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18-year experience with transseptal procedures through baffles, conduits, and other intra-atrial patches
Abstract
The presence of an intra-atrial patch (IAP) has been considered a relative contraindication to transseptal puncture (TSP). The purpose of this study is to determine the efficacy and safety of the TSP through baffles, conduits, pericardial patches and other prosthetic materials in the intra-atrial septum. We reviewed the records of all pediatric patients with IAP who underwent TSP at Texas Children's Hospital from November 1979 through February 1998. The review included the cardiac diagnoses, indications for TSP, technical difficulties and follow up echocardiograms specifically addressing residual atrial shunts A total of 1958 TSP were performed. Thirty-nine patients had IAP. Cardiac diagnoses in those 39 patients included D-transposition of the great arteries after Mustard (10) or Senning procedure (6), single ventricle variant post-Fontan operation (4), total anomalous venous return repair (4), atrioventricular canal repair (9) and atrial septal defect with patch repair (6). Patients' age ranged from 1-31 years (median 7 years). The duration from the time of surgical repair to TSP ranged from 0.1-21 years (median 5 years). Indications for TSP included diagnostic and therapeutic intervention for pulmonary venous obstruction (12), creation of a baffle fenestration (2), prosthetic mitral valve evaluation (1), left ventricular outflow tract evaluation (1), access the left heart for hemodynamic evaluation (23). The IAP was traversed in 38/39 patients (97.5%), followed by diagnostic or therapeutic prograde left-heart catheterization. No complications were encountered. Follow up echocardiography in 30/38 PTS demonstrated no residual shunting across the atrial septum except for two cases in which the atrial baffle had been intentionally fenestrated. Transseptal puncture through an intra-atrial patch is a safe procedure. This technique is effective in permitting diagnostic and therapeutic left heart catheterization and does not result in residual shunting through the patch.
... 33 Using the retrograde aortic approach could result in complications concerning the femoral artery, including loss of pulse, excessive postcatheterization bleeding, and thromboembolic events. 60 Furthermore, manipulating the ablation catheter past the aortic and tricuspid valve could lead to valvular damage. 29,33 Another method to reach the PVA is transseptal puncture, which was first described in 1959. ...
... Furthermore, the material of the patch did not seem to affect the success of the transseptal procedure. 60 Performance of a transseptal puncture can be guided by angiogram only or by transesophageal echocardiography/ICE. 22,33,35,62,63 Successful puncture can be confirmed by hand injection of radiological contrast, fluoroscopic examination of tip position, pressure recording through the central needle lumen, and ICE/transesophagal echocardiography. 22,29,33,35,50,62,63 The transseptal method is particularly useful when the retrograde aortic approach is not possible because of technical or anatomical reasons or when the desired ablation site cannot be reached. ...
The arterial switch operation has been the procedure of first choice for correction of transposition of the great arteries (TGA) for several decades now. However, a large number of adult TGA patients nowadays were palliated previously by either a Mustard or a Senning procedure. Atrial tachyarrhythmias (AT) are frequently observed during long-term follow-up of TGA patients after these atrial switch corrections and are associated with both morbidity and mortality. Due to the complex postoperative anatomy in these patients, ablative therapy of these tachyarrhythmias can be challenging. The goal of this review is to discuss the most prevalent AT in patients after the Mustard or Senning procedure and to summarize (long-term) outcomes of ablative therapy. In addition, recent developments in ablative therapy of AT in this patient population will be outlined.
... Transbaffle access to the PVA is the only technique that has been used safely and effectively in patients after atrial switch procedure or with a Fontan circulation for ablation of ART within the PVA using an anterograde catheter access. 10,12,15 This technique additionally allows more precise catheter steering compared with a retrograde, transaortic approach. We therefore adopted this technique to gain access to the PVA for catheter ablation in selected patients after a Mustard or Fontan procedure. ...
... 12,19,20 Others used mainly fluoroscopy. 10,15 In present series of patients, it proved challenging to exactly visualize the transseptal needle on transoesophageal echocardiography, possibly due to the presence of baffle-calcification and/or stents/pacing lead material. This, however, should not deter future operators from using transoesophageal echocardiography in such procedures. ...
Aims
Catheter ablation of atrial re-entrant tachycardia in patients after atrial switch procedure for transposition of the great arteries or with a Fontan circulation is technically challenging if the critical part of the re-entry circuit is located within the pulmonary venous atrium (PVA). We report our experience in transbaffle access (TBA) to the PVA for ablation of atrial re-entrant tachycardia focusing on technical details.
Methods and results
In eight patients, six after Mustard procedure and two with a Fontan circulation, endocardial mapping of atrial re-entrant tachycardia revealed the critical part of the re-entry circuit within the PVA. A total of 10 ablation procedures were performed. Detailed angiographic assessment of the anatomy of the systemic and pulmonary venous atria was performed prior to baffle puncture. Transbaffle access was successfully established with a standard transseptal needle in 9 of 10 procedures. No major complications occurred. At the end of the procedure and the removal of the transseptal sheath, there was no residual shunt in any patient.
Conclusion
Transbaffle access to the PVA for ablation of atrial re-entrant tachycardia is feasible, less invasive than alternative approaches and can be safely applied in patients after Mustard procedure or with a Fontan circulation. However, the rigidity of prosthetic material may preclude baffle puncture at least in a subset of those patients.
... There are limited data in the literature in regard to this new technique consisting mainly of case reports and small case series with encouraging results. [9][10][11][12] The goals of this study are to find the frequency of the use of transbaffle access (TBA) for mapping or ablation of atrial tachycardias in this patient population, the safety of this procedure along with the acute success rate, and an initial report of a longer-term success rate. ...
... There has been so far no strong evidence to support the risk or safety of the intervention in this regard. In the series by El-Said et al, 9 after the 38 cases with successful TBA, they had follow-up echocardiograms on 30 with the only 2 who had evidence of a persistent shunt being those who had the procedure with the goal of creating a fenestration. ...
In Fontan and atrial switch patients, transcatheter ablation is limited by difficult access to the pulmonary venous atrium. In recent years, transbaffle access (TBA) has been described, but limited data document its safety and utility.
All ablative electrophysiological study cases of this population performed between January 2006 and December 2010 at Boston Children's Hospital were reviewed. Pre-case and follow-up clinical characteristics were documented. Adverse events were classified by severity and attributability to the intervention. We included 118 cases performed in 90 patients. TBA was attempted in 74 cases and was successful in 96%: in 20 via baffle leak or fenestration and in 51 (94%) of 54 using standard or radiofrequency transseptal techniques. There were 10 procedures with adverse events ranked as moderate or more severe. The event rate was similar in both groups (TBA 8% versus non-TBA 9%, P=1), and no events were directly attributable to TBA. There was a trend to higher proportion of cases having a >5-point drop in saturations from baseline in the TBA group versus the non-TBA group in Fontan cases (15% vs 0%, P=0.14). When cases with follow-up >90 and >365 days were analyzed, the median initial arrhythmia score of 5 significantly changed -3 points in both time periods (P≤0.001).
TBA is feasible in this population; its use was not associated with a higher incidence of adverse events; and changes in clinical scores support its efficacy. Desaturation observed in some patients is of uncertain significance but warrants postablation monitoring and prospective study.
... The transseptal approaches across surgical baffles has been found to be very safe with an extremely low risk of residual shunts or other complications. 8,9 However, 2 cases in which there was residual shunt after baffle puncture were in patients with fenestrated atrial baffles. 9 Although our patient did not have a fenestrated baffle, she did have an existing baffle leak. ...
... 8,9 However, 2 cases in which there was residual shunt after baffle puncture were in patients with fenestrated atrial baffles. 9 Although our patient did not have a fenestrated baffle, she did have an existing baffle leak. As there are no data on whether baffle puncture would result in further residual shunt in a patient with a preexisting baffle leak, we decided the safest approach to the ventricular side of the tricuspid annulus would be a retrograde aortic approach. ...
A 42-year-old woman with a history of D-transposition of the great arteries and a Mustard correction at age 5 years presented to an outside hospital with palpitations and chest pain. The electrophysiology study and strategy for radiofrequency ablation are discussed.
... One option is a transvenous approach with perforation of the baffle either under fluoroscopic or intracardiac echocardiographic guidance. 18,19 However, the rigidity of the baffle material adds to the difficulty of this method. Similarly, gaining access to the functional PVA in a retrograde arterial fashion is also technically challenging when performed with the use of conventional catheters. ...
... Study of 3D reconstruction allows choosing the best approach for an individual patient, reserving potentially more challenging procedures such as transbaffle or transhepatic punctures for those rare patients in whom a retrograde arterial access is impossible (eg, metallic prosthetic valve). 9,18,19,25 ...
Improvement in outcome of infants born with congenital heart defects has been accompanied by an increasing frequency of late arrhythmias. Ablation is difficult because of multiple tachycardias in the presence of complex anatomy with limited accessibility. We report on remote-controlled ablation using magnetic navigation in conjunction with 3D image integration in patients with previous intra-atrial baffle procedures.
Thirteen patients (8 male; age, 30.5±8 years) with supraventricular tachycardia (SVT) underwent catheter ablation. Group A had a medical history of a Mustard or Senning operation, whereas group B had undergone total cavopulmonary connection. A total of 26 tachycardias were treated in 17 procedures (median cycle length of 280 ms). Group A patients had more inducible SVTs than group B, and all index SVTs were located in the remainder of the morphological right atrium in all but 1 patient. Retrograde access through the aorta was performed and led to successful ablation, using magnetic navigation with a very low total radiation exposure (median of 3.8 minutes in group A versus 5.9 minutes in group B). Only 1 of 13 patients continued to have short-lasting SVTs despite 3 ablation procedures during a median follow-up time of >200 days.
Remote-controlled catheter ablation by magnetic navigation in combination with accurate 3D image integration allowed safe and successful elimination of SVTs, using an exclusively retrograde approach, resulting in low radiation exposure for patients after intra-atrial baffle procedures (Mustard, Senning, or total cavopulmonary connection).
... ICE can be very helpful in accurately localizing the interatrial device and delineating the site for secondary puncture [5]. Successful puncture through the septal patch have been reported [55,56]. However, such approach is limited by technical challenges and higher rate of failure. ...
Purpose of Review
Transseptal puncture is a routinely performed interventional cardiology procedure for an array of cardiac diseases. We aimed to review the current status of available devices and techniques of transseptal puncture with consideration to specific interventions.
Recent Findings
Except for a few modifications, devices for transseptal puncture technique has not changed much compared to when it was first described almost 60 years ago. For difficult transseptal puncture, a few newer techniques such as radio frequency needle puncture system have been used but there is lack of robust clinical study. Advanced imaging, such as intracardiac echocardiography and transesophageal echocardiography, has been found to make transseptal puncture safer. A new transseptal approach that incorporates 3D non-fluoroscopic catheter tracking systems has shown promising results in two human studies.
Summary
While various modifications in the transseptal technique tailored to the specific interventions have improved procedural safety, further improvement in existing devices focusing on distinct procedure might be needed in the future.
... 2 AF ablation through a transeptal approach is safe and effective among patients who had undergone ASD patch closure. 3 However, the presence of an intra-atrial patch can create difficulty in performing a transeptal puncture, especially when a wide Gore-Tex patch is used. 4 In our case, TEE-guided transeptal puncture was attempted but we encountered resistance in traversing the atrial septum. ...
Key Clinical Message
The presence of a Gore‐Tex patch can create difficulty in performing transeptal puncture for atrial septal defect patients underwent atrial fibrillation ablation. The maneuverability and stability of using manually operated catheters via retrograde aortic approach could be overcome by a large‐curved catheter to form a loop facilitating approachability to all parts of left atrium.
... For both techniques, a detailed understanding of the patient's anatomy is needed and review of imaging studies such as cardiac MRI, CT, or previous catheterization angiograms can be of great benefit. Intra-procedure imaging with TEE, ICE, and angiography facilitate transbaffle procedures which have been performed extensively by interventional congenital cardiologist and electrophysiologists [33][34][35][36]. In a recent multicenter report of ablation in patients with extracardiac conduit Fontan, 63% (n = 46) were performed via transconduit puncture, 26% across an open fenestration, 13% were performed retrograde. ...
Purpose of Review
Atrial arrhythmias cause significant morbidity in patients with congenital heart disease (CHD). Catheter ablation remains one of the most effective treatment modalities for atrial arrhythmias. However, patients with congenital heart disease present unique challenges for catheter ablation.
Recent Findings
Recent expert consensus guidelines inform physicians about treating arrhythmias in patients with CHD. These guidelines outline appropriate selection criteria for ablation and highlight treatment alternatives. The authors also suggest electrophysiology laboratory and physician standards for performing these complex procedures. Recent studies report that 51% of atrial arrhythmias in CHD involve the cavo-tricuspid isthmus (CTI), 28% were non-CTI related and two types of IART were present in 21%. These studies link recurrence of tachycardia after ablation to CHD complexity, non-CTI-related arrhythmias, and patients with prolonged intra-atrial conduction. An analysis of patients with displaced AV nodes showed that cryoablation is a safe and effective technology to perform ablation in CHD with perinodal substrates. Changes in surgical Fontan palliation away from intracardiac baffles to extracardiac conduit has hopefully decreased arrhythmia burden in single ventricle patients. However, in those with atrial arrhythmias, access to the atria is complicated by no direct systemic venous access to the heart. Recent single-center and multicenter studies evaluated the success of ablation in these patients and outline safe approaches to transbaffle puncture. Acute success was 83% with similar complication profile to other CHD patients.
Summary
The anatomic variations of congenital heart disease create special problems for catheter ablation. Teams performing ablation need pre-procedural preparation and specialized understanding of a vast anatomic variation and surgical repairs. This understanding coupled with the knowledge of the pathophysiology of arrhythmia disorders and the biophysics of catheter ablation technology is required to perform successful and safe ablation procedures.
... Balloon atrial septostomy is a life-saving emergent procedure with rare complications. Rupture of the balloon with embolization of the fragments can occur and require retrieval [17]. Traumatic complications including damage or rupture of the atrial appendage, mitral valve, or pulmonary veins can occur. ...
... Atrial transseptal catheterization has been routinely used for catheter ablation of left-sided arrhythmias including accessory pathways, atrial tachycardia, ventricular tachycardia, and atypical atrial flutter. In the modern era of congenital heart surgery, the use of the Btransseptal^procedure through atrial baffles, conduits, and patches has also been described in patients for both hemodynamic measurements and for catheter ablation [1,2]. The transseptal catheterization procedure has been demonstrated to be safe with low morbidity and mortality, with the most common complications including aortic root and cardiac perforation, arterial thromboembolism, arterial air embolism, pericarditis, and transient ST-segment elevation, and rarely death [3]. ...
Purpose:
The atrial transseptal procedure is used in catheter ablation of left-sided arrhythmias. Studies in adult patients have shown the SafeSept™ transseptal guidewire (SSTG) to be effective in atrial transseptal procedures. We analyzed our 5-year experience with SSTG use in pediatric and congenital heart disease patients undergoing catheter ablation.
Methods:
This is a single-center retrospective analysis of patients undergoing catheter ablation from 2009 to 2014. We identified all procedures where SSTG was used for atrial transseptal or trans-baffle access. Success of transseptal access and complications were recorded and compared to the standard transseptal approach without the SSTG.
Results:
One hundred twenty-seven patients underwent 132 attempted atrial transseptal or trans-baffle procedures using SSTG. Median age was 14 (1.2-38) years. Arrhythmia substrates included AV reentrant tachycardia (90.2%), atrial tachycardia (4.5%), ventricular tachycardia (2.3%), and AV nodal reentrant tachycardia (2.3%). Transseptal or trans-baffle access was successful in 96.2% of the SSTG cases compared to 98.9% in the standard transseptal group without SSTG (p = NS). The youngest patient with successful atrial transseptal procedure using SSTG was 4 years old. SSTG was used to successfully cross a surgically created atrial baffle in a patient who had undergone the Mustard procedure. There was one major complication in both groups, 0.8% in the SSTG group compared to the standard transseptal group without SSTG, 1.1% (p = NS). The major complication in the SSTG group occurred when the SSTG crossed the aorta into the coronary artery system and mimicked placement in the left atrial appendage, with subsequent placement of a transseptal sheath into the aorta, requiring sternotomy and surgical intervention.
Conclusions:
SSTG is effective for use in atrial transseptal and surgical trans-baffle access in pediatric and congenital heart disease patients. Placement of the SSTG into the pulmonary vein is necessary to avoid major complications, and if not achieved requires additional methods to determine appropriate left atrial placement.
... TS access can still be gained in the presence of pericardial and prosthetic patches and has been reported at the inferoposterior border of atrial septal defect closure devices. 3 The additional use of ICE or TEE is extremely helpful in these cases. ...
Transseptal access is commonly performed for any procedure which requires access to the left side of the heart such as catheter ablation of atrial fibrillation, left atrial tachycardia, left sided accessory pathways, ventricular tachycardia, left atrial appendage closure, percutaneous mitral valvuloplasty and mitral valve repair. In order to perform this in a safe and effective manner it is important that the operator has a detailed knowledge of the relevant anatomy, the technique required, the ability to deal with difficult cases and complications. The aim of this article is to provide a detailed description of the anatomy, techniques, potential complications and difficulties associated with performing this procedure.
... In a study of 39 pediatric patients with congenital heart disease requiring intra-atrial patch (IAP), the IAP was successfully punctured in 97.5% of the patients (38/39) with no complications; follow-up echocardiography in 79% of the patients revealed no residual shunting across the atrial septum except for two cases of atrial baffle, which were intentionally fenestrated. 115 Double TSP for AF ablation was successfully (95%) performed under the guidance of intracardiac echocardiography (ICE) in a prospective study of 20 post-ASD/PFO repair patients, age-and gender-matched with 20 control patients. Lakkireddy et al showed that surgical repairs with synthetic materials like Dacron (but not Gore-Tex) can safely be punctured to gain access to the LA, while most ASD or PFO closure devices typically occlude the anteroseptal portion of the interatrial septum, leaving a relatively wide posteroinferior area for TSP [figures [1][2]. ...
Atrial fibrillation (AF) is a common complication in patients with atrial septal defects (ASDs). The link between AF and ASD is fairly complex and entails modifications in electrophysiologic, contractile and structural properties, at the cellular and tissue level, of both atria, mainly due to chronic atrial stretch and dilation. Surgical repair or percutaneous closure of ASDs are equally effective in reducing mortality and symptoms but limited in preventing or curbing AF, unless combined with an arrhythmia-specific procedure. Transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) have improved the safety and success of the above procedures. Finally, clearer understanding of the pathophysiology of AF in patients with ASD (and CHF, in general) has led to target-specific advances in medical management.
... as cardiac MRI, CT or previous catheterization angiograms can be of great benefit. Intra procedure imaging with TEE, ICE and angiography facilitate transbaffle procedures which have been performed extensively by interventional congenital cardiologist and electrophysiologists. 44,45 There are recent case reports of transbaffle puncture for ablation in patients with extracardiac fontan. 46,47 ...
Pediatric patients present unique anatomic challenges for catheter ablation. Small patient size requires special adaptation and understanding to perform safe procedures when clinically indicated. The anatomic variations of congenital heart disease also create problems that require pre-procedural preparation for each case in addition to a specialized understanding of a vast anatomic variation and surgical repairs. This understanding coupled with the knowledge of the pathophysiology of arrhythmia disorders and the biophysics of catheter ablation technology are required to perform successful and safe ablation procedures in this special population.
... Multiple case reports or small series can be found in the world literature. [18][19][20][21][22][23][24][25][26][27][28][29][30][31] ...
... The risk of perforation and bleeding, however, is very low. [679][680][681][682] There is significant practice variability in the use of thromboprophylaxis with regard to the creation of atrial septal defects, including balloon atrial septostomy. Balloon atrial septostomy is typically performed without the use of procedural heparinization. ...
... The two options for ablation are retrograde aortic access to the PVA or transbaffle puncture. 6,7 Retrograde aortic access was chosen for this patient. Electroanatomic mapping and entrainment proved that the arrhythmia was typical atrial flutter. ...
This article describes the case of a 38-year-old male patient with a history of D-transposition of the great arteries (D-TGA) status post Mustard atrial switch procedure who presented with palpitations. Electroanatomic mapping and entrainment proved that the arrhythmia was typical atrial flutter in the pulmonary venous atrium. Ablation was performed via the retrograde route with confirmation of isthmus block. This case illustrates typical mapping and ablation of atrial flutter in a patient after Mustard repair of D-TGA.
... By comparison, the retrograde aortic approach may be less problematic in the younger Mustard patient because of their smaller atrial size and less severe tricuspid regurgitation (10). We did not perform CTI ablation through a transbaffle approach, which may have potentially improved accessibility and catheter stability (17). Some pediatric/ adolescent reports have described successful CTI ablation exclusively from the systemic venous atrium (10,18). ...
Objectives
The aim of this study was to determine the acute and long-term outcome of radiofrequency catheter ablation (RFCA) for intra-atrial re-entrant tachycardia (IART) in adults with congenital heart disease (CHD), and predictors of these outcomes.
Background
Atrial myopathy can be progressive in CHD and contributes to the substrate for IART. Although the outcome of RFCA for IART has been well described in children and adolescents with CHD, it is unclear whether these results are similar in the adult population.
Methods
Clinical records of adults with CHD undergoing attempted RFCA of IART were analyzed retrospectively. Multivariate analyses identified clinical and procedural factors that predicted acute and long-term outcomes.
Results
A total of 193 procedures was performed in 130 patients (mean age 40 ± 13 years); 82 of 118 (69%) initially attempted RFCA were successful, defined as termination of all IART circuits. The use of electroanatomic mapping was associated with a successful RFCA, whereas Fontan palliation and Mustard repair were associated with an unsuccessful RFCA. Median clinical follow-up of 77 patients (≥2 months of follow-up) after a successful RFCA was 3.7 years (range 0.2 to 10.2 years). IART recurrence was noted in 48%, cardioversion/reablation in 42%, and death in 4%. Older age and Fontan palliation were independent predictors of IART recurrence.
Conclusions
In adults with CHD, acute and long-term outcomes of RFCA for IART are similar to those reported for younger cohorts. Complex atrial surgery limits the success of RFCA, and older age is associated with a higher risk of IART recurrence.
... Baffle puncture is a challenging procedure but it can be safely performed using direct visualization of the region of interest. 1,2 To our knowledge, this procedure has never been performed in a patient with dextrocardia. All equipment used for transseptal puncture is designed for left-sided hearts. ...
A baffle puncture is a challenging procedure but can be safely done using direct visualization of the region of interest. To our knowledge, however, it has never been performed in a patient with dextrocardia. We present a 62-year-old male with dextrocardia, right isomerism, congenitally corrected transposition of the great arteries, persistent left-sided superior and inferior caval veins, atrial septum defect, and pulmonary valve stenosis. The atrial septum defect was surgically closed with a Teflon patch, a variant Mustard operation was performed, and also a prosthetic tricuspid valve was implanted. The patient developed multiple episodes of atrial tachycardia leading to acute heart failure on many occasions. An electrophysiological study was undertaken in order to create a bi-atrial electro-anatomical map. Owing to the presence of a prosthetic tricuspid valve, the femoral venous access was used and a baffle puncture was performed using continuous monitoring with fluoroscopy and transoesophageal echocardiography (TEE). The baffle puncture was successful and the tachycardia was ablated in the systemic venous atrium. To our knowledge, we present the very first case report demonstrating a successful baffle puncture in a patient with dextrocardia and Mustard correction. Direct imaging using TEE seems to be a very useful tool for guiding the puncture.
... Transseptal puncture has been performed in adults and children for decades. 1,2 Initially, the indication for the transseptal puncture in children was for hemodynamic evaluation. In the last two decades, it became more widely used in pediatric patients with the evolution of ablation for arrhythmias. ...
Transseptal puncture has been performed in adults and children for decades. However, transseptal puncture can be challenging especially in pediatric patients because of an elastic septum and small atria. In adults, dedicated radiofrequency (RF) to facilitate transseptal puncture has become routine.
We wanted to assess whether RF could be used routinely in children to facilitate transseptal procedure.
The study population included all children referred to our electrophysiology lab who underwent an ablation requiring a transseptal puncture over a period of 10 months. RF was applied at the time of transseptal puncture. The source of RF was standard surgical electrocautery device with the electrosurgical pen in direct contact with the transseptal needle applied for a short period of time during transseptal puncture. RF output was set initially at 30 W in cut mode. All procedures were performed under general anesthesia. Patients were followed for possible complications.
Thirteen patients (ages 11.6 ± 3.6 years, range 5-17 years, five boys) were included. One patient had left ventricular tachycardia, and the remainder had a supraventricular tachycardia with a left-sided accessory pathway. In all but two patients, a single attempt with an RF output of 30 W applied for less than 2 seconds was sufficient to cross the septum. In two patients, three attempts were needed with a last successful attempt using 35 W. No complications were observed either acutely or during the follow-up.
Transseptal puncture facilitated by RF energy can be performed in children routinely and safely.
... However, transseptal access in these patient groups has been proven safe and feasible, especially with the aid of ICE. 33,34 In patients with ASD/PFO closure devices, puncture should be performed at the portion of the septum located inferior and posterior to the closure device. 33 In patients with surgically repaired interatrial septums, puncture can be performed directly through neighboring native interatrial tissue, or through the patch itself in case of pericardial or Dacron patch, but rather not in case of Gore-Tex patch (W.L. Gore & Associates, Flagstaff, AZ, USA) due to its resistant texture. ...
Transseptal catheterization is used by interventional cardiologists to gain access in the left atrium. This technique was initially introduced for left-sided pressure measurements and has been integrated in a variety of procedures including left atrial ablations and percutaneous mitral valvuloplasties. The establishment of catheter ablation of atrial fibrillation as an effective treatment strategy has brought transseptal catheterization back to the limelight. Technique refinements, introduction of adjunctive imaging tools, and enrichment of available technical equipment have simplified the procedure. In the present article we review the technique of transseptal catheterization, presenting tips and caveats that could be of value for safe and successful transseptal punctures.
... Transseptal puncture in patients after Mustard/Senning procedure has been used successfully. 8,9 The technique has also been used to perforate atretic systemic pathways to allow recanalization after Mustard operation for D-TGA. 1 We chose to attempt RF perforation as an alternative as we considered it likely to be safer and more controllable than needle perforation, based on our experience in infants with pulmonary atresia with intact ventricular septum. The RF technique has the additional advantage of allowing clear echocardiographic visualization of the wire tip due to the production of bubbles during energy applications. ...
Endocardial pacemaker lead placement can be challenging after Mustard and Senning operations for transposition of the great arteries (D-TGA), if there is atresia of the systemic venous pathways and because the coronary sinus cannot be used for cardiac resynchronization therapy. Radiofrequency (RF)-assisted perforation techniques have been used in congenital heart disease but have not been reported for use in pacemaker implantation.
We describe RF perforation of an atretic superior systemic venous pathway and systemic venous baffles in three patients after Senning and Mustard operations to implant endocardial pacing systems to achieve conventional or biventricular pacing.
RF-energy-assisted perforation is feasible and effective tool to facilitate endocardial lead placement during dual-chamber and biventricular pacemaker implantation in patients with Mustard or Senning operations for D-TGA.
... Few de novo transcatheter fenestration of baffle have been reported in the literature. [7][8][9][10][11][12] This case of transcatheter fenestration of TCPC baffle is probably the first of its kind in India. ...
Transcatheter creation of a de novo fenestration of a total cavopulmonary connection baffle has not been previously reported from India. We present our experience with such a procedure in a 4-year-old child with recurrent pleural effusions in the early postoperative period.
... A study proved that transseptal puncture was extremely safe over an 18 year period, including through baffles and interatrial patches. 10 In the first case presented, the use of a transseptal approach additionally allowed the device to be aligned appropriately with the septal flap rather than "bunching" the septal flap together in one area of the device. ...
Two patients with long tunnel-type patent foramen ovale presented for elective transcatheter closure following transient ischaemic attack and stroke. Right to left shunting was confirmed on transthoracic and transoesophageal echocardiography. A new technique that used a transseptal procedure was devised to enable closure of the tunnel-type patent foramen ovale using the CardioSEAL transseptal occluder to avoid "bunching up" of the device and residual transatrial shunting.
This chapter reviews the typical arrhythmias encountered in patients with congenital heart disease (CHD). Patients who have undergone repair of CHD are at risk for atrial and ventricular tachyarrhythmias and sudden cardiac death, because of altered substrate for arrhythmias and an altered hemodynamic response. The onset of cardiac tachyarrhythmia is often related to functional decline of “anatomical” defects. Therefore, relevant cardiac imaging and functional studies to assess the anatomy and hemodynamics and their interval changes are important in CHD patients who present with new onset of arrhythmias. Detailed mapping and confirmation of the 3D mapping data by conventional electrophysiology pacing maneuvers are key for a successful ablation procedure. While the non‐corrected atrial septal defect (ASD) patient presents mostly with right atrial (RA) enlargement and subsequent RA inferior isthmus‐dependent flutter, the operated patient can present with reentry around the ASD patch or around the atriotomy scar at the RA free wall.
Background:
Atrial transseptal puncture (TSP) for cardiac catheterization procedures remain challenging in children and adults with complex congenital heart disease (CHD).
Objectives:
We sought to evaluate our experience using radiofrequency (RF) current via surgical electrocautery needle for TSP to facilitate diagnostic and interventional procedures.
Methods:
Retrospective chart review of all patients (pts) who underwent TSP using RF energy (10-25 W) via surgical electrocautery from three centers from January 2011 to January 2017 were evaluated. Echocardiograms were reviewed to define the atrial septum as normal and complex (thin aneurysmal, thick/fibrotic, synthetic patch material, and extra cardiac conduit).
Results:
A total of 54 pts underwent 55 successful TSP. Median age was 12.5 years (1 day-54 years) and weight was 52.7 kg (2-162). Indications for TSP included; EP study and ablation procedures in structurally normal hearts (n = 24) and in complex atrial septum/CHD and structural heart disease pts (n = 30): Electrophysiology study and ablation in 4, diagnostic catheterization in 9, and interventional procedures in 17 pts were performed. Atrial TSP was successful in 54/55 (98%). Atrial perforation with tiny-small pericardial effusion not requiring intervention was noted in 2 pts. TSP was unsuccessful in one critically ill neonate with unobstructed TAPVR and restricted atrial septum who experienced cardiac arrest requiring CPR, ECMO, and emergent surgery.
Conclusions:
RF current delivery using surgical electrocautery for TSP is a feasible and an effective option in patients with complex CHD for diagnostic, interventional, and electrophysiology procedures.
Complete transposition of the great arteries (d-TGA) is a common congenital heart disease. The surgical strategy for d-TGA has changed from the atrial switch operation to the arterial switch operation. This chapter describes the postoperative concerns regarding these two switch operations as well as details of the management of adult patients with repaired d-TGA. Long-term complications after the atrial switch operation include intra-atrial baffle-related problems, arrhythmias, right ventricular (systemic ventricular) failure, and tricuspid regurgitation. Transcatheter reintervention for baffle leaks or obstructions has been reported as effective. Right ventricular failure is common, and reintervention options for this are cardiac resynchronization therapy, arterial switch conversion, and cardiac transplantation. Atrial arrhythmias after the atrial switch operation are frequent. Catheter ablation and/or pacemaker implantation is indicated for some patients; however, the approach is complex. In recent years, the arterial switch operation has been the surgical option of choice. This procedure has the advantage of maintaining an almost normal anatomy. Long-term sequelae after the arterial switch procedure include pulmonary artery stenosis, coronary artery complications, and aortic valvular dysfunction. When pulmonary artery stenosis is severe, surgical repair should be performed. Sequential coronary angiography can reveal coronary stenoses in asymptomatic patients. The fate of the neo-aortic valve has been a major concern. In conclusion, there remain a number of concerns regarding repaired d-TGA patients; regular follow-up and appropriate timing of reinterventions are important.
Patients who undergo surgery for complex congenital cardiac anomalies exhibit intracardiac structural changes, so advancing a transcutaneous catheter into an intracardiac target site is sometimes risky and difficult in such patients. This report describes the case of a 4-year-old male with total cavopulmonary connection（TCPC）involving a common atrium and a single ventricle who underwent successful cardiac catheter ablation for paroxysmal supraventricular tachycardia. During the ablation procedure, a transcutaneous catheter was inserted into the femoral vein and advanced into the atrium through the extracardiac conduit under transesophageal echocardiographic monitoring because the inferior vena cava is isolated from the right atrium in patients with TCPC. We consider transesophageal echocardiography to be a safe monitoring method that can aid the insertion of catheters into intracardiac target sites in such patients.
Besides antiarrhythmic medication, there are now very good options for a potentially curative therapy by catheter ablation targeting the origin of the underlying arrhythmias in patients with complex congenital heart disease. Three-dimensional (3D) reconstruction of tomographic imaging (MRI or computed tomography) is helpful to understand the underlying cardiac anatomy, identify the most likely target chamber, and help with planning access. Use of the available 3D mapping systems (sequential or simultaneous acquisition) and (if available) more advanced navigation systems, such as remote magnetic navigation, can improve the acute and long-term outcomes of catheter ablation in congenital heart disease.
Transcatheter Fontan fenestration is a valuable option in situations of prolonged pleural drainage or low cardiac output in patients with failing Fontan circulation. This procedure relies on controlled baffle perforation without separation of the Fontan circuit from the pulmonary venous atrium, and placement of an accurately sized covered stent. We report a novel technique for transcatheter extracardiac Fontan fenestration using the SafeSept transseptal guidewire® and snare-controlled diabolo-shaped covered stent placement. © 2015 Wiley Periodicals, Inc.
© 2015 Wiley Periodicals, Inc.
-Patients with surgically-palliated total caval pulmonary connection (TCPC) are at risk for recurrent atrial arrhythmia requiring catheter ablation. Transcatheter procedures for those with extracardiac conduits (E-TCPC) are perhaps the most challenging due to exclusion of the venous circulation from the arrhythmia substrate. Puncture through the inferior vena cava (IVC) to the pulmonary venous atrium (PVA) may be an effective route for access in these patients.
-The pediatric and adult congenital surgical databases were explored for patients with E-TCPC and postoperative CT imaging in order to assess for the presence of clinically relevant (>3 mm) apposition between the IVC and PVA ("cavoatrial overlap"). The degree of overlap between the structures was measured by 2 blinded reviewers. Patients were stratified by surgical repair in childhood versus adult congenital heart disease (ACHD). Thirty-seven patients were identified, with cavoatrial overlap observed in 9 (36%) of pediatric and 1 (9%) of ACHD-repaired patients. Time elapsed after surgery was associated with cavoatrial overlap in the pediatric cohort (p=0.034) and was identified in all pediatric patients with CT imaging ≥8 years after surgery. Three patients underwent successful transcaval puncture during the study period without complication.
-Puncture through a region of overlap between the IVC and PVA is feasible. Cavoatrial overlap is present in a substantial proportion of patients undergoing E-TCPC in childhood and is associated with a longer time elapsed since surgery.
Tachycardia arising from the pulmonary venous atrium (PVA) has not been adequately characterized in the setting of surgically repaired congenital heart disease (CHD).Objective
To determine the mechanisms, approach, and outcomes of catheter ablation of PVA tachycardia after CHD repair.Methods
The adult CHD procedural database was searched for consecutive ablation procedures over a 4-year period. Procedural characteristics of the population with tachycardia arising from the PVA were compared to those without PVA tachycardia. Groups were classified as 1) biventricular CHD, 2) single ventricle, or 3) DTGA-baffle.ResultsComplete 3D mapping was possible for 113/124 sustained tachycardias during 81 procedures. Of these, 31 (19%) arose from the PVA, including 11 (15%) tachycardias for biventricular CHD, 8 (31%) for single ventricle, and 12 (80%) for DTGA-baffle procedures. IART was less frequently observed in the PVA versus the systemic venous atrium (SVA) (p=0.012). Independent predictors of PVA tachycardia were absence of biventricular CHD (OR 0.19, CI 0.05 to 0.64, p=0.010) and ipsilateral atrial surgery (OR 15.7, CI 4.8 to 59.9, p<0.001). PVA procedure duration was greater than SVA-only procedures (median 5.3 versus 4.0 hours, p=0.012) but acute success rates were similar (87% vs 82%, respectively, p=ns).ConclusionsPVA tachycardia is not unusual after surgical repair of CHD. Predictors include ipsilateral atrial surgery and absence of biventricular CHD. Such procedures involve increased complexity and unique tachycardia substrates but are equally amenable to catheter ablation
Transseptal puncture (TSP) is commonly used to access the left heart for catheter ablation procedures. The specific complication risk of this procedure has not been determined. This study assesses the risk of TSP using a single standard technique during electrophysiology study (EPS) in pediatrics and congenital heart disease (CHD).
Retrospective cohort study of patients undergoing TSP during EPS at the University of Michigan Congenital Heart Center between 1999 and 2011.
There were 373 left heart ablation procedures during the study period. Excluded were six adults without CHD, five procedures using an alternative imaging modality, five procedures using retrograde aortic access, one transhepatic access, and one where TSP was performed during a prior procedure. Included were 321 pediatric (≤18 years old without CHD) TSP procedures (median age 13 years) and 34 TSP procedures in patients with CHD (median age 28 years). There was one complication directly attributable to TSP: needle perforation of the left atrium without development of effusion in the pediatric group. Post-procedure echocardiograms were performed in 351 (99 %) cases, showing only trivial effusions in seven (1.9 %).
This single center experience over 12 years shows the risk of TSP in pediatric and CHD patients to be low, with a 0.3 % (95 % confidence interval (CI) 0, 0.9 %) risk for complications directly related to TSP using only single plane fluoroscopy for visualization.
Objectives
We sought to review our current philosophy that all primary invasive electrophysiologic (EP) studies in patients with atrial switch procedures (ASPs) should undergo hemodynamic evaluation and have interventional expertise available.Background
Patients who have undergone an ASP for dextro-transposition of the great arteries have a high incidence of both hemodynamic and EP sequelae. We present our data to support the combined assessment approach for these patients.Methods
Hemodynamic evaluation and interventions performed concurrently during a primary invasive EP procedure in patients with ASP were reviewed.ResultsA total of 18 patients underwent concurrent EP invasive procedure and cardiac catheterization. The median age was 31 (14–43 years) with the majority being male (67%). Patients underwent a total of 30 concurrent primary invasive EP procedure and cardiac catheterization; 14 (47%) of the catheterization procedure were interventional. Some of the catheterization procedures required more than one intervention with total of 19 separate interventions. There were nine (47%) unexpected interventions. The majority of patients (n = 14, 77.8%) had one or more abnormal hemodynamic finding including baffle obstruction (n = 13, 72%), elevated filling pressures (n = 3, 17%), and secondary pulmonary hypertension (n = 3, 17%). Non-EP–related interventional procedures included systemic or pulmonary venous baffle stenting for significant obstruction (n = 7). EP-related interventions included transbaffle puncture for ablation of left-sided reentry circuits (n = 5), closure of previously undiagnosed baffle leaks prior to pacemaker/implantable cardioverter defibrillator (ICD) placement to prevent paradoxical embolism (n = 3), superior baffle stenting to facilitate pacemaker/ICD lead placement (n = 2), and retrieval of retained transvenous pacemaker/ICD lead (n = 2).Conclusion
Due to the frequency of abnormal hemodynamics or interventional needs, strong consideration for routine concurrent hemodynamic assessment and availability of interventional expertise is warranted during primary invasive EP procedures in patients post ASP.
Arrhythmia in the adult congenital heart disease (ACHD) population is recognized as a major source of morbidity and mortality and has contributed to an increasing burden on the health care system over the past several decades. Abnormalities of impulse formation and propagation encountered in this population are distinct from those encountered in the general adult population. Such differences are related to the anatomic variability of congenital heart disease, the resulting postoperative hemodynamic disturbances, and the effects of prior cardiac surgery on the underlying myocardial substrate. Effective arrhythmia therapy in this population therefore requires a detailed understanding of these diverse processes and often results in specialized care at regional centers of excellence. Given the large and evolving body of literature dealing with the treatment of cardiac arrhythmia in the congenital heart population, a coherent picture of arrhythmia treatment and efficacy can be difficult to establish. The existing data is therefore dissected and summarized in this manuscript. In addition, recent expert consensus guidelines for the management of arrhythmia in the ACHD population have been published and will be reviewed in this article, with a special emphasis on unique considerations when treating CHD patients presenting with a disturbance in cardiac rhythm.
Balloon atrial septostomy or Rashkind is a technique described almost half a century ago to dilate a preexisting atrial communication in order to enhance atrial mixing and to decompress the left atrium in congenital heart disease. With the contribution of fetal echocardiography this technique can be pre-planed, but, still many complications can arrive. It is done almost routinely in all case of transposition of the great arteries with restrictive interatrial communication. Many other techniques developed, but Rashkind intervention remains a reference in congenital heart interventions in newborn or small infant. It is a challenging procedure that needs trained interventional/congenital cardiologists and a well prepared catheterization laboratory, with the possibility for surgical or circulatory back-up. Nowadays, few complications can arrive, but are not to be neglected.
Atrial fibrillation (AF) frequently occurs late after atrial septal defect (ASD) closure. Transseptal puncture (TSP) is critical to successful catheter ablation of AF. In the following, we describe our experience on how to perform TSP in 9 patients with a previously implanted ASD occluder. All patients had a secundum-type ASD, successfully closed with an Amplatzer device in 8 and a Lifetech device in 1 patient. The closure device was implanted at a median of 16 (6-36) months prior to the index procedure. Single or double TSP was performed. Circumferential pulmonary vein isolation (PVI) was completed following successful TSP. In 6 patients with an ASD closure device and a waist diameter of ≤26 mm, double TSP was successful at a site posteroinferior to the implanted device. In the remaining 3 patients, the diameter of the ASD occluder measured 28, 30 and 34 mm, and TSP was performed directly through the posteroinferior portion of the occluder. The puncture site was sequentially dilated using a PCI balloon. Only a single 8.5F long sheath was placed following successful dilatation. PVI was achieved in all patients without complications. In summary, successful TSP can be performed at a site posteroinferior to the ASD closure device if the diameter measures ≤26 mm. In larger devices, direct puncture through the ASD occluder is feasible and safe > 6 months following implantation.
Atrial fibrillation (AF) is a frequent comorbidity in adults with atrial septal defect (ASD), one of the most common congenital heart defects. However, there are currently limited recommendations for the management of AF associated with ASD. This article describes a case using a planned approach of catheter ablation followed by transcatheter device closure and discusses management options.
Background:
Patients with congenital heart disease carry a high burden of arrhythmias and may pose special challenges when these arrhythmias are addressed invasively. We sought to describe our early experience with radiofrequency (RF) needle transseptal perforation to facilitate ablation procedures in this population.
Methods:
Retrospective chart review to identify all cases of attempted transseptal access with a commercial RF needle at Children's Hospital Boston between February 2007 and January 2010.
Results:
A total of 10 patients had attempted RF transseptal perforation. Median age was 27 years. Five patients had undergone atrial switch procedures (Mustard/Senning), four had undergone Fontan operations, and one had atrial septal defect repair. The indication for left atrial access was mapping/ablation of atrial flutter in nine cases, and left-sided accessory pathway in one case. The RF needle was chosen primarily in eight of 10 cases, whereas in the remaining two cases RF was used only after failed attempts with a conventional Brockenbrough needle. Septal material was atrial muscle in five cases, pericardium in three, and synthetic fabric in two. In nine of 10 patients, RF transseptal perforation was successful, including both patients in whom a conventional needle had failed. There were no clinically significant complications.
Conclusions:
RF transseptal perforation can be an effective method of obtaining left atrial access for electrophysiologic procedures in patients with complex congenital heart disease, including cases where a conventional Brockenbrough needle has failed.
Background:
Targets for catheter ablation of atrial tachyarrhythmias (AT) in post-Mustard procedure patients are often located in the pulmonary venous atrium (PVA). Traditional access to this chamber is retrograde via the aorta. However trans-baffle puncture may be a key determinant of successful ablation in many cases.
Methods:
All AT ablations performed in patients late after Mustard and Senning operations by a single operator from 2007 to 2012 were reviewed.
Results:
Nine procedures were identified. In total, 12 ATs were treated, seven persistent, the remainder induced, consisting of counterclockwise cavotricuspid isthmus dependent flutter (5), macroreentrant with isthmus in the systemic venous atrium (SVA) (2), macroreentrant with isthmus in the PVA (1), focal from the PVA (3), and focal from the SVA (1). Ablation within the PVA was required in all procedures to treat AT. Retrograde access in one patient was impossible due to the presence of a Bjork-Shiley tricuspid valve replacement; retrograde access in another two patients was attempted but catheter manipulation was ineffective and AT could not be mapped and ablated. Trans-baffle puncture was performed with transoesophageal echocardiographic guidance in all cases without complications and resulted in successful ablation of AT.
Conclusions:
Access to the pulmonary venous atrium is essential for successful ablation of AT in many Mustard patients. Trans-baffle puncture remains a relevant technique to modern practice and can be performed safely and effectively.
Remote Magnetic Mapping After Mustard/Senning Procedure.
Mapping of intraatrial reentrant tachycardia (IART) still presents a challenge in complex congenital heart disease. The goal of this work was to present our initial experience with remote magnetic navigation (RMN) for mapping of IART in four patients after the atrial switch procedure (Mustard n = 1, Senning n = 3) for d-transposition of the great arteries.
Three-dimensional (3D) mapping of the systemic venous atrium and the pulmonary venous atrium (PVA) was performed using RMN (Niobe) in conjunction with 3D mapping (CartoRMT). The maps were fused with a CT-based 3D anatomy.
All patients had cavotricuspid isthmus-dependent IART with a mean atrial cycle length of 305 ms. Mapping of both atria (PVA retrogradely by passing the aortic and tricuspid valve) was feasible and safe. The procedure time for IART mapping ranged from 210 to 320 minutes with a mean of 251 minutes. The fluoroscopy time for IART mapping ranged from 15.8 to 45.0 minutes (mean 31.6 minutes) for patients, and ranged from 12.3 to 24.3 minutes with a mean of 19.5 minutes for physicians. No procedural complications occurred.
Precise mapping of IART in the complex anatomical structures after an atrial switch procedure was feasible and safe using RMN. The maneuverability of the catheter was possible even with a retrograde access crossing two valves. Further reduction of procedural and fluoroscopy times for both patients and physicians seems possible.
Since publication of the last American Heart Association (AHA) scientific statement on this topic in 1998,1 device technology, advances in interventional techniques, and an innovative spirit have opened the field of congenital heart therapeutic catheterization. Unfortunately, studies testing the safety and efficacy of catheterization and transcatheter therapy are rare in the field because of the difficulty in identifying a control population, the relatively small number of pediatric patients with congenital heart disease (CHD), and the broad spectrum of clinical expression. This has resulted in the almost exclusive “off-label” use of transcatheter devices, initially developed for management of adult diseases, for the treatment of CHD.
The objective of the present writing group, which included representatives of the AHA and endorsements from the Society for Cardiovascular Angiography and Interventions and the American Academy of Pediatrics, was not only to provide the reader with an inventory of diagnostic catheterization and interventional treatment options but also to critically review the literature and formulate relative recommendations that are based on key opinion leader expertise and level of evidence. The writing group was charged with the task of performing an assessment of the evidence and giving a classification of recommendations and a level of evidence to each recommendation. The American College of Cardiology/AHA classification system was used, as follows:
### Classification of Recommendations
Atrial tachycardia (AT) and atrial fibrillation (AF) were observed in a 21-year old male who had a history of patch closure for an atrial septal defect (ASD) at the age of 5 and a persistent left superior vena cava (LSVC). During electrophysiologic study, atrial extrastimuli reproducibly induced AT which spontaneously terminated or changed into AF. Electroanatomical mapping revealed focal AT arising from the floor of the proximal LSVC. Radio- frequency applications within LSVC targeted to the earliest activation site of AT as well as the complex fractionated potential eliminated both AT and AF without trans-septal puncture.
The purpose of this study was to investigate if remote magnetic navigation (RMN) offers a reduction of fluoroscopy time when used for atrial tachycardia (AT) mapping in a spectrum of patients with congenital heart disease (CHD) after "simple" or "complex" atrial surgery.
Data about AT mapping using RMN in larger populations of patients with CHD are scarce.
RMN in combination with electroanatomic mapping was used for AT mapping in 22 patients. According to anatomic complexity, patients were classified into 3 groups: Group 1: patients after minor atrial surgery (n = 7); Group 2: patients after the Fontan operation (n = 9); and group 3: patients after the Senning/Mustard operation (n = 6).
Atrial mapping with a nonirrigated tip RMN catheter was completed successfully in all patients. In Group 1 no significant reduction in fluoroscopy time was noticed over time (mean fluoroscopy time 7.9 minutes). In the 15 patients of group 2 and group 3 with complex CHD, the fluoroscopy time for mapping in the last 9 patients (6.4 +/- 2.8 minutes) was significantly shorter than in the first 6 patients (29.7 +/- 10.5 minutes, P < 0.0001). Acutely successful ablation was achieved in 21 of 22 patients (97%) using the RMN catheter (n = 3) or a conventional catheter (n = 18) without procedural complications.
RMN for AT mapping in patients with complex atrial anatomy leads to a significant reduction of fluoroscopy time.
The authors performed this study to report their initial preclinical experience with real-time magnetic resonance (MR) imaging-guided atrial septal puncture by using a MR imaging-conspicuous blunt laser catheter that perforates only when energized.
The authors customized a 0.9-mm clinical excimer laser catheter with a receiver coil to impart MR imaging visibility at 1.5 T. Seven swine underwent laser transseptal puncture under real-time MR imaging. MR imaging signal-to-noise ratio profiles of the device were obtained in vitro. Tissue traversal force was tested with a calibrated meter. Position was corroborated with pressure measurements, oximetry, angiography, and necropsy. Intentional non-target perforation simulated serious complication.
Embedded MR imaging antennae accurately reflected the position of the laser catheter tip and profile in vitro and in vivo. Despite having an increased profile from the microcoil, the 0.9-mm laser catheter traversed in vitro targets with similar force (0.22 N +/- 0.03) compared with the unmodified laser. Laser puncture of the atrial septum was successful and accurate in all animals. The laser was activated an average of 3.8 seconds +/- 0.4 before traversal. There were no sequelae after 6 hours of observation. Necropsy revealed 0.9-mm holes in the fossa ovalis in all animals. Intentional perforation of the aorta and atrial free wall was evident immediately.
MR imaging-guided laser puncture of the interatrial septum is feasible in swine and offers controlled delivery of perforation energy by using an otherwise blunt catheter. Instantaneous soft tissue imaging provides immediate feedback on safety.
Intracardiac Echo-Guided Radiofrequency Catheter.
Patients with atrial septal defect (ASD) are at higher risk for atrial fibrillation (AF) even after repair. Transseptal access in these patients is perceived to be difficult. We describe the feasibility, safety, and efficacy of pulmonary vein antral isolation (PVAI) in these patients.
We prospectively compared post-ASD/patent foramen ovale (PFO) repair patients (group I, n = 45) with age-gender-AF type matched controls (group II, n = 45). All the patients underwent PVAI through a double transseptal puncture with a roving circular mapping catheter technique guided by intracardiac echocardiography (ICE). The short-term (3 months) and long-term (12 month) failure rates were assessed.
In group I, 23 (51%) had percutaneous closure devices and 22 (49%) had a surgical closure. There was no significant difference between group I and II in the baseline characteristics. Intracardiac echo-guided double transseptal access was obtained in 98% of patients in group I and in 100% of patients in group II. PVAI was performed in all patients, with right atrial flutter ablation in 7 patients in group I and in 4 patients in group II. Over a mean follow-up of 15 +/- 4 months, group I had higher short-term (18% vs 13%, P = 0.77) and long-term recurrence (24% vs 18%, P = 0.6) than group II. There was no significant difference in the perioperative complications between the two groups. Echocardiography at 3 months showed interatrial communication in 2 patients in group I and 1 patient in group II, which resolved at 12 months.
Percutaneous AF ablation using double transseptal access is feasible, safe, and efficacious in patients with ASD and PFO repairs.
Access to targets for radiofrequency ablation in patients with congenital heart disease may be limited by anatomy and by surgically placed obstacles. In patients with atrial switch anatomy for d-transposition of the great arteries, the critical isthmus for maintenance of intraatrial macroreentry circuits is found often on the pulmonary venous side of the atrial baffle. A retrograde approach is extremely difficult for these arrhythmias. Use of transseptal techniques for diagnostic catheterization in these patients has been reported. We report the use of a transseptal technique in two cases in conjunction with 3-dimensional electroanatomic mapping for the successful ablation of atrial reentry tachycardias in patients with Mustard and Senning anatomy.
Observations on the blood pressure of a group of 660 displaced male Tibetans revealed striking dissimilarities in regard to the mean systolic and diastolic figures as compared to those reported for Europeans and Americans. The average Tibetan figures are lower than those of Western populations; however, a comparable variability after the fourth decade and a parallel spread of values with age and weight were found in the Tibetan data. The socioeconomic status and height bore no relation to the blood pressure levels. The results obtained from this survey on the Tibetans are compared with those of other Mongolian groups. It is suggested that the differences of blood pressure among related Mongolian groups and populations studied in the West are largely determined by environment.
The incidence of cardiac complications from atrial transseptal catheterization has never been quantified in patients with normal-sized atria. Series defining the complication rate are derived from diseased hearts with structural changes that may alter the complication rate of the procedure. The generation of a standardized incidence of perforation in a population of structurally normal atria has important implications. A total of 46 atrial transseptal catheterizations guided by transesophageal echocardiography (TEE) for radiofrequency ablation of left-sided accessory pathways was performed in 42 patients during a 3-year period (1990-1993). Clinical and echocardiographic data were analyzed, with special attention given to TEE reports pre- and post-transseptal catheterization. Only one complication occurred in the 46 procedures (2.2%): a perforation of the left atrium that led to pericardial effusion and cardiac tamponade. In a small series of patients with normal sized atria, we have demonstrated that TEE-guided transseptal catheterization in a procedure with a low complication rate.
The introduction of balloon valvuloplasty and new devices for coronary intervention has increased the incidence and changed the site and clinical presentation of cardiac perforation. We reviewed all cases of cardiac perforation that occurred during 11,845 consecutive catheterization procedures during a 6-yr period (1986-91). Fourteen cardiac perforations (overall incidence 0.12%) occurred as a result of the following procedures: mitral valvuloplasty 7 of 150 (4.7%), aortic valvuloplasty 4 of 260 (1.5%), pericardiocentesis 1 of 90 (1.1%), temporary pacer 1 of 1,660 (0.06%), and diagnostic left heart catheterization 1 of 6,965 (0.01%). Perforation was recognized in the catheterization laboratory in 11 patients, within 1 hr of leaving the laboratory in two patients, and 15 hr later in one patient. Hemodynamic evidence of tamponade developed in 13 patients and was confirmed by fluoroscopy (immobile heart borders) or echocardiography. Pericardiocentesis is definitive therapy in nearly half of the cases; the remaining patients require pericardiocentesis plus surgical repair of the perforation.
Left-sided accessory pathways are a common substrate for supraventricular tachycardias in children. A transseptal approach to catheter ablation has been primarily advocated in this population because of concerns regarding vascular injury, aortic, and mitral valvular damage using the transaortic approach via retrograde femoral arterial cannulation. However, the transaortic approach is simpler and may be less time consuming. We, therefore, compared the efficacy and safety of the transseptal vs the transaortic approach in 49 consecutive pediatric patients. In both groups, the atrial insertion site of the accessory pathways was targeted. Postprocedure two-dimensional and Doppler echocardiograms were obtained in all patients. The transseptal and transaortic groups were similar in age (15.8 +/- 1.6 vs 13.5 +/- 3.6 p NS), manifest vs concealed (9/5 vs 20/15), and number of radiofrequency lesions (4 vs 6). Fluoroscopy time was significantly shorter in the transaortic group (33 vs 58 min, p < 0.05). The only evident complications were mild mitral regurgitation seen in two patients (one in each group). Two patients in the transseptal group had recurrence of tachycardia on follow-up and were successfully ablated by the transaortic method. In this series from a single center, a transaortic approach to ablation of left-sided accessory pathways in children older than 4 years was as effective as a transseptal approach.
A specially adapted needle on the end of a Jackson's suction tube has been used to pierce the left auricle of the heart through the upper end of one of the main bronchi. Pressure measurements and wave forms have been recorded in patients suffering from lung disease with normal hearts, in those with mitral stenosis and mitral regurgitation. This preliminary communication describes the method and shows some typical results.