TUTORIAL
A Safe, Simple Technique for Transseptal Catheterization MICHAEL C. GIUDICI, M.D., STEVEN R. MICKELSEN, M.D., PRASHANT D. BHAVE, M.D., ROQUE B. ARTEAGA, M.D., and OMER J. IQBAL, M.D. From the Division of Cardiology, University of Iowa Hospitals, Iowa City, Iowa
Transseptal catheterization is required for atrial fibrillation ablation and many ablations for atrial tachycardias, left atrial flutters, and accessory pathways. Using a Brockenbrough needle or other specialized device adds time, expense, and risk of potential complications such as atrial or aortic perforation, pericardial effusion, and tamponade to these procedures. We present a simple, low-risk technique for transseptal catheterization. (PACE 2015; 00:1–2) ablation, transseptal catheterization
Background Transseptal catheterization is required for atrial fibrillation ablation and many ablations for atrial tachycardias, left atrial flutters, and accessory pathways. Using a Brockenbrough needle or other specialized device adds time, expense, and risk of potential complications such as atrial or aortic perforation, pericardial effusion, and tamponade to these procedures. For many years, we have been using a unique method of transseptal catheterization, which we have found to be simple, safe, and cost-effective. We describe the procedural technique. Methods We begin by placing a standard SL1 Sheath (St. Jude Medical, St. Paul, MN, USA) over the 0.032 J-tipped guidewire included with the sheath into the superior vena cava from a right femoral venous approach. With fluoroscopy in the 45° left anterior oblique view, and guided by intracardiac ultrasound (ICE), the sheath is directed toward the interatrial septum and brought down the septum from the superior vena cava with the guidewire pulled back from the tip of the introducer. When the tip of the introducer has reached the fossa ovalis and tenting is seen on ultrasound (Figs. 1 and 2), the catheter is advanced slightly to stretch the atrial septal tissue over the tip of the introducer. At that point the Address for reprints: Michael C. Giudici, M.D., F.H.R.S., University of Iowa Hospitals, 200 Hawkins Drive, 4426JCP, Iowa City, IA 52242. Fax: 319-384-6247; e-mail: [email protected] Received October 7, 2014; revised December 3, 2014; accepted December 10, 2014. doi: 10.1111/pace.12576
guidewire is advanced, tapping on the interatrial septum until it pushes through the septum into the left atrium. The wire is advanced to the left superior pulmonary vein (LSPV) under ICE and fluoroscopic guidance (Fig. 3). The sheath is then advanced over the wire, which has been directed into the LSPV and the sheath is brought back and forth across the septum to dilate the opening. For ablation using a larger sheath such as the Arctic Front cryoballoon or the Ablation Frontiers catheter system (both Medtronic, Inc., Minneapolis, MN, USA), the SL1 sheath is left temporarily in the left atrium and the SL1 guidewire is exchanged for an Amplatz wire (0.032 J-wire), which is usually advanced into the LSPV (for more technically challenging septae, the Amplatz wire may be placed in the right superior pulmonary vein) and then the SL1 is exchanged for the larger deflectable sheath. For physicians who do not use ICE guidance for transeptal catheterization, this method is still applicable. Simply maneuver the SL1 sheath to the fossa ovalis, remove the guidewire, confirm with a puff of contrast, and reinsert and advance the 0.032 J-wire as above. Similarly, we have also performed this guidewire-only technique with Agilis (St. Jude Medical) and Bard Channel (Bard Medical, Covington, GA, USA) sheaths. Results Using this technique, we have been able to perform transseptal catheterization in less than 10 minutes and without other equipment in 99 of 100 consecutive patients (55 male/45 female, mean age 59.7 years, range 32–85 years) who were undergoing transeptal catheterization for ablation of atrial fibrillation, left atrial flutter, focal left
© 2015 Wiley Periodicals, Inc. PACE, Vol. 00
2015
1
GIUDICI, ET AL.
Figure 1. Left anterior oblique view of the SL1 sheath in the fossa ovalis.
Figure 3. Left anterior oblique view with the guidewire directed into the left superior pulmonary vein.
wire-only technique for many reasons. There is a cost savings of at least $160–200 per patient by not using a Brockenbrough needle, SAFESEPT wire (Pressure Products, San Pedro, CA, USA), or other specialized tool. There is also lower risk by not having sharp objects in the heart and superior vena cava (SVC) that could inadvertently protrude during manipulation and perforate or tear the SVC or atrium. If there is a redundant fossa, the risk of perforating the posterior wall of the left atrium is much less with a J-tipped wire than the Brockenbrough needle. Our technique limits the number of exchanges through the transseptal sheath, which affords not only some time savings but also a lower risk of air embolization and thrombus formation. A limitation of this technique, when compared to a Brockenbrough needle, is the lack of an open lumen to easily inject contrast or measure pressure. By demonstrating clear tenting of the fossa on ICE, we can be assured of a safe position for transseptal puncture and are able to watch the wire cross into the left atrium in real-time with both fluoroscopy and ultrasound.
Figure 2. Intracardiac ultrasound view of tenting of the fossa ovalis.
atrial tachycardia, or left-sided accessory pathways. We have had no patients with significant effusions, tamponade, or thromboembolic events during a procedure or during the postprocedural period. The one patient in whom this technique was unsuccessful was a 55-year-old male with previous cardiac surgery and a very thick interatrial septum. In this case, a Brockenbrough needle was required for successful transseptal catheterization.
Conclusions Crossing the interatrial septum with an SL1 sheath and its standard guidewire is simple, inexpensive, quick, and safe. Exchanging guidewires for Brockenbrough needles is rarely required using this transseptal technique.
Discussion Although there are certainly many techniques for transseptal catheterization, we prefer this
2
2015
PACE, Vol. 00
A Safe, Simple Technique for Transseptal Catheterization MICHAEL C. GIUDICI, M.D., STEVEN R. MICKELSEN, M.D., PRASHANT D. BHAVE, M.D., ROQUE B. ARTEAGA, M.D., and OMER J. IQBAL, M.D. From the Division of Cardiology, University of Iowa Hospitals, Iowa City, Iowa
Transseptal catheterization is required for atrial fibrillation ablation and many ablations for atrial tachycardias, left atrial flutters, and accessory pathways. Using a Brockenbrough needle or other specialized device adds time, expense, and risk of potential complications such as atrial or aortic perforation, pericardial effusion, and tamponade to these procedures. We present a simple, low-risk technique for transseptal catheterization. (PACE 2015; 00:1–2) ablation, transseptal catheterization
Background Transseptal catheterization is required for atrial fibrillation ablation and many ablations for atrial tachycardias, left atrial flutters, and accessory pathways. Using a Brockenbrough needle or other specialized device adds time, expense, and risk of potential complications such as atrial or aortic perforation, pericardial effusion, and tamponade to these procedures. For many years, we have been using a unique method of transseptal catheterization, which we have found to be simple, safe, and cost-effective. We describe the procedural technique. Methods We begin by placing a standard SL1 Sheath (St. Jude Medical, St. Paul, MN, USA) over the 0.032 J-tipped guidewire included with the sheath into the superior vena cava from a right femoral venous approach. With fluoroscopy in the 45° left anterior oblique view, and guided by intracardiac ultrasound (ICE), the sheath is directed toward the interatrial septum and brought down the septum from the superior vena cava with the guidewire pulled back from the tip of the introducer. When the tip of the introducer has reached the fossa ovalis and tenting is seen on ultrasound (Figs. 1 and 2), the catheter is advanced slightly to stretch the atrial septal tissue over the tip of the introducer. At that point the Address for reprints: Michael C. Giudici, M.D., F.H.R.S., University of Iowa Hospitals, 200 Hawkins Drive, 4426JCP, Iowa City, IA 52242. Fax: 319-384-6247; e-mail: [email protected] Received October 7, 2014; revised December 3, 2014; accepted December 10, 2014. doi: 10.1111/pace.12576
guidewire is advanced, tapping on the interatrial septum until it pushes through the septum into the left atrium. The wire is advanced to the left superior pulmonary vein (LSPV) under ICE and fluoroscopic guidance (Fig. 3). The sheath is then advanced over the wire, which has been directed into the LSPV and the sheath is brought back and forth across the septum to dilate the opening. For ablation using a larger sheath such as the Arctic Front cryoballoon or the Ablation Frontiers catheter system (both Medtronic, Inc., Minneapolis, MN, USA), the SL1 sheath is left temporarily in the left atrium and the SL1 guidewire is exchanged for an Amplatz wire (0.032 J-wire), which is usually advanced into the LSPV (for more technically challenging septae, the Amplatz wire may be placed in the right superior pulmonary vein) and then the SL1 is exchanged for the larger deflectable sheath. For physicians who do not use ICE guidance for transeptal catheterization, this method is still applicable. Simply maneuver the SL1 sheath to the fossa ovalis, remove the guidewire, confirm with a puff of contrast, and reinsert and advance the 0.032 J-wire as above. Similarly, we have also performed this guidewire-only technique with Agilis (St. Jude Medical) and Bard Channel (Bard Medical, Covington, GA, USA) sheaths. Results Using this technique, we have been able to perform transseptal catheterization in less than 10 minutes and without other equipment in 99 of 100 consecutive patients (55 male/45 female, mean age 59.7 years, range 32–85 years) who were undergoing transeptal catheterization for ablation of atrial fibrillation, left atrial flutter, focal left
© 2015 Wiley Periodicals, Inc. PACE, Vol. 00
2015
1
GIUDICI, ET AL.
Figure 1. Left anterior oblique view of the SL1 sheath in the fossa ovalis.
Figure 3. Left anterior oblique view with the guidewire directed into the left superior pulmonary vein.
wire-only technique for many reasons. There is a cost savings of at least $160–200 per patient by not using a Brockenbrough needle, SAFESEPT wire (Pressure Products, San Pedro, CA, USA), or other specialized tool. There is also lower risk by not having sharp objects in the heart and superior vena cava (SVC) that could inadvertently protrude during manipulation and perforate or tear the SVC or atrium. If there is a redundant fossa, the risk of perforating the posterior wall of the left atrium is much less with a J-tipped wire than the Brockenbrough needle. Our technique limits the number of exchanges through the transseptal sheath, which affords not only some time savings but also a lower risk of air embolization and thrombus formation. A limitation of this technique, when compared to a Brockenbrough needle, is the lack of an open lumen to easily inject contrast or measure pressure. By demonstrating clear tenting of the fossa on ICE, we can be assured of a safe position for transseptal puncture and are able to watch the wire cross into the left atrium in real-time with both fluoroscopy and ultrasound.
Figure 2. Intracardiac ultrasound view of tenting of the fossa ovalis.
atrial tachycardia, or left-sided accessory pathways. We have had no patients with significant effusions, tamponade, or thromboembolic events during a procedure or during the postprocedural period. The one patient in whom this technique was unsuccessful was a 55-year-old male with previous cardiac surgery and a very thick interatrial septum. In this case, a Brockenbrough needle was required for successful transseptal catheterization.
Conclusions Crossing the interatrial septum with an SL1 sheath and its standard guidewire is simple, inexpensive, quick, and safe. Exchanging guidewires for Brockenbrough needles is rarely required using this transseptal technique.
Discussion Although there are certainly many techniques for transseptal catheterization, we prefer this
2
2015
PACE, Vol. 00
