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Trans septal puncture

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Trans interatrial septal puncture technique under fluoroscopy guidance - basics and beyond

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Trans septal puncture

  1. 1. TRANS-SEPTAL PUNCTURE SATYAM RAJVANSHI
  2. 2. Dr John Ross Ross J Jr. Trans-septal left heart catheterization: a new method of left atrial puncture. Ann Surg 1959;149:395– 401.
  3. 3. EVOLVING INDICATIONS FOR TRANS-SEPTAL CATHETERIZATION • BMV • Edge-to-edge MV repair • PFO/ASD closure • Antegrade BAV • LAA occlusion • Paravalvular leak closure • Percutaneous LVAD (Tandem Heart)
  4. 4. EVOLVING INDICATIONS FOR TRANS-SEPTAL CATHETERIZATION • BMV • Edge-to-edge MV repair • PFO/ASD closure • Antegrade BAV • LAA occlusion • Paravalvular leak closure • Percutaneous LVAD (Tandem Heart) • EP – LA and LV arrhythmias • Dilation/Stenting of PV stenosis (post-ablation)
  5. 5. EVOLVING INDICATIONS FOR TRANS-SEPTAL CATHETERIZATION • BMV • Edge-to-edge MV repair • PFO/ASD closure • Antegrade BAV • LAA occlusion • Paravalvular leak closure • Percutaneous LVAD (Tandem Heart) • EP – LA and LV arrhythmias • Dilation/Stenting of PV stenosis (post-ablation) • Left heart hemodynamics • Rarely Aortic stent grafts • Historically Transeptal TAVI
  6. 6. CONTRAINDICATIONS • Absolute! LA cavity or septal thrombus/tumour
  7. 7. CONTRAINDICATIONS • Absolute! LA cavity or septal thrombus/tumour • Relative • Distorted anatomy – heart/thorax/spine • Huge LA/RA enlargement • Enlarged aortic root • Interrupted IVC • Post ASD patch repair Experts can find a way around!
  8. 8. WE NEED 3 THINGS Anatomical Landmarks Hardware Imaging Guidance
  9. 9. WE NEED 3 THINGS Anatomical Landmarks HARDWARE Imaging Guidance
  10. 10. 21 gauge 18 gauge 270° curve 71 cm 67 cm 59 cm
  11. 11. MULLINS SHEATH AND DILATOR SYSTEM (Medtronic Inc.) Size Sheath length Dilator length Wire size max. ADULT 8 Fr +/- hemostatic valve 59 cm 67 cm .032 in PEDIATRIC 8 Fr 44 cm 52 cm .025 in 6 Fr 44 cm 52 cm .025 in BROCKENBROUGH NEEDLE (Medtronic Inc.) Shaft Size Tip Size Length ADULT 18 gauge 21 gauge 71 cm PEDIATRIC 19 gauge 22 gauge 56 cm
  12. 12. WE NEED 3 THINGS ANATOMICAL LANDMARKS Hardware Imaging Guidance
  13. 13. 12 9 3 6
  14. 14. 12 9 3 6 IAS plane in supine patient From 2’ to 7’ o clock
  15. 15. 12 9 3 6 Normal Fossa ovalis plane 4’ to 6’ o clock
  16. 16. 12 9 3 6
  17. 17. 1 2 9 3 6 Huge LA with Bulging septum – Fossa ovalis shifts inferiorly and posteriorly to 7’ or even 8’ o clock
  18. 18. 1 2 9 3 6 Small LA with inward septum – Fossa ovalis shifts more anteriorly 3’ to 4’ o clock
  19. 19. RAO
  20. 20. AP
  21. 21. LAT
  22. 22. WE NEED 3 THINGS Anatomical Landmarks Hardware IMAGING GUIDANCE
  23. 23. IMAGING GUIDANCE • FLUOROSCOPY • TTE • TEE • ICE • CT • MRI • ECG
  24. 24. INUOE ANGIOGRAPHIC METHOD Cath Cardiovasc Diagn. 1993;28:119-25.
  25. 25. INUOE ANGIOGRAPHIC METHOD Cath Cardiovasc Diagn. 1993;28:119-25.
  26. 26. INUOE ANGIOGRAPHIC METHOD Cath Cardiovasc Diagn. 1993;28:119-25. PM=1.2 times vertebral width
  27. 27. HUNG’S MODIFIED METHOD (no Angio – only aortic root pigtail) Cath Cardiovasc Diagn. 1992;26:275-84.
  28. 28. Cath Cardiovasc Diagn. 1992;26:275-84. HUNG’S MODIFIED METHOD (no Angio – only aortic root pigtail)
  29. 29. TRANS-SEPTAL PUNCTURE
  30. 30. 0.032 WIRE IN INNOMINATE VEIN
  31. 31. SHEATH DILATOR ASSEMBLY IN INNOMINATE VEIN
  32. 32. TRACKING BROCKENBROUGH NEEDLE WITH TIP JUST INSIDE DILATOR
  33. 33. DESCENT FROM SVC – RA RA – FOSSA
  34. 34. IMAGINARY MID-LINE (If LA silhouette not visible – Take RA ± PA angiogram for LA)
  35. 35. CHECK IN RAO (check needle tip away from Aorta and CS)
  36. 36. CHECK IN LAO/LATERAL (check needle tip away from Aorta and in inferoposterior third)
  37. 37. PUSH ASSEMBLY/ NEEDLE PUNCTURE (If satisfied by anatomical landmarks and/or pulsation)
  38. 38. CHECK IN AP/RAO VIEW BY ANGIO / PRESSURE / SATURATION (If SATISFIED – advance dilator/sheath)
  39. 39. LA WIRE ENTRY
  40. 40. SPECIAL SITUATIONS
  41. 41. Giant RASmall LA Normal LA Septal bulge Giant RA Forceful torque to middle of IAS Enlarged LA 6’ or 7’o clock Enlarged RA Bend the needle No jumps/pulsation Anatomic landmarks
  42. 42. PROCEDURE SPECIFIC PUNCTURE SITE
  43. 43. OTHER APPROACHES/TECHNIQUES • Left Femoral • Transjugular (LA-crosse system) • Transhepatic • TTE/TEE/ICE guidance • Safe-sept wire • Electrocautery • RFA (Toronto RF catheter) • Laser
  44. 44. COMPLICATIONS
  45. 45. • Overall Mortality <1% • MUST LEARN PERICARDIOCENTASIS BEFORE SEPTAL PUNCTURE • Echo must be readily available
  46. 46. STITCH PHENOMENA In large LA - no septum beyond or near the right lateral and inferior border of LA - Overlapping walls of RA and LA form this region - If this region punctured - both RA and LA get involved in effusion! (Puncture- RA free wall - PERICARDIAL SPACE – LA lateral wall) Needs emergency surgery! Case report of injecting cyanoacrylate glue in the perforation site Indian Heart Journal 2004:56;328-332
  47. 47. THINK BEFORE PULLING OUT! After septal puncture – always wait for 2 minutes, watch hemodynamics/echo, then give heparin MANAGEMENT OF STITCH/EFFUSION Only a needle puncture-wait and watch.defer the procedure and repeat echo in regular intervals If effusion is small and Balloon in left atrium - do BMV as reduction in LA pressure will decreases the leak If septum is dilated, don’t remove the dilator - Pigtail insertion and SHIFT TO CTVS with dilator in situ Reverse Heparin (1 mg protamine per 100 U of UFH) Autotransfusion
  48. 48. AORTIC ROOT STAIN • Abandon procedure • Observe for hemodynamics/effusion • Only a needle puncture - wait and watch.defer the procedure and repeat echo in regular intervals
  49. 49. HOW TO SUCCESSFULLY PUNCTURE SEPTUM The take-home points
  50. 50. FAMILIARISE WELL WITH HARDWARE
  51. 51. RAO LAT AP FAMILIARISE WELL WITH ANATOMY
  52. 52. BE WATCHFUL FOR COMPLICATIONS

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