Download Disclosure Zoltan Turi MD, MSCAI

How to Perform a Successful
Transseptal Puncture
Zoltan G Turi MD, MSCAI, FACC
Seton Hall University School of
Medicine
Hackensack University Medical Center
Disclosure
Zoltan Turi MD, MSCAI
Clinical Events Committee - Mitralign
Research Support - Abbott Vascular
Training Grant Support - Abbott Vascular, Medtronic
Alkhouli
JACC CI 2016
DePonti JACC 2006
1958 - 1979
B
A
B
A
Puncture?
No
G. Joseph CCVD 42:138,1997
G. Joseph CCVD 42:138,1997
AP
2 cm
20 degree RAO
Puncture?
No
90o lateral
90 degree lateral
Cheng J Cardiovasc Electrophys 6 2007
STOP
– Check needle pressure
– Check oxygen saturation
– Inject dye
LA
RA
Alternate Methods
• Right atrial angiogram
• Levophase LA gram
• Aortic root angiography
Superior
atrial
boundary
Gauri Indian Pacing Electrophysiology J 2003
Aortic root
Posterior
atrial
boundary
Left ventricle
1-3 cm
x
Inferior
atrial
boundary
Plane of
mitral valve
Inoue technique
(40° right anterior oblique projection)
Faletra JASE 2011
Atlas of Percutaneous Mitral Valve Repair
Puncture high and posterior
Puncture low and posterior
Singh GD, Intervent Cardiol Clin 2016
Alkhouli JACC CI 2016
Other Approaches to the Left Atrium
•
•
•
•
Transhepatic
Transjugular
Subclavian
Retrograde
Singh SM Circ Arrhythmia Electrophys 2011
Complications
• Tamponade 0.5 -4 %
• Embolic events: air/clot
•
•
•
•
– Ischemia, MI, TIA/stroke
~ 1%
Mortality 0.1 – 1.4 %
Arrhythmias
Vagal stimulation
Transient ST elevation
Clot
Kim JS Circ Arrhythmia Electrophys 2013
• Flush needle
frequently
• Be ready to proceed
as soon as needle and
sheath are introduced
• Anticoagulate as soon
as secure access to
left atrium is obtained
and patient is stable
Alkhouli JACC CI 2016
Factors Influencing Complication Rates
• Diagnostic versus interventional
– Diagnostic – 1.3% (Roelke CCD 1994)
– Interventions - 3.8% (Liu AHJ 2006)
•
•
•
•
•
•
Level of anticoagulation
Sheath size
Left atrial pressure
Presence and compliance of pericardium
Use of echo guidance
Most important
– Operator learning curve
Be on the Hemodynamic Alert
• Bradycardia
• Hypotension
– But can have hypertension and tachycardia
• Call for echo but don’t wait
– Check fluoro for straightening and immobility of
left heart border
Errant Punctures
• Free wall – right and
left atrium
• Pulmonary vein hemothorax
• Aorta – sometimes
benign
• Stitch perforation
RA
LA
Predisposing Factors to Bad Sticks
•
•
•
•
Severe kyphoscoliosis
Giant left atrium
Prominent Eustachian Valve
Anatomic variations
Eustachian valve
Not All Fossa Are The Same
Bulging
May not be where you expect it to be
“Controlled perforation”
Thick, fibrotic,
aneurysmal
septum
.014 wire
stylet
Winkle Heart Rhythm 2011
Bidart Heart Rhythm 2008
RF vs Standard
N
575 vs 975
Failure to cross
0.17 vs 1.23%
Tamponade
0
vs 0.92 %
Conclusions: Negative LA pressures in conjunction with air-leaking sheaths
are identified as potentially important factors for air intrusion into the LA.
Catheterization and Cardiovascular Interventions 71:553–558 (2008)
Complications of Transseptal Access: Air Embolism
Courtesy Dr. Kalyanam Shivkumar
How Do You Become Competent
DePonti JACC 2011
Go Where Diseases Requiring Transseptal are
Prevalent
Stay Sharp