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Transseptal puncture: Use of an angioplasty guidewire for enhanced safety
Abstract
During transseptal puncture, once the needle tip has successfully accessed the left atrium, advancement of the needle, dilator and sheath into the left atrium can risk left atrial free wall perforation, particularly if the interatrial septum is aneurysmal and tents far into the left atrial cavity during puncture. We have modified our transseptal technique such that once the left atrium is accessed with the needle tip, a 0.014'' angioplasty guidewire is advanced down the Brockenbrough needle. This is guided into the left upper pulmonary vein, and the needle, dilator and sheath advanced over this wire towards the left upper pulmonary vein. In this way, the risk of perforation of the left atrial free wall is negated. We have since used this technique in 30 cases without difficulties.
... The penetrability of the guidewire is greatly decreased after it enters the LA because it loses catheter support; therefore, the probability of an accidental puncture and tear is low. Furthermore, the back end of the PTCA guidewire will be exchanged with the softer front end after confirming establishment of access to further ensure the safety of the procedure [17,18]. The advancement of the microcatheter also serves to envelop the end of the guidewire, thereby reducing the risk of accidental punctures. ...
... Most groups limit this technique to patients where a conventional puncture of the septum is difficult or unsuccessful, as it was in our series of patients [9]. Some others advocate the use of a 0.014-inch wire as soon as the needle tip has entered the LA [12]. This is generally done in order to minimize the risk of perforation from additional movements of the transseptal needle and further confirm the correct positioning of the transseptal needle within the body of the LA, but does not eliminate the risk of uncontrolled needle movement after it penetrates a stretched atrial septum. ...
An increasing number of patients undergo left atrial ablation procedures, since several approaches have proven efficacy in the treatment of atrial fibrillation. Although transseptal catheterization was generally shown be a safe technique, it harbors the principal risk of cardiac injury. Therefore, there is a need for a safe and effective tool to enable transseptal puncture in difficult cases as well.
In 158 consecutive patients, a transseptal puncture was intended for mapping and ablation of left atrial tachycardias. In seven patients of this series transseptal puncture using different sheaths and needle designs, the operators failed to cross the interatrial septum as a result of severe tenting. Three patients were known to have a septal aneurysm; a redo procedure was performed in two patients. In the remaining patients, there was no obvious explanation for the difficulty in crossing the interatrial septum conventionally. In all seven patients, a 120-cm-long nitinol guidewire ("needle wire") with a 0.014-inch diameter was used to cross the atrial septum with the following idea: after tenting the fossa ovalis with the transseptal dilator and the Brockenbrough needle positioned just inside the tip, effortless advancement of the needle wire perforates the membranous fossa. Unsupported by the needle and dilator, the tip of the wire immediately assumes a "J" shape, rendering it incapable of further tissue penetration after its entry into the left atrium. In all seven patients, the needle wire could be placed into a left pulmonary vein. In five patients, a single attempt was sufficient to reach the left atrium with the wire, two patients needed two and three attempts, respectively. No complications occurred.
Additional use of a needle wire to perform transseptal puncture in a subset of patients at higher risk for complications appears safe and effective.
... The dilator and sheath are then advanced over the needle (without advancing the needle) to avoid injury to the posterior LA wall. Some operators introduce a 0.014-inch angioplasty wire through the needle into the LA and pulmonary vein to prevent inadvertent puncture of the LA free wall by the needle or dilator (16). Fortunately, serious morbidity or mortality after needle puncture of the LA free wall or aorta is uncommon if the sheath and dilator are not advanced. ...
Transseptal (TS) catheterization was introduced in 1959 as a strategy to directly measure left atrial (LA) pressure. Despite acceptable feasibility and safety, TS catheterization has been replaced by indirect measurements of LA pressure using the Swan-Ganz catheter. Today, TS puncture is rarely performed for diagnostic purposes but continues to be performed for procedures such as balloon mitral valvuloplasty, antegrade balloon aortic valvuloplasty, and ablation of arrhythmias in the LA. Thus, the "art" of TS puncture has been lost, except in centers that perform these procedures with regularity. Recently, there has been a renewed interest in the TS technique because of emerging therapeutic procedures for structural heart disease and atrial fibrillation ablation. Invasive cardiologists will have to refamiliarize themselves with the TS technique, newer TS devices, and advanced ultrasound imaging for guidance of the procedure.
Transseptal catheterization (TS) is an essential procedural skill required in the current era. The role of TS is increasingly gaining importance in the field of structural heart disease interventions. Isolated fluoroscopy‐guided technique was initially used. In the current era, most of the centers have changed to utilization of transthoracic echocardiogram/intra‐cardiac echocardiogram along with fluoroscopy to improve the safety of the procedure. Newer radio‐frequency based puncture system has been shown to improve safety. Ideal puncture sites differ among different procedures involving left heart chambers. In this chapter, we discussed the embryology of interatrial septum, ideal puncture sites for different procedures, different types of equipment used to TS puncture including TS puncture needles, wires, bail‐outs in case of resistant septum, complications of TS procedure and their management.
Introduction:
Transseptal puncture (TSP) is routinely performed for left heart intervention, but it can sometimes be complex and life-threatening. This study introduced a safe and effective method to facilitate TSP for left atrial access.
Methods and results:
A total of 200 patients (190 with atrial fibrillation, 10 with a left accessory pathway) were prospectively analyzed. In the guidewire group, TSP was performed using a SWARTZ sheath and a Brockenbrough needle with a 0.014-inch coronary guidewire instead of an inner stylet. The needle tip position was confirmed by pushing the guidewire into the left superior pulmonary vein after initial puncture in 100 patients. In the contrast group, TSP was performed in 100 patients using standard devices by injecting contrast to confirm needle-tip position. Left atrial access was achieved successfully in all patients in the two groups without serious complications. The guidewire group showed a higher first-pass rate for left atrial access compared with the contrast group (81.1% vs. 75% p<0.001, respectively).
Conclusion:
Coronary guidewire TSP is safe and is associated with a high success rate, and it is thus a useful alternative to conventional TSP. This method is useful for patients with septal aneurysms and contrast allergies. This article is protected by copyright. All rights reserved.
With the increasing volume of structural heart procedures and a growing number of congenital heart patients reaching adulthood, there has been a recent expansion of left-sided diagnostic and interventional procedures and a resurgence of transseptal (TS) cardiac catheterizations. Understanding the interatrial septal anatomy, the technical aspects of TS puncture, contraindications, and its associated complications are paramount to preserving procedural efficacy and safety. Alternative techniques for the difficult, high-risk patient are important to be familiar with, and the use of multimodality imaging is essential for accurate TS localization. More advanced imaging such as fusion imaging may play a greater role as site-specific TS puncture is required. Overall, TS access, a valuable procedure that can be successfully performed with minimal risk to the patient, is an essential procedure for the interventionalist to master.
A number of interventional procedures based on the transseptal puncture (TSP) have been developed over the last years. The increasing number of interventional procedures, as well as the use of large-bore sheaths and complex devices, has led to improvements in technique and equipment. The combined use of fluoroscopy and of trans-esophageal echocardiography (TEE) has increased safety and precision. However, TSP still represents a tricky procedure, it may become even more difficult in case of challenging interatrial septa and life-threatening complications may occur. Consequently, a deep knowledge of procedural steps, equipment, echocardiographic views, fossa ovalis anatomy and most frequent complications management are critical to perform successful TSP.
Objectives
We evaluated the safety and efficacy of percutaneous left atrial appendage (LAA) occlusion performed as a day case procedure.
Background
LAA occlusion has been shown to be safe and effective for stroke prevention in patients with atrial fibrillation. It has not been shown if the procedure can safely be performed on a day‐case basis.
Methods
Retrospective analysis was made of 117 LAA occlusion procedures in a single large teaching hospital in the UK. Procedural success, procedural complications, length of stay, and readmission data were examined.
Results
Successful deployment of a device was possible in all but one patient (whose appendage was too large). Major in‐hospital complications occurred in 1.7% of patients (both femoral vascular). Same‐day discharge was made in 66% of patients overall. Since January 2016, only 3 of 59 patients (5%) have remained in hospital overnight following LAAO. Echocardiography 2–4 hr postprocedure was undertaken prior to discharge. One patient was readmitted within 7 days but this readmission would not have been prevented by overnight stay.
Conclusions
LAA occlusion can be safely performed as a day case procedure with acceptable complication rates and no increment of complications related to the lack of routine overnight stay.
Transseptal catheterization (TS) remains an integral yet specialized technique for interventional cardiologists and electrophysiologists. It was introduced in the late 1950s. This chapter describes the technical aspects of the procedure, including guidance by imaging, then addresses the specific aspects related to specific interventions performed for which TS is the first step. Both transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) provide excellent imaging of the interatrial septum, which is useful to guide the orientation of the catheter and needle in the fossa ovale, to show proper positioning and tenting of the septum, and monitor the crossing of the septum. The Brockenbrough needle is the most commonly used transseptal needle. Transseptal catheterization can also be used during percutaneous left ventricular assist device implantation. Embolism can be caused by a pre-existing thrombus, usually in the left atrial appendage, or one developed during the procedure.
A well executed transseptal puncture is crucial for successful percutaneous transvenous mitral balloon valvotomy. We report a case
of accidentally damaged Mullins sheath dilator. Due to immediate unavailability of another dilator at cardiac catheterization laboratory,
angioplasty guidewire and balloon was used as an additional assisting armamentarium for successful percutaneous transvenous mitral
balloon valvotomy.
With the increasing volume of structural heart procedures and growing number of congenital heart patients reaching adulthood, there has been a recent expansion of left-sided diagnostic and interventional procedures and a resurgence of transseptal (TS) cardiac catheterizations. Understanding the interatrial septal anatomy, the technical aspects of TS puncture, contraindications, and its associated complications are paramount to preserving procedural efficacy and safety. Alternative techniques for the difficult, high-risk patient are important to be familiar with, and the use of multimodality imaging is essential for accurate TS localization. More advanced imaging such as fusion imaging may play a greater role as site-specific TS puncture is required. Overall, TS access, a valuable procedure that can be successfully performed with minimal risk to the patient, is an essential procedure for the interventionalist to master.
To compare the safety and efficacy of a new dilator method vs the traditional needle method for transseptal puncture (TSP) in a large cohort study.
From February 1995 to December 2010, 4443 consecutive patients undergoing TSP done either by a needle method or by a new dilator method were reviewed retrospectively. Data as procedure-related time and complications were evaluated. For the standard needle method, TSP was performed by extending out the needle. In comparison, for the new dilator technique, TSP was performed without an outer sheath and with the needle kept within the dilator; the blunt tip of the dilator was used to help locating the position of the fossa ovalis on purpose. Transseptal puncture was performed by the new dilator method in 2151 patients (48.4%) and by the traditional needle method in 2292 patients (51.6%). The average TSP time needed by the dilator method was longer than that needed by the needle method (5.6 ± 3.9 vs. 3.8 ± 2.9 min, P< 0.05). Additional left atrial angiography was required in seven (0.33%) patients for the dilator and in 39 patients (1.70%) for the needle method (P< 0.05). The total rate of severe complications and obvious TSP-related complications was significantly lower in patients who underwent the dilator method than in those who underwent the needle method (0.33 vs. 1.18%, and 0.20 vs. 1.00%, respectively, P < 0.05).
Our data suggest that the new dilator technique is much safer than that of the standard needle method. It needs relatively longer procedure time but results in significantly fewer episodes of severe complications. Particularly, the blunt tip of the dilator can be used to help locate the fossa ovalis. Therefore, the new dilator technique might be a better choice for relatively less-experienced operators.
With the expansion in catheter-based treatments for atrial fibrillation the number of transseptal punctures being performed by cardiac electrophysiologists has increased significantly. Although in general transseptal puncture is successful, in a small percentage of cases it cannot be achieved due to complex intraatrial anatomy. We report the case of a difficult transseptal puncture (TSP), performed where the conventional approach using a Brockenbrough needle sheath was unable to perforate the septum. TSP was only achieved using a novel technique assisted by an angioplasty wire.
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.
We describe a new approach that may enhance safety of atrial transseptal puncture using a commercially available laser catheter that is capable of perforation only when energized. We test this approach in swine.
Despite wide application, conventional needle transseptal puncture continues to risk inadvertent nontarget perforation and its consequences.
We used a commercial excimer laser catheter (0.9-mm Clirpath, Spectranetics). Perforation force was compared in vitro with a conventional Brockenbrough needle. Eight swine underwent laser transseptal puncture under X-ray fluoroscopy steered using a variety of delivery catheters.
The 0.9-mm laser catheter traversed in vitro targets with reduced force compared with a Brockenbrough needle. In vitro, the laser catheter created holes that were 25-30% larger than the Brockenbrough needle. Laser puncture of the atrial septum was successful and accurate in all animals, evidenced by oximetry, pressure, angiography, and necropsy. The laser catheter was steered effectively using a modified Mullins introducer sheath and using two different deflectable guiding catheters. The mean procedure time was 15 +/- 6 min, with an average 3.0 +/- 0.8 sec of laser activation. There were no adverse sequelae after prolonged observation. Necropsy revealed discrete 0.9-mm holes in all septae.
Laser puncture of the interatrial septum is feasible and safe in swine, using a blunt laser catheter that perforates tissues in a controlled fashion.
We report the data from the Italian Survey on trans-septal catheterization (TSP-C) for catheter ablation of arrhythmias in the left heart that covered 2003 and previous years.
Over the last decade the use of TSP-C in the electrophysiology laboratory has greatly increased. Recent data on number of procedures, accomplishment rate, and complications related to this procedure are lacking in a large cohort of patients.
Thirty-three centers participated in the survey. The data collected retrospectively for 2003 included the number of procedures, indications, methods, and the number and reason for unaccomplished cases along with complications. Retrospective data collected for previous years included the annual number of procedures and cumulative data concerning indications, accomplishments, and complications.
Since 1992, 5,520 TSP-C procedures were used in arrhythmia ablation, with the peak increase in the use occurring in 2001. Trans-septal catheterization was performed for atrial fibrillation (AF) ablation in 78.3% of the procedures in 2003. The electrophysiologist independently performed the procedure in 29 of 33 centers. Trans-septal catheterization was successfully performed in 99.1% of the cases; the main reason for TSP-C not being performed was related to fossa ovalis/atrial septum anatomy. Complications were low both in 2003 and in the previous years (0.79% and 0.74%, respectively).
Trans-septal catheterization in the electrophysiology laboratory is associated with a high success and low complication rate. The use of TSP-C has progressively increased over the last decade and is currently used primarily for AF ablation. Although possible, severe complications were rare.
Arrhythmosenic Foci of Atrial Fibrillation. Introduction : Use of endocardial atrial activation sequences from recording catheters in the right atrium. His bundle, and coronary sinus to predict the location of initiating foci of atrial fibrillation (AF) before an atrial transseptal procedure has not been reported. The purpose of the present study was to develop an algorithm using endocardial atrial activation sequences to predict the location of initiating foci of AF before transseptal procedure.
Methods and Results : Seventy‐five patients (60 men and 15 women, age 68 ± 12 years) with frequent episodes of paroxysmal AF were referred for radiofrequency ablation. By retrospective analysis, characteristics of the endocardial atrial activation sequences of right atrial, His‐bundle, and coronary sinus catheters from the initial 37 patients were correlated with the location of initiating foci of AF, which were confirmed by successful ablation. The endocardial atrial activation sequences of the other 38 patients were evaluated prospectively to predict the location of initiating foci of AF before transseptal procedure using the algorithm derived from the retrospective analysis. Accuracy of the value <0 msee (obtained by subtracting the time interval between high right atrium and His‐bundle atrial activation during atrial premature beats from that obtained during sinus rhythm) for discriminating the superior vena cava or upper portion of the crista terminalis from the pulmonary vein (PV) foci was 100%. When the interval between atrial activation ostial and distal pairs of the coronary sinus catheter of the atrial premature beats was <0 msec, the accuracy for discriminating left PV foci from right PV foci was 92% in the 24 foci from the left PVs and 100% in the 19 foci from the right PVs.
Conclusion : Endocardial atrial activation sequences from right atrial, His‐bundle, and coronary sinus catheters can accurately predict the location of initiating foci of AF before transseptal procedure. This may facilitate mapping and radiofrequency ablation of paroxysmal AF.
With the introduction of interventional procedures such as percutaneous mitral valvuloplasty and radiofrequency ablation of left-sided bypass tracts, there has been renewed interest in the technique of transseptal left heart catheterization. We review our experience with 1,279 transseptal catheterizations performed over the last 10 years. The most common indications for transseptal catheterization included direct measurement of left atrial pressure or access to the left ventricle in patients with prosthetic aortic or mitral valves, and in patients undergoing percutaneous mitral valvuloplasty. A total of 17 major complications occurred (1.3%), including cardiac tamponade (15 patients, 1.2%), systemic emboli (1 patient, 0.08%), and death secondary to aortic perforation (0.08%). We conclude that when performed by experienced operators, transseptal left heart catheterization is associated with low morbidity and mortality.
Use of endocardial atrial activation sequences from recording catheters in the right atrium, His bundle, and coronary sinus to predict the location of initiating foci of atrial fibrillation (AF) before an atrial transseptal procedure has not been reported. The purpose of the present study was to develop an algorithm using endocardial atrial activation sequences to predict the location of initiating foci of AF before transseptal procedure.
Seventy-five patients (60 men and 15 women, age 68 +/- 12 years) with frequent episodes of paroxysmal AF were referred for radiofrequency ablation. By retrospective analysis, characteristics of the endocardial atrial activation sequences of right atrial, His-bundle, and coronary sinus catheters from the initial 37 patients were correlated with the location of initiating foci of AF, which were confirmed by successful ablation. The endocardial atrial activation sequences of the other 38 patients were evaluated prospectively to predict the location of initiating foci of AF before transseptal procedure using the algorithm derived from the retrospective analysis. Accuracy of the value <0 msec (obtained by subtracting the time interval between high right atrium and His-bundle atrial activation during atrial premature beats from that obtained during sinus rhythm) for discriminating the superior vena cava or upper portion of the crista terminalis from the pulmonary vein (PV) foci was 100%. When the interval between atrial activation of ostial and distal pairs of the coronary sinus catheter of the atrial premature beats was <0 msec, the accuracy for discriminating left PV foci from right PV foci was 92% in the 24 foci from the left PVs and 100% in the 19 foci from the right PVs.
Endocardial atrial activation sequences from right atrial, His-bundle, and coronary sinus catheters can accurately predict the location of initiating foci of AF before transseptal procedure. This may facilitate mapping and radiofrequency ablation of paroxysmal AF.
To assess long-term outcome in a typical Western population of predominantly unfavourable patients undergoing Inoue balloon mitral valvuloplasty. Outcome amongst patients has only been undertaken in the medium term. Long-term echocardiographic data in particular are scarce.
Inoue mitral valvuloplasty was attempted in 106 patients. There were six technical failures; the procedure was therefore completed in 100 patients, who underwent annual clinical and echocardiographic follow-up.
Patients were aged 63.5+/-10. 3 years. 82% were female. Unfavourable characteristics included age >65 (52%), NYHA class III or IV (87%), >/=1 significant co-morbidity (63%), atrial fibrillation (82%), previous surgical commissurotomy (25%) and echocardiographic score >8 (59%, mean 8.9+/-2.1). Mitral valve area increased from 0.98+/-0.23 to 1.54+/-0.31 cm(2). There were three major complications. Post-procedure, symptoms improved in 88% of patients. Haemodynamic success (mitral valve area increase >50%, final mitral valve area >1.5 cm(2), mitral regurgitation </=grade 2) was achieved in 61% of cases. Mean follow-up was 4.3+/-1. 4 years. Survival was 97%, 88% and 82% at 1, 3 and 6 years. Event-free survival (freedom from death, mitral valve replacement or repeat valvuloplasty) was 96%, 82% and 56% at 1, 3 and 6 years. Freedom from restenosis (loss of >50% gain in mitral valve area, mitral valve area <1.5cm (2)) was 98%, 92% and 75% at 1, 3 and 6 years. Pre-procedural predictors of event-free survival were male sex, absence of co-morbidities, lower echocardiographic score and smaller left atrial diameter.
In a Western population with predominantly unfavourable characteristics for mitral valvuloplasty, long-term outcome post-procedure is reasonable. A moderate increase in mitral valve area can be achieved at low procedural risk, and the subsequent rate of restenosis is low. Nonetheless, 6 years after the procedure, half of the patients will have required further intervention or died. For fitter patients willing to accept significant operative risk, mitral valve replacement remains a valuable alternative.
We prospectively analyzed the learning process for transseptal catheterization guided by intracardiac echocardiography, in 50 patients who underwent radiofrequency ablation for left atrial arrhythmias. In 20 patients the intracardiac echocardiography catheter was positioned in the right atrium to visualize the fossa ovalis and the tenting of the fossa caused by the Brockenbrough needle. In the other 30 patients, the intracardiac echocardiography catheter was positioned so that it impinged upon the fossa ovalis, and the needle was advanced alongside the intracardiac echocardiography catheter under fluoroscopic guidance in two orthogonal projections. In all but one patient, transseptal catheterization was performed successfully on the first attempt. The learning process for transseptal puncture guided by intracardiac echocardiography was uncomplicated, resulting in a procedure that is safe and effective. The intervention is simplified by positioning the echocardiography catheter at the fossa ovalis and using this as a reference point for fluoroscopic monitoring of the progress of the Brockenbrough needle.
These studies were conducted to evaluate the feasibility of percutaneous left atrial appendage (LAA) occlusion using the PLAATO system (ev3 Inc., Plymouth, Minnesota).
Patients with atrial fibrillation (AF) have a five-fold increased risk for stroke. Other studies have shown that more than 90% of atrial thrombi in patients with non-rheumatic AF originate in the LAA. Transvenous closure of the LAA is a new approach in preventing embolism in these patients.
Within two prospective, multi-center trials, LAA occlusion was attempted in 111 patients (age 71 +/- 9 years). All patients had a contraindication for anticoagulation therapy and at least one additional risk factor for stroke. The primary end point was incidence of major adverse events (MAEs), a composite of stroke, cardiac or neurological death, myocardial infarction, and requirement for procedure-related cardiovascular surgery within the first month.
Implantation was successful in 108 of 111 patients (97.3%, 95% confidence interval [CI] 92.3% to 99.4%) who underwent 113 procedures. One patient (0.9%, 95% CI 0.02% to 4.9%) experienced two MAEs within the first 30 days: need for cardiovascular surgery and in-hospital neurological death. Three other patients underwent in-hospital pericardiocentesis due to a hemopericardium. Average follow-up was 9.8 months. Two patients experienced stroke. No migration or mobile thrombus was noted on transesophageal echocardiogram at one and six months after device implantation.
Closing the LAA using the PLAATO system is feasible and can be performed at acceptable risk. It may become an alternative in patients with AF and a contraindication for lifelong anticoagulation treatment.
United Kingdom 2 Birmingham Children's Hospital, Birmingham, United Kingdom *Correspondence to: David Hildick-Smith, Department of Cardiology, Royal Sussex County Hospital, Eastern Road E-mail: david.hildick-smith@bsuh.nhs.uk Received
- Brighton
- Sussex
Brighton, Sussex, United Kingdom 2 Birmingham Children's Hospital, Birmingham, United Kingdom *Correspondence to: David Hildick-Smith, Department of Cardiology, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, United Kingdom. E-mail: david.hildick-smith@bsuh.nhs.uk Received 28 September 2006; Revision accepted 29 September 2006 DOI 10.1002/ccd.20987 Published online 7 February 2007 in Wiley InterScience (www. interscience.wiley.com).
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI)
- Hildick-Smith
Hildick-Smith et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).