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Cardiology
Transseptal Catheterization
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
9 sections · 89 slides
Overview
- Scope of this presentation
Anatomy of the interatrial septum
- Origins of transseptal catheterization
- Decline of transseptal left heart catheterization
- Revival of transseptal puncture
- Development of the adult interatrial septum
- Fossa ovalis as the only true septum
- Composition of the muscular rim
- Structures at risk around the fossa ovalis
- Medial wall of both atria on three-dimensional echo
- Interatrial groove and epicardial fat
Indications for transseptal puncture
- Interventional indications
- Diagnostic indications
- Pulmonary capillary wedge pressure as a surrogate
- Wedge pressure compared with direct left atrial pressure
- Antegrade gradient measurement in hypertrophic cardiomyopathy
- Transseptal access for electrophysiology
- Rare arterial access through the septum
Equipment for transseptal puncture
- Exclusion of thrombus and anticoagulation strategy
- Anticoagulation maintenance after puncture
- Femoral venous access and sheath strategy
- Fixed-curve and steerable transseptal sheaths
- Fixed-curve sheaths, steerable sheath and Brockenbrough needle
- The Brockenbrough needle
- Electrocautery applied to the Brockenbrough needle
- Radiofrequency transseptal systems
- Advantages of radiofrequency puncture
- VersaCross radiofrequency wire
- Blunt radiofrequency needle and preformed radiofrequency wire
- SafeSept and integrated needle systems
- FlexCath integrated dilator and needle
- Integrated transseptal dilator and needle system
- Classification of transseptal puncture systems
Performing the puncture
- Standard sequence of the procedure
- Sequence of transseptal access
- Fluoroscopy-only technique
- Fluoroscopic landmarks for the fossa
- Sheath and needle position in oblique projections
- Confirming left atrial entry
- Transoesophageal echocardiographic guidance
- Tenting of the septum on transoesophageal echocardiography
- Limitations of transoesophageal guidance
- Intracardiac echocardiographic guidance
- Puncture guided by intracardiac echocardiography
- Left atrial structures as position markers on ICE
- Three-dimensional intracardiac echocardiography
Site-specific transseptal puncture
- Puncture site for mitral valve intervention
- Puncture site for appendage occlusion and leak repair
- Site-specific puncture map for intracardiac interventions
- Puncture site in electrophysiology
Challenging septal anatomy
- Aneurysmal, thick and fibrotic septa
- When the needle crosses but the sheath will not
- Balloon dilation of the interatrial septum
- Puncture in the presence of a septal occluder
- Crossing a pre-existing atrial septal occluder
- Difficulty engaging the fossa ovalis
Congenital heart disease
- Previously repaired atrial septum
- Transbaffle puncture after atrial switch
- Trajectory of transbaffle puncture after Mustard palliation
- Adjunctive imaging in congenital transseptal work
- Transseptal access in the Fontan circulation
- Techniques and indications in Fontan patients
- Trans-Fontan puncture orientation on angiography
Complications
- Incidence of pericardial effusion and tamponade
- Imaging guidance and effusion risk
- Early recognition of pericardial effusion
- Management of pericardial effusion
- The stitch phenomenon
- Mechanism of the stitch phenomenon
- Embolic complications
- Persistent iatrogenic atrial septal defect
- Closure of an iatrogenic atrial septal defect
- Future direction of transseptal practice
- Key points
- References
- References (continued)
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- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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