
and dye injected into the lumen of the transeptal needle using a Luer lock
syringe. The roof of the left atrium is clearly defined and this demonstrates
beyond doubt that the tip of the needle is within the lumen of the left atrium.
Video 6: advance dilator into left atrium
The needle is held firm and the dilator and sheath are together advanced over
the needle into the left atrium.
Video 7: advance sheath into left atrium
The needle and dilator are held firm and the sheath is advanced over the
needle and dilator into the left atrium. The needle and dilator are then
removed from the catheter. The transeptal catheter is then aspirated and
flushed and is ready to deliver an ablation catheter into the left atrium.
Image 2: successful ablation site
This fluoroscopic image shows the radiofrequency ablation catheter (RF),
entering the left atrium via the transeptal sheath (TS), in contact with the
lateral mitral valve annulus at the site of the accessory pathway. Energy was
delivered here and pre excitation on the ECG disappeared.