Trans-septal puncture for EP procedures

1. How To Perform
Transseptal Puncture
Alireza Ghorbani Sharif, MD
Electrophysiologist
Tehran arrhythmia Clinic
Sep 2016

2. TSP (Trasseptal Puncture)
• The left atrium (LA) is the most difficult cardiac
chamber to access percutaneously.
• It can be reached via the left ventricle and mitral
valve manipulation of catheters that have made
two180 turns is cumbersome.
• The transseptal puncture permits a direct route to
the LA via the interatrial septum and systemic
venous system.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

3. History
• Access to the left atrium via the transseptal
approach was originally developed by Drs. Andrew
Morrow, Eugene Braunwald, and John Ross, Jr. in
the 1950s primarily for assessing intracardiac
hemodynamics.
• As time evolved, the procedure was required less
for assessing hemodynamics but rather as a
means to gain for therapeutic procedures such as
mitral valvuloplasty, placement of assist devices
and radiofrequency ablation.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

4. History
• Bethseda in the late 1950s to allow left heart
catheterization principally for the evaluation of valvular
heart disease.
• Brockenbrough’s description of the technique in 1962
differs little from that used now.
• Mullins developed a combined catheter and dilator set
designed precisely to fit over the Brockenbrough
needle, which gives a smooth taper from the tip of the
needle, over the dilator to the shaft of the sheath.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

5. History
• Pediatric and adult patients with pulmonary arterial
hypertension (PAH) have certain similarities.
• Patients with idiopathic PAH who have a patent FO
(Fossa Ovalis ) survive longer than those who do not.
• Furthermore, patients who have Eisenmenger syndrome
live longer and develop heart failure less frequently than
patients with idiopathic PAH or secondary pulmonary
hypertension.

6. History
• In 1966, William Rashkind, an American pediatric
cardiologist at the Children’s Hospital of
Philadelphia, invented the lifesaving procedure that
bears his name.
• Atrial Septostomy (AS), or Rashkind Septostomy, is
an endovascular intervention that maintains this
vitally important opening between the right and left
atria until definitive surgery is performed.

7. William Rashkind

8. Introduction
• A technique for producing an atrial septal
defect without thoracotomy or anesthesia. It
can be performed rapidly in any cardiac
catheterization laboratory.
• (William J. Rashkind, 1966)

9. Indications in Congenital Heart Disease
• In addition to infants with cyanotic heart disease,
specifically transposition of the great arteries, AS is
currently recommended for patients with specific
criteria that can be considered palliative or bridging.
1. Severe PAH and intractable right heart failure despite maximal medical
therapy, including optimized PAH specific agents and inotropes.
2. Palliation with restoration and maintenance of clinical stability until lung
transplantation can be performed
3. When no other option exists, for example in regions where modern PAH
medical therapy is not available due to technical difficulty or cost.

10. Indications
• PTMC
• Transseptal access is widely used for ablation:
– Left Accessory Pathway
– Ventricular Tachycardia
• Huge increase in its use is due to AF cases
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

11. TSP
• Previously the technique was used infrequently
by cardiologists for mitral valvuloplasty and
ablation in the left heart.
• Explosion of interest in catheter ablation of atrial
fibrillation (AF) has meant the transseptal
puncture is a routine skill of the modern cardiac
electrophysiologist.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

12. Introduction
• Over the last 15 years, cardiac electrophysiologists
have become the most proficient in performing
transseptal puncture and are by far the most
common cardiac subspecialists called upon to
effectively and safely puncture the interatrial
septum.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

13. TSP
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

14. Avoiding Complications
Know the 3-D relational anatomy
Know the imaging: Fluoro and Echo
Know the equipment
Fastidious Technique
Anticipate complications

15. Embryology of the interatrial septum
• The primitive sinuatrium is separated into right
and left atria by the downward growth of the
septum primum from the roof of the sinuatrium
toward the atrioven-tricular (AV) canal, thereby
creating an inferior intera-trial opening known as
the ostium primum.
The Journal of Innovations in Cardiac Rhythm Management, October 2013

16. Embryology of the interatrial septum
• Soon after, numerous perforations form in the
anterior–superior portion of the septum primum,
eventually coalescing to form the ostium secundum.
• The septum secundum begins to develop to the right
of the septum primum and eventually leads to
complete separation of the left and right atria with the
exception of a small central opening the Fossa Ovalis
(FO).
The Journal of Innovations in Cardiac Rhythm Management, October 2013

17. Embryology of the interatrial septum
• The area of fusion of the muscular septum secundum
and the thinner portion of the septum primum is
known as the limbus which forms a raised margin
around the superior aspect of the FO.
• The FO is covered by thin, fibrous tissue from the
septum primum forming the valve of the foramen
ovale.
The Journal of Innovations in Cardiac Rhythm Management, October 2013

18. Anatomy of the Interatrial Septum
• The FO usually located posteriorly at the junction
of the mid- and lower third of the right atrium has
traditionally been the targeted site for (TSP) given
the relatively thin tissue overlying this region which
facilitates needle puncture and advancement of the
transseptal dilator and sheath apparatus across the
atrial septum.
The Journal of Innovations in Cardiac Rhythm Management, October 2013

19. The Journal of Innovations in Cardiac Rhythm Management, October 2013
Anatomy of the Interatrial Septum

20. Anatomy of the Interatrial Septum

21. Equipments & Technique

22. Brockenbrough Needle and Mullins Sheath

23. Brockenbrough Needle and Mullins Sheath

24. BRK-1 may be easier for flat septum, normal size LA
BRK may be better for curved LA septum eg mitral stenosis
You can bend the needle to alter the curve

25. Transseptal Procedure
• The placement of electrophysiology catheters in
the coronary sinus and at the His position can
demarcate important anatomic landmarks. The
use of the His catheter is based on the premise
that the location of the His bundle electrogram
marks the most caudal aspect of the aorta.
• A pigtail catheter can also be introduced into the
aortic root to directly identify the aorta, although
this requires arterial access.
The Journal of Innovations in Cardiac Rhythm Management, October 2013

26. Proper position: RAO and LAO

27. Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

28. Transseptal Procedure Steps
1. Prepare equipment. Sheath, dilator, BRK needle.
2. Introduce sheath/dilator into SVC over 0.032” wire.
3. Position BRK needle inside assembly.
4. Drag assembly into RA in PA view, it will move
medially to the left and engage the Fossa Ovalis.
5. Confirm correct position in RAO (ant-post: needle
should be post to pigtail in aorta parallel with spine.

29. TSP Points
• Withdrawing the transseptal sheath/dilator/needle
assembly from the superior vena cava (SVC) into the
RA in the left anterior oblique (LAO) view.
• Two distinct jumps of the assembly
should be visible:
– First marking passage of the sheath/dilator/needle from the
SVC into the RA.
– Second marking passage of the assembly over the muscular
limbus and into the FO.
The Journal of Innovations in Cardiac Rhythm Management, October 2013

30. TSP Points
• For the puncture the needle should be held in the
fingers of the right hand with the left hand holding the
sheath and dilator controlling movement of the whole
assembly.
• With the x ray positioned at 30 left anterior oblique
(LAO) the sheath and catheter are rotated so that both
are pointing approximately to the 4–5 o’clock position.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

31. Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

32. 6. Confirm in LAO: needle should be directed posterior.
7. Advance needle into LA. Confirm by pressure, LA
injection of contrast by fluoroscopy.
8. Advance sheath/dilator into LA. Careful about tenting
septum and not pushing needle too far into LA.
9. Remove dilator and needle.
Transseptal Procedure Steps

33. Transseptal Puncture:
Pressure Monitoring
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

34. Steps for TS Puncture
1. Advance sheath + dilator over 0.032” wire to SVC
2. Advance BRK needle to 1cm of end of dilator

35. Steps for TS Puncture
3. Withdraw the TS catheter in PA view until it moves medially.
The catheter is rotated posteriorly at 4-6 o’clock.

36. Steps for TS Puncture
3. Withdraw the TS catheter in PA view until it moves medially
PA or mild LAO RAO

37. Staining the inter-atrial septum in LAO

38. Advancing the needle across the foramen ovale

40. Challenging Anatomy
Severe LA or RA Enlargement
Aortic Root Aneurysm
Kyphoscoliosis
Atrial Septal Aneurysm
Thick Atrial Septum
Pacing wires
Repeat Procedures

41. ICE & TEE
• The use of Intra-Cardiac Echocardiography (ICE)
can also facilitate double TSP when the use of
multiple sheaths in the LA is required.
• Both Transesophageal Echocardiography (TEE)
and ICE can accomplish these goals, ICE has the
additional advantages of not requiring a second
operator or general anesthesia.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

42. ICE
• Steerable and deflectable ICE 8F and 10F
diagnostic ultrasound catheter :
– 64-element vector phased-array transducer (5.5-10 MHz)
with full Doppler capabilities including color Doppler, tissue
Doppler and spectral Doppler.
– Biplane fluoroscopy is recommended to safely advance the
catheter to the desired position.

43. TEE Should Make it Safer and Easier than
Fluoro Guided Puncture

44. TEE Guided TSP
heart.bmj.com on 16 June 2009

45. TEE Guided: Tenting Atrial Septum

46. Sheath enters LA and tents or pulls the septum, then “pops” through.
You have to be well inside the LA with the sheath, or the sheath may
spring back into the RA when you remove the dilator or guidewire.

47. Thick Atrial Septum

48. ICE
• Intracardiac echocardiography in preventing
serious or even fatal complications in transseptal
procedures when the cardiac anatomy is unusual
or distorted. It also helps to understand the
possible mechanisms of mechanical complications
in cases where fluoroscopic images are apparently
normal.

49. ICE

50. Aneurysmal Atrial Septum

51. Aneurysmal Atrial Septum

52. Thick Atrial Septum

53. Thick Atrial Septum

54. Radiofrequency Perforation of LA
Septum

55. Radiofrequency Perforation of LA
Septum
• 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
puncture and in the presence of anatomical
atrial septum abnormalities.

56. Radiofrequency Perforation of LA
Septum
• Radiofrequency current delivery to the fossa
ovalis through the TS needle in the presence or
absence of manifest atrial septum abnormalities
facilitated TS puncture in patients with difficult
standard puncture.

57. Alternate Techniques
• Application of Bovie electrocautery
at hub of BRK
• Puncture septum with stiff end
of 0.014 guidewire
• SafeSept Guidewire

58. SafeSept trans-septal guidewire
• The “SafeSept” is a trans-septal guidewire
designed to easily cross the interatrial septum
through the trans-septal needle thanks to a special
sharp tip that allows it to penetrate the fossa ovalis
without the use of a particular hard contact.
• SafeSept is non-traumatic when advanced into the
left atrium thanks to its rounded J shape.
World J Cardiol 2015 August 26; 7(8): 499-503 ISSN 1949-8462

59. SafeSept trans-septal guidewire
World J Cardiol 2015 August 26; 7(8): 499-503 ISSN 1949-8462

60. SafeSept trans-septal guidewire
World J Cardiol 2015 August 26; 7(8): 499-503 ISSN 1949-8462

61. Complications of TSP
Pericardial Effusion Tamponade
RA and LA needle puncture
Aortic Puncture/Perforation
Death
Air Embolism or TIA
Transient ST Elevation
Persistent ASD

62. Complications of Transseptal Puncture
De Ponti et al. JACC 2006;47:1037-1042
Italian Multicenter Survey: 5520 procedures over 12 years

63. Pericardial Tamponade
Reverse Anticoagulation
Heparin: Protamine Coumadin:
FFP
Pericardiocentesis and placement of
pericardial drain

64. Transient ST Elevation
• Transient ST elevation in the inferior ECG leads with
or without chest pain has been reported in 0.6% of
cases.
• It has been proposed this is a vagal response to the
direct mechanical disruption of the autonomic
network of the heart by the catheter during the
puncture or alternative explanation is a coronary air
embolism which may occur by not paying rigorous
attention to delaying the assembly.

65. Persistence ASD
• The presence of a patent Foramen Ovalis with right
to left shunting is associated with stroke and
migraine. It is a concern that a persistent iatrogenic
hole in the atrial septum following AF ablation may
carry the same risks, although large prospective
studies to measure this risk have not been done.

66. Persistence ASD
• In a study that performed a TEE 9 months
post-AF ablation, eight (30%) of 27 patients
who had two catheters through a single
transseptal puncture had an iatrogenic
ASD compared with none of 15 patients
who had two separate punctures.

67. RA Needle Perforation
Operator Reported “Atrial Stitch”

68. Aortic Root Perforation

69. Aortic Root Perforation

70. Aortic Root Perforation

71. Aortic Root Perforation

72. Aortic Root Perforation

73. Transcatheter Repair of Aortic Perforation
Webber MR et al. J Invasive Cardiol 2013 May;25(5):E10-13

74. Conclusion:
• The transseptal puncture is a core technique for a
cardiac electrophysiologist and training should be
at a center that performs large numbers of
procedures.
• In experienced hands it is a safe procedure
however in institutions that perform limited
numbers of cases routine use of ICE may ensure
virtually no complications.
Heart 2009;95:85–92. doi:10.1136/hrt.2007.135939

75. Conclusion:
1.Understand the Anatomy
2.Know the Fluoroscopic Landmarks
3.Use TEE or ICE
4.Be Prepared to Deal With Challenging
Anatomy
5.Be Prepared to Deal with Complications

76. Tehran Arrhythmia Center
www.IranEP.org
info@IranEP.org