Trans septal Puncture in Cardiology

Trans Septal Puncture (TSP) in Cardiology
Dr Raghu Kishore Galla
Trans Septal Puncture(TSP) in Cardiology

• The left atrium(LA) is the most difficult cardiac chamber to access per
cutaneously.
• Although it can be reached via the left ventricle and mitral valve,
manipulation of catheters that have made two 180° turns is cumbersome.
• The trans septal puncture permits a direct route to the LA via the intra
atrial septum and systemic venous system
• The technique of trans septal puncture was developed to gain access to the
left atrium (LA) for pressure measurement

• Although the Radner technique meant that
the needle could traverse the pulmonary
artery or aorta on its way to the LA, it had a
very good safety record.
• These methods illustrated that the walls of
the cardiac chambers and great vessels
could tolerate passage of a very thin sterile
needle.

• The transseptal puncture was developed by Ross, Braunwald and Morrow at the
National Heart Institute (now the National Heart, Lung, and Blood Institute), Bethseda
in the late 1950s to allow left heart catheterisation, principally for the evaluation of
valvular heart disease.
• Important refinements were made to the needle and catheter such that
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

Ross J Jr. Trans-septal left heart catheterization:
a new method of left atrial puncture.
Ann Surg 1959;149:395– 401.
Dr John Ross

Safety feature was incorporated into the
transseptal equipment when the originalRoss
needle was modified to have the distal 1.5 cm of
the needle of smaller caliber.
The needle has at its hub a direction arrow that
corresponds to the needle curve, necessary when
viewing the needle on fluoroscopy.
The Brockenbrough catheter allows the distal 1.5
cm of the needle to protrude beyond its tip. It distal
side holes for contrast injection.
The Brockenbrough needle can also be used with
the Mullins catheter, which has a more tapered tip
without side holes . It allows the distal 1 cm of the
needle to protrude

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

• Previously the technique was used frequently by interventional cardiologists for
mitral valvuloplasty..
• Explosion of interest in catheter ablation of AF has meant the transseptal
puncture is a routine skill of the modern cardiac electrophysiologist.
• Over the last 25 years, cardiac electrophysiologists have become the most
proficient in performing trans septal puncture and are by far the most common
cardiac subspecialists called upon to effectively and safely puncture the
interatrial septum.

Embryology of inter atrial 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 AV canal,
thereby creating an inferior intera-trial opening known as the ostium primum.
• 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 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.
Embryology of inter atrial septum

Anatomy of the inter atrial septum

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

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!

WE need 3 things
Anatomical
Landmarks
HARDWARE
Imaging Guidance

21
gauge
18
gauge
270° curve
71 cm
67 cm
59 cm

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

• 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

WE need 3 things
ANATOMICAL
LANDMARKS
Hardware
Imaging Guidance

12
9 3
6

12
9 3
6
IAS plane in supine patient
From 2’ to 7’ o clock

12
9 3
6
Normal Fossa ovalis plane
4’ to 6’ o clock

12
9 3
6
Huge LA with Bulging septum –
Fossa ovalis shifts inferiorly and posteriorly
to 7’ or even 8’ o clock

12
9 3
6
Small LA with inward septum –
Fossa ovalis shifts more anteriorly
3’ to 4’ o clock

RAO VIEW

AP VIEW

LATERAL VIEW

WE need 3 things
Anatomical
Landmarks
Hardware
IMAGING
GUIDANCE

IMAGING guidance
• FLUOROSCOPY
• TTE
• TEE
• ICE
• CT
• MRI
• ECG

INUOE Angiographic method
Cath Cardiovasc Diagn. 1993;28:119-25

INUOE Angiographic method
PM=1.2 times vertebral width

HUNG’S MODIFIED METHOD
(no Angio – only aortic root pigtail)

TRANS-SEPTAL PUNCTURE

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.

0.032 wire in
innominate vein

Sheath dilator assembly
in innominate vein
1. Advance sheath + dilator
over 0.032” wire to SVC
2. Advance BRK needle to 1cm
of end of dilator

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

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.

Descent from SVC –
RA
RA – fossa

Imaginary mid-line
(If LA silhouette not visible – Take RA
± PA angiogram for LA)

In the RAO
projection it is vital to keep
the tip of the needle
posterior to the pigtail or
running parallel
to the coronary sinus
catheter to avoid
puncturing the aortic root

Check in RAO
(check needle tip away from Aorta
and CS)

Check in LAO/lateral
(check needle tip away from Aorta and in
inferoposterior third)

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

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

Push assembly/
needle puncture
(If satisfied by anatomical
landmarks and/or pulsation)

Check in AP/RAO view
by angio / pressure / saturation
(If satisfied – advance dilator/sheath)

Transseptal Puncture: Pressure Monitoring
Pressure tracing from the tip of the transseptal needle during a successful puncture of the intra-atrial septum.As the assembly is
pulled down from the SVC to the right atrium and into the fossa ovalis, the pressure tracing gradually dampens and then becomes a
straight line to indicate the dilator is abutting the septum. When the puncture is made (arrow) there is a sudden elevation of pressure
as the needle passes through the septum before a definite left atrium pressure wave is seen.

Giant RA
Small 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

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

TEE Should Make it Safer and Easier than Fluoro Guided
Puncture

TEE Guided TSP
heart.bmj.com on 16 June 2009 Trans Septal Puncture(TSP) in Cardiology

TEE Guided: Tenting Atrial Septum

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.

Thick Atrial Septum

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.

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.

ICE

Radiofrequency Perforation of LA Septum

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

SafeSept trans-septal guidewire
• The “SafeSept” is a trans-septal guidewire designed to easily cross
the IAS 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
because of its rounded J shape.
World J Cardiol 2015 August 26; 7(8): 499-503 ISSN 1949-8462

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

(A) Fixed-curve sheath. (B) Steerable sheath (Agillis). (C) BRK (Brockenbrough) transseptal
needle. (D) SafeSept wire. (E) NRG radiofrequency needle.

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

• Overall Mortality <1%
• MUST LEARN
PERICARDIOCENTASIS
BEFORE SEPTAL
PUNCTURE
• Echo must be readily
available

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

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!

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

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

Aortic root perforation

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

THROMBOEMBOLISM
• A higher than expected incidences of intraoperative thrombus detected on the
transseptal sheath and in the LA during PVI procedures (8% to 11%), PBMV and
MV repair.
• Routinely administer 2,000 to 5,000 U of unfractionated heparin before TSP and a
total of 200 U/kg to achieve an ACT >300 s after obtaining access to the LA.
• Cerebral protection with bilateral carotid filters can be used in patients undergoing
TSP who are at higher risk for stroke (e.g., those with LAA thrombus or dense
spontaneous echocardiographic contrast).
• If detected on TEE or ICE, intracardiac thrombus can be effectively removed with
vigorous aspiration

THROMBOEMBOLISM
(A, B) Thrombus on the transseptal sheath in the right atrium detected on transesophageal echocardiography (arrow). (C, D) Large
thrombus formed on the transseptal sheath in the LA detected on intracardiac echocardiography.

AIR EMBOLISM
• Air embolism is often a clinically silent event because of its transient nature and
the procedural sedation.
• Coronary ischemia, stroke, hypotension, and cardiac arrest have been reported
• Air emboli may enter the LA because of accidental injection of air or inadequate
de-airing of the system.
• Prompt interventions including volume loading, oxygenation, lidocaine, manual
thrombectomy, vasopressors, and hyperbaric oxygen can be effective in treating
patients with large air emboli and those with dramatic symptoms.

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

IATROGENIC ATRIAL SEPTAL DEFECT
• Not uncommon, especially when large-bore
transseptal sheaths are used.
• Possible detrimental effects (hypoxemia,
heart failure, and systemic embolization) in
some patients
• Systematic surveillance with serial
echocardiography following large-bore access
into the LA might be necessary,
• Elective closure of the iatrogenic septal defect
should be considered in selected patients

Rare complications
• Vena cava perforation
• Coronary artery dissection
• Detachment of the tip of the transseptal sheath
• Acute pericarditis

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

Emerging techniques requiring TSP

TS catheterization in electrophysiology (EP)
• The cardiac subspecialty of EP accounts for the single most common context in
which TS punctures are performed
• Interest in the refinement and perfection of the TS technique has paralleled the
dramatic increase in the number of ablative procedures performed AF in the last
10 years
• In addition to RF ablation of AF, TSP is routine for
- accessory pathways along the mitral annular region
- LA tachycardias and flutters
- variants of AVNRT.

• The TSP is also a useful alternative to the
retroaortic approach for ablation within the left
ventricle and left ventricular outflow tract.
• In most centers, TS puncture is performed
under fluoroscopic biplanar guidance .
• a diagnostic catheter in the coronary sinus aids
in the localization of the fossa ovalis.

Fluoroscopic images demonstrating the correct positioning of the TS assembly on the FO using a decapolar coronary sinus
(CS) catheter as an anatomical guide. The proximal poles of the catheter have been positioned at the os of the CS. A second
sheath is also visible in the RA. In the LAO projection the needle is pointing medially and is superior to the CS os. In the RAO
projection it can be appreciated that the needle is posterior to the CS os and runs approximately parallel to the decapolar
catheter. By confirming this position inadvertent puncture of the aortic root is avoided.

• Often, EP procedures require 2 or more sheaths across the fossa ovalis.
• This can be accomplished by 2 separate TS punctures or a single pass with the
Brockenbrough needle.
• The initial sheath, which is already across the atrial septum, can be withdrawn into
the RA over a guidewire in the LA.
• A second sheath or ablation catheter can then pass through the previously created
rent in the septum. The initial sheath is then reinserted over the guidewire.
• On occasion, patients require repeat TS procedures for AF ablation

(a) A RAO projection where the first transseptal sheath (with circular mapping catheter) can be visualized in the LA. The second
transseptal needle/dilator apparatus can be seen engaging the IAS in a more anterior position (slightly to the right of the spine) in
anticipation of the second transseptal puncture. The ICE catheter can be seen in the body of the RA (overlying the spine) with
slightly posterior tilt to bring the IAS into view. A duodecapolar catheter is positioned in the coronary sinus. (B) A corresponding
left anterior oblique (LAO) projection is shown after the second transseptal sheath has been position in the LA.

• If previous punctures have been performed, the fossa ovalis can become thickened
and fibrotic.
• This can obscure the physical landmarks, prevent the characteristic leftward
movement of the TS needle into the fossa, and require significant forward pressure
for puncture with the needle.
• In this situation and in the case of prior aortic root surgery adjuncts to fluoroscopic
visualization, such as intracardiac or TEE, are most useful.

Transcatheter mitral valve repair
• Percutaneous edge-to-edge mitral valve repair
using the MitraClip device (Abbott Vascular, Santa
Clara, California) demonstrated superior safety and
similar improvement in clinical outcomes compared
with conventional surgery in patients with severe
degenerative MR who are at high risk for surgery.
• The MitraClip device has been used in more than
30,000 patients worldwide for both functional and
degenerative MR.

Transcatheter mitral valve-in-valve therapy
• Initial results with transcatheter transseptal
mitral valve-in-valve implantation are
promising.
• If this therapy is proved durable, it would
provide an excellent alternative to re-
operation for patients with failed mitral bio
prostheses.

Transcatheter mitral valve implantation
• Several dedicated transcatheter
mitral valve systems are in the early
phase of development.
• The CardiAQ valve (CardiAQ, Irvine,
California) is currently the only trans
catheter mitral valve with a trans
femoral transseptal delivery system
under testing

Mitral paravalvular leak (PVL) repair
• PVL occurs in 5% to 17% of patients after valve
replacement surgery.
• Repeat surgery has been the traditional
treatment for PVL, but it is associated with high
operative mortality and variable results.
• Percutaneous repair of mitral PVL using a
transseptal route is an effective alternative to
surgery, with feasibility and efficacy
demonstrated in multiple studies

Mitral valve interventions
• Proper guiding catheter position is the most important initial step of the MitraClip
procedure. Targeted TSP facilitates suitable guide position and allows the clip to
reach the middle of the mitral orifice.
• A suboptimal TSP site may result in inadequate treatment of MR .
• For central MR jets, the operator aims for a posterior and slightly superior TSP.
• Higher TSP heights are needed for more medial jets, while lower transseptal sites
are more appropriate when lateral jets are targeted.
• The position of the TSP for mitral PVL closure requires similar forethoughts.

Mitral valve interventions
• For defects away from the IAS, the location of the puncture is less
critical.
• However, for medial defects, a posterior and slightly superior puncture
provides the appropriate working height within the LA and allows readily
access to the defect.
• In PBMV and transseptal mitral valve-in-valve implantations, a
midposterior puncture is usually adequate and provides a favorable
working height in the LA and a coaxial plane with the MV.

• The efficacy of PVI in treating drug-refractory
AF has been established, with more than 15
years of clinical studies.
• This indication has accounted for most of the
growth in the use of TSP in the past 2 decades.
• Ensuring adequate reach of the radiofrequency
(RF) or cryoballoon (CB) catheter is essential to
achieve successful ablation, especially when
addressing right-sided veins
Pulmonary Vein Isolation(PVI)

Pulmonary Vein Isolation(PVI)
• In RF ablation, some experts prefer a relatively anterior crossing of the IAS to allow
adequate room for deflectable sheaths and catheters.
• Others suggest that a posterior TSP allows better angling of the ablation catheters
toward the PVs.
• In CB ablation, the CB catheter uses the anterior balloon surface to push against the
atrial tissue around the PV ostium.
• Therefore, a more anterior crossing of the IAS provides the most favorable approach
for accessing all PVs with the CB, particularly the right inferior PV.

LA appendage(LAA) closure
• Percutaneous occlusion of the LAA is equivalent
to warfarin in preventing stroke in patients with
nonvalvular AF and is associated with a lower
bleeding risk.
• Percutaneous LAA closure can be achieved with a
transseptal approach with the Watchman device
(Boston Scientific, Marlborough, Massachusetts)
and the Amplatzer Cardiac Plug (St. Jude
Medical, St. Paul, Minnesota),
• an epicardial approach with the Aegis system
(Aegis Medical, Vancouver, British Columbia,
Canada), or a hybrid approach with the LARIAT
system (SentreHEART, Palo Alto, California).
• The Watchman device is the only LAA occluder to
receive approval in the United States.

LA appendage(LAA) closure
• The long axis of the LAA is oriented anteriorly, and the plane of the LAA ostium is
perpendicular to that axis.
• Successful coaxial device deployment depends on the ability to position the
delivery sheath with sufficient depth into the LAA.
• This is best accomplished with a posterior-anterior trajectory of the sheath.
Therefore, a posterior TSP provides the most favorable sheath orientation
• For the Watchman device and the Amplatzer Cardiac Plug, midseptal to slightly
inferior TSP is ideal.
• For the LARIAT device, a more superior location has been suggested.
• A TSP that is too superior or too anterior can make it difficult to align the sheath
with the long axis of the LAA and poses a challenge to device delivery, especially
with retroverted LAAs Trans Septal Puncture(TSP) in Cardiology

Percutaneous LV assist Devices
• Percutaneous left ventricular assist devices such as
the TandemHeart (Cardiac Assist, Pittsburgh, Penn -
sylvania) can be used to support patients in
cardiogenic shock or as a temporary application
during high-risk coronary intervention.
• Another form of percutaneous LV assist device is
transseptal ECMO
• This technique is applied in patients with persistent
pulmonary edema despite traditional venoarterial
extracorporeal membrane oxygenation.

Percutaneous LV assist Devices
• In these cases, a “venting” cannula is placed in LA through a TSP and is
incorporated into the extracorporeal membrane oxygenation circuit using
a Y connection
• Mid-FO access for central transseptal catheter positioning allows more
room in the left atrium and reduces the likelihood of device malfunction
because of cannula–LA wall contact.

Different sites of TSP
• Mitra clip or paravalvular leak closure
• Trans septal PFO closure
•Percutaneous LV assist device placement
• LAA closure
• Pulmonary vein interventions

DIFFICULT TSP

DIFFICULTY WITH ACCESS TO THE RIGHT ATRIUM
• Sometimes obtaining a TSP through RFV access is challenging or not
possible
• Extreme venous tortuosity - the transseptal sheath can be exchanged with
a long (45-cm) sheath that is 2 F larger in diameter
• Attempting to the needle in a kinked sheath can result in perforation of
the sheath
• A secondary bend in the transseptal needle 2 to 3 cm proximal to the
primary bend provides adequate reach and allows a targeted TSP

DIFFICULTY WITH ACCESS TO THE RIGHT ATRIUM
• Presence of an IVC filter does not preclude successful execution of the procedure,
even when large sheaths and cannulas must be advanced through the filter
• Iliofemoral veins and/or the IVC are patent but have severe stenosis, percutaneous
revascularization may be considered to allow access
• Alternative access should be considered - Left FV and right IJV access has been
successfully used to perform catheter ablation of AF and BMV .
• Transapical access is the alternative access of choice. On rare occasions, direct
right atrial access can be used as a last resort

DIFFICULTY WITH ENGAGEMENT OF THE FO
• Severe kyphoscoliosis
• Abnormally rotated heart due to ventricular hypertrophy or prior surgery
• Enlarged left or right atrium
• dilated ascending aorta
• excessive cardiac motion with respiration
Can overcome by…
• using a large-curved transseptal needle
• manually adding a secondary bend to the transseptal needle
• using adjunctive real-time imaging guidance

DIFFICULTY WITH NEEDLE ADVANCEMENT
Thickened septum…
• 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
Can overcome by….
• 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
• using an RF transseptal needle
• Adjunctive imaging with ICE

Prior septal occluder
• In case of a prior septal occluder device, transseptal access can be obtained in
portions of the native IAS in the majority of cases.
• Direct transoccluder puncture is rarely necessary but has been reported .
• In patients with surgically repaired IAS, puncture can be performed through
neighboring native IAS tissue or through the patch itself in case of a pericardial or
Dacron patch, but not in case of a Gore-Tex patch because of its resistant texture

DIFFICULTY WITH SHEATH AND GUIDE ADVANCEMENT.
• Even if the transseptal needle is able to cross the IAS, significant difficulty may be
encountered with advancing the sheath across the FO
• Particularly a problem with braided or steerable sheaths because of the “step” in
size between the dilator and the sheath.
• Forceful advancement of the transseptal apparatus can reduce fine control and
potentially lead to atrial perforation.
Can overcome by…
• Redirecting the sheath and dilator apparatus with careful clockwise or counter
clockwise torsion often allows the apparatus to penetrate the resistant IAS.

DIFFICULTY WITH SHEATH AND GUIDE ADVANCEMENT.
• This is best done over a SafeSept or a coronary wire to avoid perforating the left
atrium.
• Alternatively, lower profile sheath-dilator combinations (e.g., SR0, Mullins) may be
used to further dilate the FO.
• Finally, balloon septostomy may be needed to adequately dilate the FO.
• Balloon septostomy is often required in transseptal interventions that use large-
bore sheaths (e.g., mitral valve-in-valve)

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

THANK YOU

Trans septal Puncture in Cardiology

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