No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Repeat Transseptal Catheterization After Ablation for Atrial Fibrillation
Abstract
A substantial number of patients require a second left atrial procedure after ablation for atrial fibrillation (AF), either for left atrial flutter or recurrent AF. The success and complication rates of repeat transseptal catheterization in these patients are unknown. The aim of this study was to determine the difficulty and/or success rates of repeat transseptal catheterization after left atrial ablation for AF.
Consecutive patients undergoing repeat left atrial procedures after ablation for AF over a 1-year period were enrolled. Difficulties with, success rates, and complications of the first and second transseptal catheterizations were recorded. Sixteen patients underwent a repeat transseptal catheterization. Of the 4 in whom the first procedure was performed with an ablation catheter across a patent foramen ovale (PFO), 3 required a transseptal puncture for their repeat procedure. The remaining 12 underwent transseptal puncture without difficulty for their first procedure, and, despite the same operators for each patient, the repeat transseptal was noted to be difficult in 5. Of those 5, the transseptal puncture was unsuccessful due to increased interatrial septal thickness in 2 patients. One repeat transseptal attempt was aborted after posterior right atrial puncture with the transseptal needle occurred, attributed to distorted interatrial septal anatomy not observed prior to the first case.
Compared with the first procedure, repeat transseptal catheterization after ablation for AF, whether initially performed across a PFO or via a transseptal puncture, is more difficult, less often successful, and potentially associated with more complications.
... Patients, particularly those with who have undergone ablation for AF, having a repeat procedure pose more difficulties and complications during repeat TSP attributable to thickened or distorted septum, requiring extra caution and guiding tools [22,58]. One of the two patients having a complication in our series was undergoing his third TSP; he had his first procedure 7 years earlier for accessory pathway ablation and the second TSP 1 year earlier for persistent AF. ...
... Nevertheless, TSP was successful in 13 (92.9%) of 14 patients having a repeat procedure guided by fluoroscopy alone. Other investigators have reported only 81% successful repeat TSP among 16 patients despite ICE guidance [58], however, larger series had higher success rates with ICE guidance [19]. ...
... Finally, when TSP proves difficult with use of fluoroscopy alone, guidance by TEE or ICE should be strongly entertained [58,59]. Some have advocated that topology of the TSP site may be important to facilitate different procedures, e.g., posteroinferior region for PVI, center or inferior aspect of the septum for LAA occlusion, and superior and posteriormid aspect of the fossa ovalis for the MitraClip, but sitespecific TSP is usually not necessary for other types of LA procedures [60,61]. ...
Background:
Transseptal puncture (TSP) remains a demanding procedural step in accessing the left atrium with inherent risks and safety concerns, mostly related to cardiac tamponade.
Objective:
Based on our own experience with 249 TSP procedures and in-depth literature review, we present our results and offer several tips and tricks that may render TSP successful and safe.
Methods:
This prospective study comprised 249 consecutive patients (146 men), aged 41.6+17.4 years, undergoing TSP by a single operator for ablation of a variety of arrhythmias, most related to left accessory pathways (n=145) or left atrial tachycardias (n=33) and more recently, atrial fibrillation (n=70). TSP was guided by fluoroscopy alone in all patients without use of echocardiography imaging. In addition, an extensive literature review of TSP-related topics was carried out in PubMed, Scopus and Google Scholar.
Results:
Among the 249 patients, 33 patients were children or young adolescents (aged 7-18 years); 14 patients were undergoing a repeat procedure. Patients with a manifest accessory pathway were the youngest (mean age 33.7+15.9) and patients with atrial fibrillation the oldest (mean age 56.0+10.8 years). A successful TSP was accomplished in 247 (99.2%). Two (0.8%) procedures were complicated by cardiac tamponade managed successfully with pericardiocentesis or surgical drainage. Review of the literature revealed no systematic reviews and meta-analyses of TSP studies; however, several patient series have documented that fluoroscopy-guided TSP, with various modifications of the technique employed in the present series, have been effective in 95-100% of the cases with a complication rate ranging from 0.0% to 6.7%, albeit with a mortality rate of 0.018%-0.2%. Echo imaging techniques were employed in cases with difficult TSP.
Conclusions:
Employing a standardized protocol with use of fluoroscopy alone minimized serious complications to 0.8% (2 patients) among 249 consecutive patients undergoing TSP for ablation of a variety of cardiac arrhythmias. Based on this single-operator experience and review of the literature, a list of practical tips and tricks are provided for a successful and safe procedure, reserving the more expensive and patient inconveniencing echo-imaging techniques for difficult or failed cases.
... Transseptal puncture (TSP) is now widely used in interventional cardiology. [1][2][3] This technique may result in life-threatening complications at times. [4][5][6] Proper location of the puncture site on septum is the first and also the most critical step during TSP. ...
... However, this method more or less increases the procedure time and it requires the application of a high-pressure injector, which may not be a constantly standby facility in some centers. [1] The collection process may also increase the risk of contamination. Additionally, a silhouette of the left atrium (LA) is not clear in the patients with tricuspid insufficiency. ...
... Although, many operators also took typical second catheter movement as the optimal TSP site on the X-ray screen. [1][2][3] The CTP-2 method was generally used as reference in their final decision. Additionally, many patients might have no second typical jump due to the lack of apparent prominence in anterior-inferior aspect of fossa ovalis. ...
The current used parameters for transseptal puncture (TSP) under fluoroscopic guidance is from left atriography and need to be verified by precise anatomic measurement. From February 2009 to July 2013, consecutive patients who received computed tomography (CT) were included. Landmarks and parameters were preliminary studied by right atriography, and further evaluated on the CT images of 1001 patients. A method (CTP-2) was proposed for guiding TSP. In right anterior oblique 45 degrees view, the CTP-2 method was defined by points C, T, and P, and 2 areas: point C is in coronary sinus; point T is at a distance of dCT (usually 1.5 +/- 0.2 vertebral height) over point C; then point P, the optimal puncture site, was located at 0.5 +/- 0.2 vertebral body height posterior to point T; puncture should avoid the aortic root area and the rear triangle area; the aortic root area could be negatively revealed by right atriography at the orifice of inferior vena cava, and the rear triangle area is demarcated by points C, C, and T (C and T are 2 points horizontally posterior to, and at dCT away from points C and T, respectively). The initial application of CTP-2 in 2820 patients showed that it might be helpful in reducing the need of left atriography and the possibility of cardiac perforation.
... Transseptal puncture for LA access is becoming more common because of the growing adaptation of catheter ablation and structural heart procedures involving left-sided access. [1][2][3][4][5][6][7] However, the transseptal puncture procedure can be time consuming 13,14 and can result in important complications. 15,16 Prolonged transseptal procedures may increase Values are reported as meanAESD or n (%). ...
... Finally, although not statistically significant, 40% of those who failed with the conventional needle (and succeeded with the RF needle) had a previous transseptal puncture, a previously established predictor of a difficult procedure. 13 However, given this large difference and previous evidence that repeat transseptal punctures are more challenging, the RF needle may be particularly preferred in the repeat transseptal puncture population. In fact, we used a conservative estimate when designating "failure" of the assigned transseptal needle: 3 additional patients assigned to the conventional needle had difficulty in achieving LA access despite forward pressure and tenting, and based on operator discretion, application of electrocautery to the conventional needle was performed against protocol, each time resulting in success. ...
... We performed shaving in this manner to mimic the course of the needle through the dilator/sheath outside the patient's body. In fact, our method of conventional needle introduction without the stylet and with forward flushing is the most common method employed in published reports, 10,13,16 and is reflected in the original report of shaved visible particles. 9 We acknowledge that the frequency of plastic shavings might be reduced if the stylet is left in place until the needle/stylet tip is close to the dilator tip; however, removing the stylet within the body may increase the risk of air embolism and does not preclude unseen shaving production from the unprepared distal portion of the dilator. ...
Transseptal puncture is a critical step in achieving left atrial (LA) access for a variety of cardiac procedures. Although the mechanical Brockenbrough needle has historically been used for this procedure, a needle employing radiofrequency (RF) energy has more recently been approved for clinical use. We sought to investigate the comparative effectiveness of an RF versus conventional needle for transseptal LA access.
In this prospective, single-blinded, controlled trial, 72 patients were randomized in a 1:1 fashion to an RF versus conventional (BRK-1) transseptal needle. In an intention-to-treat analysis, the primary outcome was time required for transseptal LA access. Secondary outcomes included failure of the assigned needle, visible plastic dilator shavings from needle introduction, and any procedural complication. The median transseptal puncture time was 68% shorter using the RF needle compared with the conventional needle (2.3 minutes [interquartile range {IQR}, 1.7 to 3.8 minutes] versus 7.3 minutes [IQR, 2.7 to 14.1 minutes], P=0.005). Failure to achieve transseptal LA access with the assigned needle was less common using the RF versus conventional needle (0/36 [0%] versus 10/36 [27.8%], P<0.001). Plastic shavings were grossly visible after needle advancement through the dilator and sheath in 0 (0%) RF needle cases and 12 (33.3%) conventional needle cases (P<0.001). There were no differences in procedural complications (1/36 [2.8%] versus 1/36 [2.8%]).
Use of an RF needle resulted in shorter time to transseptal LA access, less failure in achieving transseptal LA access, and fewer visible plastic shavings.
http://www.clinicaltrials.gov. Unique identifier: NCT01209260.
... More than half of the patients (22/41) had at least one previous TSP, known to cause fibrosis and stiffening of the interatrial septum [12]. ...
... About 20-30% of patients with structural normal hearts and paroxysmal AF ablation require at least one redo procedure, whilst patients with persistent and longstanding-persistent AF have even higher rates of reablation [13]. Repeated TSP is known to result in stiffening of the interatrial septum, making further TSP a technical challenge, frequently encountered in EP lab [12]. Children and adults with CHD present an even greater challenge to TSP mostly because of the presence of an artificial septum, due to either a surgical patch or device closure [14]. ...
Introduction:
Transseptal puncture (TSP) is a routine access route in patients with left-sided ablation substrates and is performed safely on fluoroscopy (+/- echocardiographic guidance). We report on our experience using a radiofrequency (RF) needle in an unselected group of patients to demonstrate safety and usefulness of direct tip visualization on the 3D electroanatomical mapping (EAM) system with specific emphasis on total radiation exposure.
Methods and results:
We retrospectively reviewed 42 consecutive left-sided ablation procedures with TSP performed using an RF needle guided by fluoroscopy and/or EAM visualization by a single operator. The procedures included atrial fibrillation (n = 33), atrial tachycardia (n = 8), and ventricular tachycardia (n = 1) ablations. Fourteen of 41 patients had congenital heart disease, including 9 patients with previous septal closure. Twenty-two patients had at least one previous TSP. All TSPs were performed successfully and without complications. The overall median fluoroscopy time amounted to 3.2 min and median exposure of 199.5 µGy
∗
m2. In a subgroup of patients (n = 27), the RF needle was visualized on the EAM system: median radiation time was 0.88 (interquartile range: 0-3.4) min and median exposure 33.5 [0-324.8] µGy
∗
m2.
Conclusions:
TSP using an RF needle is an effective technique, also in congenital patients with artificial patch material and in normal patients with multiple previous TSPs. Moreover, the RF needle tip visualization on EAM allows a low (or even zero) fluoroscopy approach.
... In addition, in the RF group, transseptal time was similar between patients undergoing their initial or a repeat procedure compared to the conventional group, where there was a trend for longer time. This is compatible with the results of a previous study where repeat transseptal access was frequently more difficult [9,15]. Small focal scar of 1-2 mm was found at autopsy in animals following RF puncture [13]. ...
... Intra-procedural imaging is useful to exclude left atrial thrombus, to guide transseptal puncture and catheter positioning, to help identification of pulmonary veins ostia, and to monitor complications [14]. In a previous study, transseptal access was difficult in 5/12 patients undergoing a repeat transseptal procedure and was unsuccessful in two patients (17%) [15]. In an experienced group, the conventional technique was unsuccessful in 5%, but transseptal access was easily obtained with the use of RF [7]. ...
Patients undergoing left atrial ablation require transseptal puncture, which can be challenging, even for experienced physicians. This study compared the efficacy and safety of radiofrequency (RF) energy transseptal punctures to conventional approach.
Patients requiring transseptal puncture for left atrial access were included using either conventional approach or the NRG™ RF transseptal needle as first attempt. Procedure time for transseptal access, fluoroscopy time, crossover, and safety of both techniques were compared.
A total of 241 transseptal punctures were performed in 148 consecutive patients (114 men, 54 ± 10 years, left atrial volume 32 ± 10 ml/m(2)) who underwent 157 procedures with left atrial access, mainly for atrial fibrillation. It was a repeat transseptal procedure in 49 patients. Procedures were guided by transesophageal echocardiography. RF transseptal puncture was planned in 119 procedures. RF was delivered in 98 procedures (82%) for 139/187 punctures: 48 punctures did not require RF, including 25 punctures performed by exposing the needle tip, 22 through patent foramen ovale, and 1 RF delivery failure by the generator. Average time for RF transseptal was 4.8 ± 2.8 min compared to 7.5 ± 8.5 min for conventional approach (p = 0.045). Fluoroscopy time was 1.8 ± 1.3 min for RF transseptal and 2.9 ± 2.8 min for standard approach (p = 0.043). Four patients required crossover to RF transseptal needle in the conventional group (p = 0.003). One tamponade occurred at the end of procedure in a patient using the RF needle, and one interatrial septum dissection with aortic root hematoma occurred in the conventional group.
Transseptal needle puncture using RF energy can be performed safely and quickly under imaging guidance.
... In the last two decades, it became more widely used in pediatric patients with the evolution of ablation for arrhythmias. Transseptal puncture can be challenging [3][4][5] and lead to complications such as pericardial effusion and tamponade. In adults, methods, such as dedicated radiofrequency (RF) to facilitate transseptal puncture, have become routine. ...
... Occasionally, transseptal puncture can be very challenging. 3,4 This may be due to an elastic, aneurysmal septum primum, or a lipomatous, thick, fibrotic septum. At times, significant mechanical force needs to be applied to the dilator/sheath/needle unit to cross the septum. ...
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.
... A frequent challenge for transseptal access is a sclerotic IAS, which may be the result of prior TSC and cardiac surgery but which has also been reported in patients without a history of prior invasive procedures (e.g. in patients with myocardial calcinosis in the setting of chronic renal failure). 10,11 At times, the initial ICE images can be deceiving and the only clue lies in the fact that the IAS is more echogenic than usual. This poses a unique challenge because the operator is forced to apply more than usual forward pressure, which may be associated with increased risk of perforation and pericardial effusion leading to tamponade. ...
Atrial transseptal catheterisation is a fundamental skill of any interventional electrophysiologist. In this review, various scenarios that pose unique challenges to atrial transseptal catheterization are discussed. These scenarios include post-surgical or congenital malformations of the interatrial septum, presence of interatrial septal closure devices, absent or obstructed inferior vena cava, and complex congenital heart disease after palliative surgery. Transseptal catheterization in all of the above situations is feasible and can be performed safely with the aid of dedicated tools and specific techniques.
... The current study exclusively enrolled patients undergoing a first ablation procedure. It is known that repeat transseptal punctures are more technically challenging as the septum becomes thick, scarred, or calcified [15]. It is possible that the observed difference between groups may have been greater if we had included patients with previous transseptal access, a population where the RF needle or atraumatic stiff pigtail wire may hold a theoretical advantage [13]. ...
Background
Transseptal puncture to achieve left atrial access is necessary for many cardiac procedures, including atrial fibrillation ablation. More recently, there has been an increasing need for left atrial access using large caliber sheaths, which increases risk of perforation associated with the initial advancement into the left atrium. We compared the effectiveness of a radiofrequency needle-based transseptal system versus conventional needle for transseptal access.
Methods
This prospective controlled trial randomized 161 patients with symptomatic paroxysmal atrial fibrillation undergoing cryoballoon pulmonary vein isolation to transseptal access with a commercially available transseptal system (radiofrequency needle plus stiff pigtail wire; RF + Pigtail group) versus conventional transseptal access (standard group). The primary outcome was time required for left atrial access. Secondary outcomes included failure of the assigned transseptal system, radiation exposure, and complications.
Results
The median transseptal puncture time was significantly shorter using the radiofrequency needle plus stiff pigtail wire transseptal system compared with conventional transseptal (840 ± 323 vs. 956 ± 407 s, P = 0.0489). Compared to conventional transseptal puncture, fewer transseptal attempts were required (1.0 ± 0.5 RF applications vs. 1.3 ± 0.8 mechanical punctures, P = 0.0123) and the fluoroscopy time was significantly shorter (72.0 [IQR 48.0, 129.0] vs. 93.0 [IQR 60.0, 171.0] s, P = 0.0490) with the radiofrequency needle plus stiff pigtail wire transseptal system. Failure to achieve transseptal LA access with the assigned system was rarely observed (1.3% vs. 5.7%, P = 0.2192). There were no procedural complications observed with either system.
Conclusions
The use of a radiofrequency needle plus stiff pigtail wire resulted in shorter time to left atrial access and reduced fluoroscopy time compared to left atrial access using conventional transseptal equipment.
Trial registration
ClinicalTrials.gov identifier NCT03199703.
... Haissaguerre et al was initially introduced technique using ST puncture and double transseptal catheterization.7,19 A previous retrospective study15 and other report20 have showed that ST puncture is safe and could be used as an alternative to reduce the complications of performing a second transseptal puncture, such as pericardial tamponade, coronary artery spasm by mechanical irritation,21 and air embolism.22 However, ST puncture and double transseptal catheterization sometimes causes the problem of catheter manipulation.10 ...
Background
We have previously reported that unilateral groin‐single transseptal (ST) ablation in patients with paroxysmal atrial fibrillation (AF) was safe and significantly reduced patient discomfort compared with bilateral groin‐double transseptal (DT) ablation.
Hypothesis
In the present study, we hypothesized that ST ablation would be as effective and safe as DT ablation in real‐world practice like previous study. Among the 1765 consecutive patients in the Yonsei AF ablation cohort from October 2015 to January 2020, 1144 patients who underwent radiofrequency ablation were included for the analysis. Among them, 450 underwent ST ablation and 694 underwent DT ablation.
Results
The total procedure time, ablation time, and fluoroscopy time were longer in the ST group than in the DT group (p < .05 for all). The hospital stay after catheter ablation was 1.3 ± 1.1 days which was longer in DT group than ST group (p = .001). No significant difference was observed in the complication rate (p = .263) and AF‐free survival rate (log‐rank p = .19) between the groups. However, after excluding patients who used antiarrhythmic drugs when AF recurred, the AF‐free survival rates were lower in the DT group than in the ST group before and after propensity score matching (log‐rank p = .026 and .047, respectively).
Conclusion
Although the ST approach increases the procedure time compared with the DT approach owing to the need for more frequent catheter exchanges, the ST approach is a feasible and safe strategy for AF ablation in terms of rhythm outcomes and risk of complications.
... Since the technique of TSP was introduced in 1959, it has been widely used by electrophysiologists because of the increasing volume of interventional procedures; this procedure achieves successful left atrial access, such as catheter ablation of AF, left accessory pathways, and ventricular tachycardia [14]. This procedure remains difficult, particularly in patients with atrial septal occluders and in those with fibrosed septa due to prior TSP [11,15]. The current study, to our knowledge, is the first to propose a novel technique named 2D2G to difficult transseptal puncture. ...
Aims:
Transseptal passage is sometimes difficult to obtain. This study evaluates the feasibility and safety of a novel and easy transseptal puncture (TSP) technique named 2D2G (using two dilators and two guidewires) in patients with difficult TSP.
Methods and results:
Forty-four paroxysmal atrial fibrillation patients with difficult TSP were enrolled in this study. They were allocated to the 2D2G group or the conventional group in a 1:1 fashion. The primary endpoint in both groups was successful TSP without changing the puncture site or using auxiliary tools. The secondary endpoints were the safety, total transseptal puncture time, and ablation time. There were no differences in baseline demographic or clinical characteristics between the two groups. Successful LA access in the 2D2G group was 100% (vs. 64%, P < 0.05). The total TSP time (10 ± 3 min vs. 5 ± 1 min, P < 0.05) and ablation time (42 ± 19 min vs. 58 ± 22 min, P < 0.05) in the conventional group were significantly longer than those in the 2D2G group. No major complications occurred in either group, and all the patients underwent successful circumferential pulmonary vein isolation (CPVI).
Conclusion:
In AF patients with difficult TSP, the 2D2G technique is safe, feasible, and time-saving.
... Anticipation and definition of difficult TSP are challenging even with additional preprocedural cardiac imaging. Previous AF ablation procedures and prior surgical or percutaneous interventions in the IAS area increase the risk for difficult TSP [5,15,16]. Although punctures with the aid of the RF needle technique that could be considered difficult in our study were low, we experienced no safety or efficacy issues with fluoroless ICE-guided approach. ...
Background
Integration of intracardiac echocardiography (ICE) and 3D electroanatomic mapping (EAM) system allows transseptal punctures (TSP) without the use of fluoroscopy. Compared with fluoroscopy, ICE provides better visualization of the anatomy relevant to TSP and early recognition of complications. The aim was to evaluate efficacy and safety of entirely ICE-guided TSPs in patients who underwent fluoroless catheter ablation of left-sided tachycardias.Methods
Consecutive 524 adult and pediatric patients referred to our institution from July 2014 to December 2019 were analyzed. Patients with cardiac implantable electronic devices (CIEDs) were also included. All procedures were performed with ICE-guided TSP combined with 3D EAM. Adverse events following TSP and within 30 days of the procedure were analyzed.ResultsAltogether 949 TSPs (363 double punctures, 76.5%) were performed in 586 fluoroless ablation procedures: 451 (77%) were ablation of atrial fibrillation or atypical flutter, 75 (12.8%) of left-sided accessory pathway, 33 (5.6%) of ventricular tachycardia, and 27 (4.6%) of focal atrial tachycardia. Forty-six (7.8%) procedures were performed in pediatric population and 36 procedures (6.1%) in patients with CIED. Only 2 TSPs were unsuccessful (2/949, 0.2%). Overall procedural complication rate was 1.9% (11/586 procedures). There was only 1 TSP-related pericardial tamponade (2/949, 0.2%). In CIED patients, there was 1 lead dislocation following TSP.Conclusions
Entirely ICE-guided TSPs for different left-sided tachycardias can be safely and effectively performed in adult and pediatric population without the use of fluoroscopy. However, caution is advised in CIED patients due to possible lead dislocation risk.
... All complications were minor and none of them required any intervention. What is distinctive is a significant group of patients who had one or more TSP prior to our procedure (29%), which is known as a possible complication factor [11,12]. The rate of cardiac tamponade as a complication of TSP differs among studies and ranges from 0 to 1.2%. ...
... Uhm et al [8] recently published a work with tips on how to perform transconduit and transbaffle puncture in those patients. Marcus et al [9] showed that repeated transseptal puncture is more difficult to achieve due to interatrial scarring. Of note, none of our reported patients had undergone transseptal puncture before. ...
Purpose:
Pulmonary vein isolation (PVI) is a cornerstone therapy in patients with symptomatic atrial fibrillation. One current method is performing a PVI using a cryoballoon (CB). The CB is inserted into the left atrium via a steerable sheath. However, at times, passing of the interatrial septum by the sheath is hindered, e.g., due to septal fibrosis. Here we report our experience with an evasion maneuver to facilitate this approach using a 6F multipolar and steerable coronary Sinus catheter (CS) for predilatation of the interatrial septum.
Methods and results:
We report 10 patients undergoing a CB-PVI, where the investigator experienced difficulties in passing the interatrial septum with the CB sheath. In these cases, after three conventional abortive attempts, we predilated the transseptal puncture site using both the CS catheter and the dilatator of the CB sheath. Thereafter access of the CB sheath to the left atrium could be achieved instantly and without further resistance.
Conclusion:
We report a safe and feasible maneuver to facilitate transseptal access with the CB steerable sheath in cases complicated by excessive interatrial resistance.
... Atrial trans-septal crossing may be difficult in patients with thickened fibrous interatrial septa, aneurysmal septa, or previous surgical patch repair [10]. Commercial radiofrequency wires and needles are effective and safe compared with electrifying a Brockenbrough needle [2] The risk of thrombus formation resulting from radiofrequency energy delivery was mitigated by short duration of energy delivery and systemically anticoagulating before crossing was attempted. ...
... Despite increasing use, TSP requires an experienced operator and carries the risk of potentially severe complications [1,2]. The procedure is especially challenging in patients with elastic or aneurysmal septa but also in fibrosed septa due to prior TSP [3][4][5]. Presence of such septa not only makes the procedure more difficult but also increases the risk of cardiac perforation as excessive septal tenting (when applying pressure over the septum) may result in sudden uncontrolled forward movement of the needle (harpooning). Use of various imaging modalities (transoesophageal echocardiography and intracardiac echocardiography) or special puncture needles (radiofrequency needle, J-shaped guidewire, etc.) has been shown to reduce such complications [6][7][8][9][10]. ...
Background . Transseptal puncture (TSP) can be challenging. We compared safety and efficacy of a modified TSP technique (“mosquito” technique, MOSQ-TSP) to conventional TSP (CONV-TSP). Method. Patients undergoing AF ablation in whom first attempt of TSP did not result in left atrial (LA) pressure (failure to cross, FTC) were randomized to MOSQ-TSP (i.e., puncture of the fossa via a wafer-thin inner stylet) or CONV-TSP (i.e., additional punctures at different positions). Primary endpoint was LA access. Secondary endpoints were safety, time, fluoroscopic dose (dose-area product, DAP), and number of additional punctures from FTC to final LA access. Result. Of 384 patients, 68 had FTC (MOSQ-TSP, n=34 versus CONV-TSP, n=34 ). No complications were reported. In MOSQ-TSP, primary endpoint was 100% (versus 73.5%, p<0.002 ), median time to LA access was 72 s [from 37 to 384 s] (versus 326 s [from 75 s to 1936 s], p<0.002 ), mean DAP to LA access was 1778±2315 mGy/cm ² (versus 9347±10690 mGy/cm ² , p<0.002 ), and median number of additional punctures was 2 [1 to 3] (versus 0, p<0.002 ). Conclusion. In AF patients in whom the first attempt of TSP fails, the “mosquito” technique allows effective, safe, and time sparing LA access. This approach might facilitate TSP in elastic, aneurysmatic, or fibrosed septa.
... Many patients with AF or SHD had prior TSP or a hypertrophied or fibrotic IAS.Repeat TSPs are more difficult, less often successful, and potentially associated with more complications compared with the first TSP because of increased thickness of the FO, local scarring, or distorted IAS anatomy(59,60). Techniques to overcome these dif-ficulties include the use of a large-curved transseptal needle (e.g., BRK-1), advancement of transseptal needle stylet or sharp-tipped wires (e.g., SafeSept) through the needle to facilitate needle crossing, and using an RF transseptal needle (Figure 9B) (60,61). If RF needles are not available, brief application of RF energy using an electrocautery system connected to the proximal end of the transseptal needle may assist with passage of the needle across the FO (62). ...
The development of new transseptal transcatheter interventions for patients with structural heart disease is fueling increasing interest in transseptal puncture techniques. The authors review contemporary transseptal puncture indications and techniques and provide a step-by-step approach to challenging transseptal access and procedural complications.
... The consequent increase in the number of patients requiring repeated TSP means operators will increasingly encounter cases where standard TSP is challenging. Studies by Marcus et al. 13 and Tomlinson et al. 5 have shown repeat TSP is more likely to be difficult with a potentially greater risk of complication. Greater force imparted to puncture a tough intra-atrial septum may make a sudden jump of the needle tip more likely with the potential to puncture the atrial wall. ...
Background: We describe our alligator clip method of using radiofrequency (RF) energy via a standard Brockenbrough needle to facilitate difficult transseptal puncture. Method: If standard transseptal puncture is unsuccessful RF energy is used via our alligator clip technique. A non-sterile ablation catheter is attached to the proximal end of the Brockenbrough needle using sterile alligator clips and using a standard generator in unipolar mode we deliver RF energy to the fossa ovalis. Initial cases were transesophageal echocardiography guided but most procedures used fluoroscopy alone. Results: Two-hundred and forty-four left atrial procedures were performed during the study period. RF-assisted transseptal puncture was used in 23 cases (17 males, 6 females, mean age 63¡10 years). Redo transseptal puncture was significantly associated with difficult transseptal puncture, 20.4% (10/49) requiring RF compared with 6.66% (13/95) of first time cases (p50.0162). RF was successful after a median two bursts (maximum 4). There were no complications acutely or at follow-up (mean 10.4 months). Conclusion: RF is an effective tool to use in challenging transseptal puncture. Our simple, low-cost method is easy to institute and requires only the one-off cost of alligator clips and their sterilization between cases.
... 1 However, TP remains challenging for inexperienced operators and in difficult cases where distorted atrial anatomy is encountered. 2,3 Here we report for the first time inferior vena cava (IVC) angiography-guided TP technique and our experience of a series of patients who had successful IVC angiographyguided TP in the absence of any other imaging modality † These authors contributed equally to this work, they are co-first authors of this paper. after failing the conventional technique. ...
Intracardiac echocardiography is not routinely used to guide transseptal puncture (TP) in many centres. TP under fluoroscopy is still the common practice worldwide but remains challenging in difficult cases. This study aims to describe a simple technique to safely localize appropriate TP site during atrial fibrillation (AF) ablation procedure. Inferior vena cava (IVC) angiography was performed at RAO 45°. The IVC, right atrium (RA), right-ventricular inflow tract, and right-ventricular outflow tract were sequentially visualized while the aorta was visualized as non-opacified filling defect. The appropriate TP site was in the middle of the RA, inferoposterior to the non-coronary aortic sinus (NCAS) and superoposterior to coronary sinus ostium. The spatial relationship of these structures was studied in 81 patients. The distance between optimal TP site and surrounding landmarks was analysed. Out of 393 consecutive TPs performed from August 2011 to January 2012, this technique was applied in 17 patients. Under RAO 45° on IVC angiography, an imaginary horizontal line was drawn across the middle point between NCAS and the top of the coronary sinus ostium. The line was divided into four quarters. In 78 (96%) patients, the optimal TP site was identified in the second one. In 94% (16/17) of the patients, all above-mentioned structures were clearly visualized and TP was successfully performed in all of them without complications. IVC angiography is a simple and safe technique which can facilitate TP in difficult cases. Optimal TP site can be easily identified on IVC angiography.
... Less frequent indications currently include a mitral valvuloplasty or measurement of hemodynamic parameters in the presence of artificial aortic valve. At experienced workplaces this method has had a very high success rate performance and a low risk of potential complications, which outset is often associated with possible anatomical varieties of interatrial septum (hypermobility or septum thickening, aneurysmal sinus, individual heart chambers dilation, atypical heart position, prior transseptal puncture) [2]. The described complications include punctures of coronary sinus, aortic root, free right wall or left wall atrium with the risk of pericardial effusion up to tamponade [3], then the emergence of reflex vasovagal hypotension or bradycardia, transient ST segment elevation in leads II, III, and VF with possible stenocardia from temporary coronary arteries spasm because of parasympathetic irritation. ...
IntroductionTransseptal puncture is a commonly used method which we can see being applied nowadays predominantly in electrophysiological studies. This interventional method has been very successful at experienced electrophysiological laboratories and has a low risk of potential complications. One of the described complications is emergence of hypotension or bradycardia or transient ST segment elevation on the basis of parasympathetic activation or air embolism into the coronary artery.Patient, methodsIn the case history we present a substantial response in the context of transseptal puncture during electrophysiological examination with pulmonary vein isolation in a patient with persistent atrial fibrillation. This patient subsequently developed bradycardia and there was no response to atropine so he needed temporary cardiac pacing. Furthermore, a stenocardia was observed, as well as ECG elevations of ST segment in II, III and aVF leads and even in the chest leads, and also a severe hypotension with the need for catecholamine support. Echocardiography examination excluded pericardial effusion, and urgent coronary angiography showed normal findings on coronary arteries. Problems gradually subsided and further course did not require pacing and catecholamine support, and subsequently the performance was completed without any other problems.Discussion and conclusionLiterature describes individual cases with signs of ischemia in the inferior wall after the transseptal puncture. It has always been a temporary complication, and often with a decline of problems after intravenous administration of calcium channel blockers or nitrate. It was therefore suspected that this is a transient coronary artery spasm due to irritation of the autonomic nervous system with vagus nerve activation. Prompt administration of atropine, and if the problems persist also administration of norepinephrine, leads to a decline of problems. It becomes apparent that the need for timely treatment of this complication is necessary. After remission of symptoms and at the exclusion of other possible complications it is possible to finish the electrophysiological study.
... Two previous studies 11,12 showed that difficulties in TSP-C are mainly related to a repeat procedure, possibly owing to atrial septal thickening and/or upward displacement of the AS puncture site. Another study 7 demonstrated that the only parameter associated with a resistant septum was the total number of prior TSP-C procedures. ...
Transseptal catheterization (TSP-C) is a demanding procedure and at the same time one of the key points of atrial fibrillation ablation, an increasingly diffused procedure. This study prospectively evaluates the usefulness of a novel sharp-tip, J-shaped 0.014'' transseptal guidewire (TSP-GW) to facilitate TSP-C in case of resistant atrial septum (AS).
Consecutive patients undergoing TSP-C for arrhythmia ablation in a single centre were considered for the study. TSP-C was performed according to a standardized technique. The criterion to use the TSP-GW was a resistant AS, defined as inability to perforate the fossa ovalis by applying moderate pressure to a standard Brockenbrough needle. The TSP-GW was inserted in the needle lumen and advanced to puncture the AS and enter the left atrium; subsequently, the transseptal assembly was advanced over the TSP-GW. Double transseptal puncture was routinely performed for ablation of atrial fibrillation. Eighty-one patients (54 males, 27 females; mean age 54 +/- 17 years, range 12-81) undergoing TSP-C were enrolled; 132 TSP-C procedures were planned and accomplished. Nineteen patients (23%) in 27 procedures showed a resistant AS. In all these procedures, the TSP-GW was safely and successfully used to accomplish the TSP-C. In patients with a resistant AS, only a significantly lower prevalence of structural heart disease was observed when compared with controls. No complication related to TSP-C was observed.
The TSP-GW facilitates TSP-C in 23% of the patients, in whom a resistant AS is encountered. In this population, there was no clinical predictor of such anatomy.
... 6 -8 Crossing the atrial septum may be more difficult because of different anatomy or increased septal thickness or fibrosis caused by the previous puncture. Marcus et al. 7 reported 16 patients undergoing a repeat TS catheterization. Compared with the first procedure, the repeat TS catheterization after the ablation for AF was more difficult and potentially associated with more complications. ...
Although it has been shown that a transseptal (TS) puncture in the electrophysiology laboratory is associated with a high success and a low complication rate, this procedure remains challenging particularly in difficult septum anatomies (aneurismal septum and thick septum) and during repeat TS catheterization. Radiofrequency (RF) electrocautery current delivery through the TS needle has been shown to facilitate the TS puncture. The aim of this study was to verify prospectively the feasibility, safety, and outcome of RF energy delivery associated with the standard TS technique in patients undergoing a challenging TS puncture.
Over a 14-month period, 162 consecutive patients underwent left atrial (LA) arrhythmia ablation in our centre. Among them, we enrolled 18 patients who failed LA access after two TS puncture attempts. In these patients, an RF delivery through TS (RF-TS) needle approach was used to reach the LA. All 18 patients had a successful RF-TS at the first attempt. A transoesophageal echocardiography (TEE) guidance and fluoroscopy views were used in all patients. No acute complications were reported. There have been no clinical sequelae after 10 +/- 4 months of follow-up following the RF-TS approach. Challenging TS punctures were more frequent in repeat LA catheterization when compared with the first LA catheterization, respectively, in 35% (13 of 37) and 4% (5 of 125) of the patients.
Radiofrequency electrocautery delivery associated with the standard TS approach is a safe and reproducible technique to reach the left atrium, using the TEE guidance. This technique is helpful during repeat TS catheterization and in the presence of anatomical atrial septum abnormalities.
... Initially developed by Ross for measurement of left atrial pressure [1], this technique is now widely used in electrophysiological studies for performing catheter ablation procedures which target various arrhythmias such as left side accessory pathway tachycardias, ventricular tachycardias, left atrial tachycardias, and more recently, atrial fibrillation [2]. Despite growing popularity, catheterization of the left atrial chamber requires an experienced operator, and can be associated with potentially severe complications3456. While generally a safe maneuver for most patients, the principal risk is cardiac perforation due to uncontrolled movement of the needle tip into the left atrium. ...
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.
Background
Transseptal puncture is a necessary component of many electrophysiology and structural heart procedures. Improving this technique has broad ramifications for the overall efficiency and safety of these interventions. A new technology uses a specialized introducer wire to cross the septum with radiofrequency (RF) energy, eliminating the need for a transseptal needle and wire/needle exchanges.
Objectives
This study sought to compare the efficacy and safety of an RF needle versus RF wire approach for transseptal puncture.
Methods
Individuals ≥18 years of age undergoing double transseptal puncture for atrial fibrillation or left atrial flutter ablation were randomized to a transseptal approach with either an RF needle or RF wire. The primary outcome was time to achieve first transseptal puncture. Secondary outcomes included second and combined transseptal puncture time, fluoroscopy time, number of equipment exchanges, and complications.
Results
A total of 75 participants were enrolled (36 RF needle, 39 RF wire). No crossovers occurred. Randomization to the RF wire resulted in a significant reduction in first transseptal time compared with the RF needle (median 9.2 [IQR: 5.7-11.2] minutes vs 6.9 [IQR: 5.2-8.4] minutes, P = 0.03). Second and combined transseptal times, and number of equipment exchanges, were also reduced with the RF wire. One participant in the RF needle group experienced transient atrioventricular block due to mechanical trauma from the sheath/dilator assembly. There were no complications in the RF wire group.
Conclusions
The RF wire technique resulted in faster time to transseptal puncture and fewer equipment exchanges compared with an RF needle with no difference in complications.
Aims:
Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the associations of TSP-related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our centre from 2016-2020.
Methods and results:
Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinised to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. 3,239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP-related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above-median age (OR 2.4 (1.19-4.2), p=0.006) and those undergoing re-do procedures (OR 1.95 (1.29-3.43, p=0.042) were at higher risk of TRCT. Of the operator-dependent variables, choice of transseptal needle (Endrys vs Brockenbrough, p>0.1) or puncture sheath (Swartz vs Mullins vs Agilis vs Vizigo vs Cryosheath, all p>0.1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk (OR 4.42 (2.45-8.2), p=0.001), whilst top quartile operator experience (OR 0.4 (0.17-0.85, p=0.002), transoesophageal echocardiogram (TOE prevalence: 26%, OR 0.51 (0.11-0.94), p=0.023), and use of the SafeSept transseptal guidewire (OR 0.22 (0.08-0.62), p=0.001) reduced TRCT risk. An increase in transseptal guidewire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R2 =0.72, p<0.001) and was associated with a relative risk reduction of 70%.
Conclusions:
During left atrial ablation, the risk of TRCT was reduced by operator experience, TOE-guidance, and use of a transseptal guidewire, and was increased by patient age, re-do procedures, and failure to cross the septum first pass.
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.
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 detailed understanding of the anatomy of the atrial septum and its relationship with critical structures such as the aortic root and the posterior atrial wall is crucial to safely perform transseptal catheterization. A biplane fluoroscopy-guided technique using conventional fluoroscopic landmarks guided by diagnostic catheters in standard positions (e.g., coronary sinus, His bundle, noncoronary sinus of Valsalva) is the historical standard for atrial transseptal catheterization. Intracardiac echocardiography and other specialized tools, such as radiofrequency-assisted transseptal needles, have significantly improved the efficacy and safety of atrial transseptal catheterization. These tools greatly facilitate transseptal catheterization in patients with challenging anatomy, such as a thickened or aneurysmal interatrial septum or the presence of an atrial septal closure device.
Introduction: The transseptal puncture (TSP) enables access to the left heart, through the fossa ovalis (FO), both in electrophysiology and in cardiac interventional procedures. TSP is usually safe in experienced hands. Sometimes TSP can be technically demanding and carries the risk of severe complications in approximately 1%. While performing a TSP, every effort should be taken in order to avoid complications. In the event of complications, prompt recognition and reaction are essential and a combined “heart-team” management may be the most effective approach.
Areas covered: Main TSP-related complications are cardiac tamponade, aortic root puncture, embolic stroke, transient ST elevation of inferior leads and iatrogenic atrial septal defect. A challenging TSP may be expected in presence of difficult IAS-FO anatomies, previous TSP, IAS occluder device and previous IAS surgical repair. Use of echo imaging and special needles (ie., radiofrequency needle and J-shaped guidewire) may avoid TSP-related complications in difficult settings.
Expert commentary: Some tools are available to help minimize the risks of TSP. However, their availability might be limited. To increase safety of TSP, an adequate training of physicians, identification of patients in whom it might be difficult and a prompt recognition of complications seem to be the most important background.
In recent years, the transseptal puncture approach has enabled passage of increasingly large and complex devices into the left atrium. Traditional tools remain effective in creating and dilating the initial puncture, with an acceptable safety profile. Even for skilled operators, the procedure is technically demanding and requires sound understanding of atrial anatomy. Intracardiac echocardiography is useful in cases of previous septal repair, poorly defined fossa ovalis anatomy or when considering patent foramen ovale portal crossing. Iatrogenic atrial septal defect (iASD) is the most commonly encountered long-term complication and there is increasing evidence that larger devices are leading to symptomatic defects. The size of the sheath crossing the septum is the strongest predictor of iASD formation but other factors such as longer procedure times, significant catheter manipulation and high pulmonary pressures also contribute. Transcatheter mitral valve repair involves the use of large 22 Fr catheters which carry alarmingly high rates of defect persistence with precipitation of symptoms and possible influence on mortality. Long-term follow up data, particularly beyond the 12-month period are lacking and resultantly, evidence to guide management is sparse. Refinements of conventional instruments, as well as innovations to puncture the septum without mechanical pressure, herald a progressively safer future for the transseptal technique.
Aims:
Percutaneous structural heart therapies, such as mitral value repair, require site-specific transseptal access (TSA). This can be challenging for interventional cardiologists. We describe a TSA catheter (TSAC) that utilises suction for enhanced control and puncture accuracy. Here, we aim to evaluate the safety and efficacy of the device.
Methods and results:
Ex vivo interatrial septum preparations were dissected from swine (n=8) and diseased human hearts (n=6) to quantify TSAC suction and needle puncture force. TSAC suction was 6.5-fold greater than the opposing needle puncture force, and thus provides sufficient stabilisation for punctures. The safety and efficacy of TSAC was evaluated in a chronic mitral regurgitation swine model (n=10) and compared to a conventional TSA device. MR was induced by disrupting one to three mitral chordae tendineae, and the progression of heart disease was followed for three weeks. During device testing, procedure time and fluoroscopy exposure were not statistically different between devices. TSAC reduced septal displacement from 8.7±0.30 mm to 3.60±0.19 mm (p<0.05) and improved puncture accuracy 1.75-fold.
Conclusions:
TSAC provides controlled TSA and improves puncture accuracy, while maintaining procedure time and workflow. These findings provide a strong rationale for a first-in-man study to demonstrate the clinical utility of the device.
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.
Ablation therapy for atrial fibrillation is constantly evolving and improving. The efficacy of AF ablation with obstructive sleep apnea is reduced when compared to patients without sleep disordered breathing even after other comorbidites have been controlled for. The ablation strategy employed as well as information from initial and subsequent ablations can be useful in predicting future AF recurrence. Early atrial arrhythmias, occurring within 3 months of ablation, are a unique situation. Early recurrences when compared to late or very late recurrence confer a worse prognosis for long-term arrhythmia control. The risks of repeat ablation are minimal over initial ablation and constantly improving. If a patient is unlikely to have sustained benefit from redo ablation, it is best not to offer it even if patient desires it. The safety of the procedure continues to improve as well, allowing electrophysiologists to more easily recommend multiple procedures to patients who need them.
There is a review on intracardiac echocardiography application in modern electro-physiological laboratory, especially, equipment and imaging demands, possibility of usage during catheter treatment of arrhythmias. Separate paragraphs dedicated to the possibilities of revealing intraoperative compli-cations of the catheter treatment with the help of intracardiac echocardiography as well as to the future development of this method in arrhythmology.
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.
Introduction
This study aimed to evaluate the safety and efficacy of utilising an innovative radiofrequency (RF) powered flexible needle to achieve transseptal puncture (TSP).
Methods and results
A RF powered flexible needle (Toronto catheter, Baylis Medical Company Inc.) associated with a stiffer dilator (Torflex Superstrong, Baylis Medical Company Inc.) was used in 125 consecutive patients referred for left sided ablations (mean age = 55.6, male = 86.5%) and compared with a standard transseptal set (BRK needle, SL0 sheath and dilator, St Jude Medical, Inc.) used in the previous 100 patients (mean age = 56, male 82%). TSP was achieved in 95/100 patients in the Brockenbrough group and in all 125 patients in the Toronto group (p = 0.01) despite an equivalent proportion of difficult situations (8 and 9% respectively) and patients with a prior TSP (17% vs 24%). 7/100 Needle related events (failure, aborted attempt or pericardial effusion) occurred in the Brockenbrough group and none in the Toronto group (p = 0.01). The Toronto needle crossed the septum at the first attempt in 123/125 (98.4%) patients and the Brockenbrough needle in 84/95 (88%) patients (p < 0.001).
Conclusion
Our data suggest that the Toronto RF powered flexible needle is safer and more efficient than a standard Brockenbrough needle and can be used not only in difficult situations but routinely to achieve TSP.
Transseptal puncture (TP) is a prerequisite for LA-ablations. LA-access can be gained by catheter probing in case of PFO (trans-PFO-method) or puncture of the interatrial septum (IAS) using a transseptal needle. A 2(nd) access can again be gained via PFO, a 2(nd) TP or catheter-probing of the previous puncture site (probe-TS-method). This study investigates the risk factors and complications related to the mode of transseptal access.
From 08/2010 to 08/2012 a total of 544 LA-ablations were performed. The mode of LA-access was either a double-TP or a single-TP followed by the probe-TS- or the trans-PFO-method, respectively. TP was always guided by TEE and was successfully performed without complications in all cases. In contrast, 6/410 patients (1.5%) in whom catheter-probing was performed (probe-TS n = 4, trans-PFO n = 2) had a dissection of the superior IAS originating from inside the oval fossa (n = 5) or perforation above the oval fossa (n = 1). Perforation into the pericardial space occurred in 4/6 patients, leading to one cardiac tamponade. In 5/6 patients LA-ablation was successfully completed, after repeated TP, despite effective anticoagulation. Patients with complications had the following characteristics: LA-size 46 ± 4 mm, persistent AF (5/6), a repeat transseptal procedure (3/6) and a right-sided pouch (RSP, 5/6).
Interatrial septum-dissection/perforation, occasionally with perforation into the pericardial space, is an unreported complication of TP, especially with the catheter-probing techniques. A RSP is an unrecognized risk factor in this context and can be visualized by TEE. This article is protected by copyright. All rights reserved.
The use of diagnostic and therapeutic methods for assessing pulmonary vein due to its status as a main source of ectopic beats for the initiation of atrial dysrrythmias is strongly recommended. We report the case of a 13-year-old girl who was admitted to our hospital with the electrocardiogram manifestation of an ectopic atrial tachycardia. The focus of arrhythmia was inside the right upper pulmonary vein. The patient underwent successful ablation with a conventional electrophysiology catheter via the retrograde aortic approach. We showed that when the origin of atrial tachycardia is in the right upper pulmonary vein, it is possible to advance the catheter into this vein via the retrograde aortic approach and find the focus of arrhythmia. This case demonstrates that right upper pulmonary vein mapping is feasible through the retrograde aortic approach and it is also possible to ablate the arrhythmia using the same catheter and approach.
Catheter ablation for atrial fibrillation (AF) has emerged as a promising treatment strategy. A thorough understanding of
cardiac anatomy is vital to prevent complications and for procedure success. Complications secondary to catheter ablation
of AF such as atria—esophageal fistula, phrenic nerve damage, pericardial effusion, pulmonary vein stenosis, and tamponade
can possibly be prevented by detailed knowledge of cardiac anatomy.
KeywordsBronchus–Esophagus–Phrenic nerve–Pulmonary veins–Recurrent laryngeal nerve–Transseptal puncture
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.
Transseptal puncture (TP) appears to be safe in experienced hands; however, it can be associated with life-threatening complications. The aim of our study was to demonstrate the added value of routine use of transoesophageal echocardiography (TEE) for the correct positioning of the transseptal system in the fossa ovalis, thus potentially preventing complications during fluoroscopy-guided TP performed by inexperienced operators.
Two hundred and five patients undergoing pulmonary vein isolation procedure (PVI) for drug-resistant paroxysmal or persistent atrial fibrillation were prospectively included. When the operator (initially blinded to TEE) assumed that the transseptal system was in a correct position according to fluoroscopical landmarks, the latter was then checked with TEE unblinding the physician. If necessary, further refinement of the catheter position was performed. Refinement >10 mm, or in case of catheter pointing directly at the aortic root or posterior wall were considered as major repositioning. Thirty-four patients required major repositioning. Regression analysis revealed age (P: 0.0001, Wald: 12.9, 95% confidence interval: 1.04-1.16), left atrial diameter (P: 0.01, Wald: 6.6, 95% confidence interval: 1.04-1.34), previous PVI (P: 0.01, Wald: 6.3, 95% confidence interval: 1.31-8.76), and atrial septal thickness (P: 0.03, Wald: 4.5, 95% confidence interval: 1.05-3.4) as independent predictors of major revision with TEE.
Routine 2D TEE in addition to traditional fluoroscopic TP appears to be very useful to guide the TP assembly in a correct puncture position and thus, to avoid TP-related complications. However, further randomized prospective comparative studies are necessary to support these suggestions.
Percutaneous transseptal left atrial (LA) access is increasingly becoming a routine procedure in the electrophysiology and cardiac catheterisation laboratories. Our aim was to review an unselected large series of this procedure performed over a period of five years. We clinically characterised difficult cases and presented a method of safe and expeditious LA access. Overall, 543 transseptal punctures were performed. Of those, 10 were classified as difficult, with failure to access the LA in three or more attempts. In all 10 cases, surgical electrocautery was successfully used to facilitate needle puncture of the septum. All patients subsequently underwent an uncomplicated procedure. In conclusion, we describe a method to trouble-shoot the difficult transseptal access procedure, outlining the clinical characteristics, echocardiographic features and special precautions that need to be considered when utilising this method.
An increasing number of transseptal punctures (TSPs) are performed worldwide for atrial ablations. Transseptal punctures can be complex and can be associated with potentially life threatening complications. The purpose of the study was to evaluate the safety and efficacy of a novel transseptal guidewire (TSGW) designed to facilitate TSPs.
Transseptal punctures were performed using a SafeSept TSGW passed through a standard TSP apparatus. Transseptal punctures were performed by standard technique with additional use of a TSGW allowing probing of the interatrial septum without needle exposure and penetration of the fossa into the left atrium (LA). Transseptal puncture using the TSGW was performed in 210 patients. Left atrial access was achieved successfully in 205 of 210 patients (97.6%) and in 96.3% of patients undergoing repeat TSP. Left atrial access was achieved with the first pass in 81.2% (mean 1.4 ± 0.9 passes, range 1-6) using the TSGW. No serious complications were attributable to the use of the TSGW, even in cases of failed TSP.
The TSGW is associated with a high success rate for TSP and may be a useful alternative to transoesophageal or intracardiac echocardiogram-guided TSP.
We developed prototype real-time 3-D intracardiac echocardiography catheters with integrated micromotors, allowing internal oscillation of a low-profile 64-element, 6.2-MHz phased-array transducer in the elevation direction. Components were designed to facilitate rotation of the array, including a low-torque flexible transducer interconnect and miniature fixtures for the transducer and micromotor. The catheter tip prototypes were integrated with two-way deflectable 10-Fr catheters and used in in vivo animal testing at multiple facilities. The 4-D ICE catheters were capable of imaging a 90° azimuth by up to 180° elevation field of view. Volume rates ranged from 1 vol/sec (180° elevation) to approximately 10 vol/sec (60° elevation). We successfully imaged electrophysiology catheters, atrial septal puncture procedures, and detailed cardiac anatomy. The elevation oscillation enabled 3-D visualization of devices and anatomy, providing new clinical information and perspective not possible with current 2-D imaging catheters.
Intracardiac echocardiography (ICE) broadens the spectrum of available echocardiographic techniques and provides the operator direct visualization of cardiac structures in real time. ICE has clear advantages over fluoroscopy, transthoracic echocardiography, and transesophageal echocardiography as the imaging modality of choice in the cardiac catheterization and electrophysiological laboratories. With the development of steerable phased array catheters with low frequency and Doppler qualities, there is marked improvement in visualization of left-sided structures from the right heart. Appropriate utilization of ICE is likely to maximize safety and efficacy of complex interventional procedures and may improve patient outcomes. Future advances in ICE imaging will further improve the ease of device guidance and, in combination with new imaging modalities, could dramatically improve other applications of echocardiography which may result in improved patient outcomes. This review describes the technical evolution of ICE, the use of ICE in guiding percutaneous interventional procedures and possible future applications of ICE in the ever-growing field of interventional cardiology.
We investigated the impact of the mode of left atrial (LA) access via patent foramen ovale (PFO) versus transseptal (TS) puncture on LA linear lesions during atrial fibrillation (AF) ablation.
We investigated 139 (PFO: 25) consecutive patients who underwent mitral isthmus (MI) and/or LA roof linear ablation. Technical endpoint was completeness of linear lesions and duration of radiofrequency (RF) application. During the initial procedure, complete MI and LA roof blocks were created in 13 of 19 (68%) and 14 of 17 (82%) patients in the PFO group, and in 57 of 94 (61%) and 54 of 70 (74%) patients in the TS group, respectively (P = NS). There was no significant difference in RF durations at MI (11.1 ± 8.9 and 15.1 ± 7.6 minutes, P = 0.11), and LA roof (10.1 ± 3.5 and 8.3 ± 5.0 minutes, P = 0.21) between the 2 groups. Among 28 patients who underwent repeat linear ablation, complete MI and LA roof blocks were created in 3 of 4 (75%) and 0 of 1 (0%) patients in the PFO group, and in 16 of 21 (76%) and 7 of 10 (70%) patients in the TS group, respectively (P = NS). There was no significant difference in RF durations at MI (15.3 ± 8.3 and 19.5 ± 18.3 minutes, P = 0.71), and LA roof (19.0 and 10.3 ± 5.4 minutes, P = 0.19) between the 2 groups. Clinical outcomes at 12 months were also similar.
There were no significant differences in the procedural success rates, durations of RF application, 12-month clinical outcomes, and complication rates of LA linear ablation between the PFO and TS groups. Accessing the LA via a PFO is not an unfavorable approach toward LA linear ablation.
The objective of this study was to demonstrate the safety and efficacy of a new transseptal needle design with a radiofrequency (RF) tip combined with the ease of use of the needle configuration. Background: RF transseptal puncture to enter the left heart, with a RF wire-catheter system is a successful technique in patients with complex access using a standard transseptal needle.
The RF transseptal needle (NRG™ Transseptal Needle; Baylis Medical, Montreal, Canada) was designed for RF percutaneous transseptal access to the left heart. Eight pigs underwent transvenous cardiac catheterization with baseline intracardiac electrograms and right atrial pressure waveforms. Transseptal RF puncture was performed followed by left atrial pressure waveform monitoring.
An intracardiac electrogram was recorded in each animal while dragging the needle tip from the superior caval vein across the atrial septum and into the inferior caval vein. Contrast staining of the atrial septum was accomplished in all animals, with subsequent RF septal puncture. After 0.1 sec, impedance increased from 300 to 1,200 Ohms with the creation of a vapor layer, and voltage increased steadily to a threshold of 230 volts over the first 0.4 sec. This dielectric breakdown results in tissue vaporization and tissue perforation. The needle's location within the left atrium was confirmed by the pressure waveform and contrast injection. Repeated RF punctures with the NRG™ was compatible with various manufactures transseptal sheaths.
RF puncture of the interatrial septum using the NRG™ Transseptal Needle facilitates an alternative effective technique to enter the left atrium. © 2010 Wiley-Liss, Inc.
The incidence and size of the patent foramen ovale were studied in 965 autopsy specimens of human hearts, which were from subjects who were evenly distributed by sex and age. Neither incidence nor size of the defect was significantly different between male and female subjects. The overall incidence was 27.3%, but it progressively declined with increasing age from 34.3% during the first three decades of life to 25.4% during the 4th through 8th decades and to 20.2% during the 9th and 10th decades. Among the 263 specimens that exhibited patency in our study, the foramen ovale ranged from 1 to 19 mm in maximal potential diameter (mean, 4.9 mm). In 98% of these cases, the foramen ovale was 1 to 10 mm in diameter. The size tended to increase with increasing age, from a mean of 3.4 mm in the first decade to 5.8 mm in the 10th decade of life.
Generation of long and continuous linear ablations is required in a growing number of atrial arrhythmias. However, deployment and assessment of these lesions may be difficult, and there are few data regarding their short- and long-term effects on atrial electrophysiology and pathology.
A nonfluoroscopic mapping and navigation technique was used to generate 3-dimensional (3D) electroanatomic maps of the right atrium in 8 pigs. The catheter was then used to deliver sequential radiofrequency (RF) applications (power output gradually increased until 80% reduction in the amplitude of the unipolar electrogram) to generate a continuous lesion between the superior and inferior venae cavae. The animals were remapped 4 weeks after ablation during septal pacing. Lesion continuity was confirmed in all cases by the following criteria: (1) activation maps indicating conduction block [significant disparities in activation times (52.0+/-16.0 ms) and opposite orientation of the activation wave front on opposing sides of the lesion], (2) evidence of double potentials (interspike time difference of 52.3+/-17.1 ms), and (3) low peak-to-peak amplitude of the bipolar electrograms (0.7+/-0.6 mV) along the lesion. At autopsy, all lesions were continuous and transmural, averaged 50.5+/-6.7 mm, and were characterized histologically by transmural fibrosis throughout the length of the lesion.
Long linear atrial ablation, created by sequential RF applications (using unipolar amplitude attenuation as the end point for energy delivery), results in long-term continuous and transmural lesions. Lesion continuity is associated with evidence of conduction block in the 3D activation maps and the presence of double potentials and low electrogram amplitude along the lesion.
We conducted a randomized, controlled trial of circumferential pulmonary-vein ablation for the treatment of chronic atrial fibrillation.
A total of 146 patients with a mean (+/-SD) age of 57+/-9 years who had chronic atrial fibrillation were randomly assigned to receive amiodarone and undergo two cardioversions during the first three months alone (the control group) or in combination with circumferential pulmonary-vein ablation. Cardiac rhythm was assessed with daily telephonic transmissions for one year. The left atrial diameter and the severity of symptoms were assessed at 12 months.
Among the 77 patients assigned to undergo circumferential pulmonary-vein ablation, ablation was repeated because of recurrent atrial fibrillation in 26 percent of patients and atypical atrial flutter in 6 percent. An intention-to-treat analysis showed that 74 percent of patients in the ablation group and 58 percent of those in the control group were free of recurrent atrial fibrillation or flutter without antiarrhythmic-drug therapy at one year (P=0.05). Among the 69 patients in the control group, 53 (77 percent) crossed over to undergo circumferential pulmonary-vein ablation for recurrent atrial fibrillation by one year and only 3 (4 percent) were in sinus rhythm without antiarrhythmic-drug therapy or ablation. There were significant decreases in the left atrial diameter (12+/-11 percent, P<0.001) and the symptom severity score (59+/-21 percent, P<0.001) among patients who remained in sinus rhythm after circumferential pulmonary-vein ablation. Except for atypical atrial flutter, there were no complications attributable to circumferential pulmonary-vein ablation.
Sinus rhythm can be maintained long term in the majority of patients with chronic atrial fibrillation by means of circumferential pulmonary-vein ablation independently of the effects of antiarrhythmic-drug therapy, cardioversion, or both. The maintenance of sinus rhythm is associated with a significant decrease in both the severity of symptoms and the left atrial diameter.
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.
Background:
In response to the increasing use of percutaneous balloon mitral commissurotomy, the National Heart, Lung, and Blood Institute established the Balloon Valvuloplasty Registry in November 1987.
Methods and results:
Between November 1, 1987, and October 31, 1989, 738 patients aged 18 or older underwent percutaneous balloon mitral commissurotomy at the clinical sites. Data were prospectively entered into the registry at the time consent was obtained. Serious complications occurred in 87 procedures, or 12%. Death in the laboratory occurred in eight patients, or 1%. Within 30 days there were 24 cumulative deaths, 18 cardiac and six noncardiac. Univariate analysis revealed that older age, a history of cardiac arrest, cerebrovascular disease, dementia, renal insufficiency, cachexia, class IV congestive heart failure, use of an intra-aortic balloon pump, use of sympathomimetic amines, and a high echo score (greater than or equal to 13) were associated with early death (p less than 0.01). Additional univariate predictors included a precommissurotomy mitral valve area of less than 0.7 cm2. Left atrial pressure greater than 12 mm Hg and a mitral valve area of less than 1.5 cm2 after the procedure were also associated with higher 30-day mortality (p less than 0.05). Multivariate analysis identified higher echo score and smaller valve area before the procedure as the strongest predictors of early death (p less than 0.001). Centers that performed more than 25 procedures also had lower complication rates.
Conclusions:
Although percutaneous balloon mitral commissurotomy appears to be effective at relieving the hemodynamic effects of rheumatic mitral stenosis, it does have risks. In properly selected patients, however, it appears to have low morbidity and 30-day mortality. Individual center experience with the procedure also appears to have great impact on complications.
A new method for the measurement of left atrial pressure in man is described. In 13 patients the interatrial septum was punctured by means of a flexible needle passed through a cardiac catheter which had been introduced from the saphenous vein and positioned with its tip against the fossa ovalis. No complications were observed after the procedures. The advantages of the technique and its present and projected usefulness are discussed.
Clinical trials with the Inoue mitral valvotomy balloon have recently begun in the United States. We assessed the effects of 17 demographic, echocardiographic, procedural, and hemodynamic variables on the immediate results, complications, and short-term follow-up of 200 patients in 15 centers undergoing valvotomy with this device. The study population had a mean age +/- SD of 53 +/- 15 years, and the total echocardiographic score was 7.2 +/- 2.4. Valvotomy was technically successful in 96.5% of procedures and increased the mean mitral valve area from 1.0 +/- 0.3 to 1.8 +/- 0.7 cm2 (p less than 0.001); 72% had an increase in valve area greater than or equal to 50%, and 67% had a final area greater than or equal to 1.5 cm2. Major procedural complications included cardiac tamponade during transseptal puncture (1.0%), systemic embolism (1.5%), and severe mitral regurgitation (2.4%); there were no procedural deaths and one hospital death. Multivariate analysis identified the absence of prior surgical commissurotomy and younger age as significant predictors of the gain in mitral valve area, but the correlation coefficients were low. Although the absence of subvalvular disease on echocardiograms was a predictor of a final valve area greater than or equal to 1.5 cm2, the total echocardiographic score did not correlate well with the immediate outcome (r = 0.01, p = NS). No variable was identified as predictive of restenosis, which occurred according to echocardiographic criteria in 14 of 66 (21%) patients evaluated 6 months after valvotomy. Good hemodynamic results with valvotomy were achieved in the majority of patients with low complication rates by many investigators with the use of the Inoue balloon device.(ABSTRACT TRUNCATED AT 250 WORDS)
In our laboratory, we performed 278 transseptal left heart catheterizations in adult patients over a period of 13 years. The left atrium was entered in 91.4% of the intended left heart catheterizations. Of 252 attempts, the left ventricle was entered in 96.1%. Major complications were aortic puncture (0.7%), pericardial puncture/suspected tamponade (3.2%), systemic arterial embolism (1.1%), and suspected perforation of the inferior vena cava (0.4%). There were no deaths. Although less frequently performed during the last decade, the transseptal catheterization technique has a complication rate of the same magnitude as during periods when this method was more commonly applied.
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.
A new method for the measurement of left atrial pressure in man is described. In 13 patients the interatrial septum was punctured by means of a flexible needle passed through a cardiac catheter which had been introduced from the saphenous vein and positioned with its tip against the fossa ovalis. No complications were observed after the procedures. The advantages of the technique and its present and projected usefulness are discussed.
Because the genesis of atrial fibrillation (AF) is multifactorial and variable, an ablation strategy that involves pulmonary vein isolation and/or a particular set of ablation lines may not be equally effective or efficient in all patients with AF. A tailored strategy that targets initiators and drivers of AF is a possible alternative to a standardized lesion set.
Catheter ablation was performed in 153 consecutive patients (mean age, 56+/-11 years) with symptomatic paroxysmal AF with the use of an 8-mm tip radiofrequency ablation catheter. The esophagus was visualized with barium. The pulmonary veins and left atrium were mapped during spontaneous or induced AF. Arrhythmogenic pulmonary veins were isolated or encircled. If AF was still present or inducible, complex electrograms in the left atrium, coronary sinus, and superior vena cava were targeted for ablation. The end point of ablation was absence of frequent atrial ectopy and spontaneous AF during isoproterenol infusion and noninducibility of AF. Routine energy applications near the esophagus were avoided. During follow-up, left atrial flutter developed in 19% of patients and was still present in 10% at >12 weeks of follow-up. A repeat ablation procedure was performed in 18% of patients. During a mean follow-up of 11+/-4 months, 77% of patients were free from AF and/or atrial flutter without antiarrhythmic drug therapy. Pericardial tamponade or transient neurological events occurred in 2% of procedures.
A tailored ablation strategy that only targets triggers and drivers of AF is feasible and eliminates paroxysmal AF in approximately 80% of patients.