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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