Transcript Transseptal Puncture Technique

Transseptal Puncture Technique
Saibal Kar, MD, FACC, FAHA, FSCAI
Heart Institute, Cedars-Sinai Medical Center,
Los Angeles, CA
Disclosure Statement of Financial Interest
Saibal Kar, MD, FACC
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
•
Grant/Research Support
•
Abbott Vascular,Boston Scientific, St
Jude Medical, Circulite, Coherex,
Gore, Biotronics
•
Consulting Fees/Honoraria
•
Abbott Vascular, Boston Scientific,
St Jude Medical, Gore
•
Other Financial Benefit
•
Coherex, Biosensors International
Introduction
• Transseptal access of the left atrium, was
initially developed to directly measure pressures
of the left atrium and ventricle
• In the present era, transseptal access of the left
atrium is critical step for a wide variety of
electrophysiological and interventional
procedures
• Accurate and safe transseptal puncture is
therefore important for the success of these
procedures
Transseptal interventions
• Electrophysiological procedures
– Pulmonary vein isolation
• Mitral valve interventions
– Valvuloplasty, Repair, replacement, paravalvular leak
closure
• Left atrial appendage closure
• Left sided support systems:
– Tandom Heart
Equipment for Transseptal Puncture
71cm BRK/BRK1 & 67cm SL1
Equipment for Transseptal Puncture
Dilator
Ross needle
Sheath
Sheath
NRG® Radiofrequency Needle( Baylis Medical)
Image guidance for successful
transseptal puncture
• Fluoro :
– Two views : AP and lateral or RAO and LAO
• Echo guidance
– Transesophageal echo or intracardiac echo
• Combined fluoro and echo
– Accurate location of TS puncture based on
pathology and procedure
– Can be used to guide the rest of procedure
– Early detection of complications
Fluoroscopy: Two orthogonal views should be used
Antero posterior View
G. Joseph CCVD 42:138,1997
Fluoroscopy: Two orthogonal views should be used
Lateral View
90 degree lateral
Basic TEE views for optimal Transseptal puncture
Bicaval view:
LA
RA
Short axis view
SVC
4 chamber view
LA
LA
AO
RA
LV
SVC
RV
Technique in different
procedures
• Mitral valve interventions
• Left atrial appendage closure
• Closure of paravalvular leak
Mitral Valvuloplasty
Posterior and superior
Anterior puncture :
Difficulty to advancing
Stiff balloon catheter in LV
MitraClip System
Steerable Guide
Catheter
Clip Delivery System
Stabilizer
MitraClip
Transseptal puncture during MitraClip
Procedure
Too close to MV
Too posterior from MV
Correct TS for MitraClip;
4.0 - 4.5 cm away from MV
Transseptal puncture during MitraClip
Procedure
Appropriate location determines the success of the
procedure Short axis: Posterior
Bicaval view: Superior
4 chamber view:
Distance From Puncture
to point of coaptation 4 to 4.5 cm
Special situation
MitraClip for Flail leaflet
4 chamber view: Distance
From Puncture to point
of coaptation 4 to 4.5 cm
Bicaval view: Superior
Short axis: Posterior
Special situation
Functional MR with very large left atrium
4 chamber view: Distance
From Puncture to point
of coaptation 4 to 4.5 cm
Bicaval view: Low
Short axis: Mid or anterior
TS puncture location :
determining factors
• Left atrial size
• Type of pathology
– Functional
– Flail/Prolapse
• Region of MV involvement
– Medial aspect ( A3P3)
– Lateral aspect (A1P1)
Optimal location for TS puncture for left atrial
appendage occlusion
Low
Posterior
•
Posterior
Puncture
LAA
Use of Fluoro and TEE for Transseptal puncture
Appropriate location and prevention of tamponade
Bicaval view (90 to 100º)
Short axis view ( 35 to 50º)
LA
LA
RA
RA
Mid Fossa
AO
SVC
Mid Fossa / Posterior
Advantages of TEE guided Transseptal puncture
• Accurate
localisation
• Avoid Puncture of
the posterior wall
or roof of LA
• Early detection of
pericardial effusion
Posterior
Puncture
Anterior
puncture
LAA
Other Important Tips during Transseptal Puncture
• Avoid excessive tenting of
septum
• Protect Needle tip with wire
• Use of stylet through needle to
puncture septum
• Use of radiofrequency needle,
Optimal TS:
Avoid/treat complications
• Cardiac perforation/cardiac tamponade
– Prevent it
– Early recognition
– Treatment
• Thrombus formation
– Prevention
– Treatment
Conclusion
• Trans-septal access is a critical step to
several structural procedures
• Echo and Fluoro guidance is essential
• Puncture is dependent on
– Procedure
– Location of the pathology
– Size of the Left atrium
• Be vigilent about potential complications