Trans septal Puncture in Cardiology

There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.

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

2. 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 Trans Septal Puncture(TSP) in Cardiology

3. Trans Septal Puncture(TSP) in Cardiology

4. Trans Septal Puncture(TSP) in Cardiology

5. 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. Trans Septal Puncture(TSP) in Cardiology

6. 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 Trans Septal Puncture(TSP) in Cardiology

7. Ross J Jr. Trans- septal left heart catheterization: a new method of left atrial puncture. Ann Surg 1959;149:395– 401. Dr John Ross Trans Septal Puncture(TSP) in Cardiology

8. 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 Trans Septal Puncture(TSP) in Cardiology

9. 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. Trans Septal Puncture(TSP) in Cardiology

10. 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. Trans Septal Puncture(TSP) in Cardiology

11. Trans Septal Puncture(TSP) in Cardiology

12. 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). Trans Septal Puncture(TSP) in Cardiology

13. 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 Trans Septal Puncture(TSP) in Cardiology

14. Anatomy of the inter atrial septum Trans Septal Puncture(TSP) in Cardiology

15. 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 Trans Septal Puncture(TSP) in Cardiology

16. 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 ! Trans Septal Puncture(TSP) in Cardiology

17. WE need 3 things Anatomical Landmarks HARDWARE Imaging Guidance Trans Septal Puncture(TSP) in Cardiology

18. 21 gauge 18 gauge 270° curve 71 cm 67 cm 59 cm Trans Septal Puncture(TSP) in Cardiology

19. 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 Trans Septal Puncture(TSP) in Cardiology

20. Trans Septal Puncture(TSP) in Cardiology

21. 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 Trans Septal Puncture(TSP) in Cardiology

22. Trans Septal Puncture(TSP) in Cardiology

23. WE need 3 things ANATOMICAL LANDMARKS Hardware Imaging Guidance Trans Septal Puncture(TSP) in Cardiology

24. Trans Septal Puncture(TSP) in Cardiology

25. 12 9 3 6 Trans Septal Puncture(TSP) in Cardiology

26. 12 9 3 6 IAS plane in supine patient From 2’ to 7’ o clock Trans Septal Puncture(TSP) in Cardiology

27. 12 9 3 6 Normal Fossa ovalis plane 4’ to 6’ o clock Trans Septal Puncture(TSP) in Cardiology

28. 12 9 3 6 Trans Septal Puncture(TSP) in Cardiology

29. 12 9 3 6 Huge LA with Bulging septum – Fossa ovalis shifts inferiorly and posteriorly to 7’ or even 8’ o clock Trans Septal Puncture(TSP) in Cardiology

30. 12 9 3 6 Small LA with inward septum – Fossa ovalis shifts more anteriorly 3’ to 4’ o clock Trans Septal Puncture(TSP) in Cardiology

31. RAO VIEW Trans Septal Puncture(TSP) in Cardiology

32. AP VIEW Trans Septal Puncture(TSP) in Cardiology

33. LATERAL VIEW Trans Septal Puncture(TSP) in Cardiology

34. Trans Septal Puncture(TSP) in Cardiology

35. WE need 3 things Anatomical Landmarks Hardware IMAGING GUIDANCE Trans Septal Puncture(TSP) in Cardiology

36. IMAGING guidance FLUOROSCOPY TTE TEE ICE CT MRI ECG Trans Septal Puncture(TSP) in Cardiology

37. INUOE Angiographic method Cath Cardiovasc Diagn . 1993;28:119-25. Trans Septal Puncture(TSP) in Cardiology

38. INUOE Angiographic method Cath Cardiovasc Diagn . 1993;28:119-25. Trans Septal Puncture(TSP) in Cardiology

39. INUOE Angiographic method Cath Cardiovasc Diagn . 1993;28:119-25. PM=1.2 times vertebral width Trans Septal Puncture(TSP) in Cardiology

40. HUNG’s modified method ( no Angio – only aortic root pigtail ) Cath Cardiovasc Diagn . 1992;26:275-84. Trans Septal Puncture(TSP) in Cardiology

41. Cath Cardiovasc Diagn . 1992;26:275-84. HUNG’s modified method ( no Angio – only aortic root pigtail ) Trans Septal Puncture(TSP) in Cardiology

42. Trans-septal puncture Trans Septal Puncture(TSP) in Cardiology

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

44. 0.032 wire in innominate vein Trans Septal Puncture(TSP) in Cardiology

45. Sheath dilator assembly in innominate vein Advance sheath + dilator over 0.032” wire to SVC Advance BRK needle to 1cm of end of dilator Trans Septal Puncture(TSP) in Cardiology

46. Steps for TS Puncture Withdraw the TS catheter in PA view until it moves medially PA or mild LAO RAO Trans Septal Puncture(TSP) in Cardiology

47. TSP Points W ithdrawing 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. Trans Septal Puncture(TSP) in Cardiology

48. Descent from SVC – RA RA – fossa Trans Septal Puncture(TSP) in Cardiology

49. Imaginary mid-line ( If LA silhouette not visible – Take RA ± PA angiogram for LA) Trans Septal Puncture(TSP) in Cardiology

50. 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 Trans Septal Puncture(TSP) in Cardiology

51. Check in RAO ( check needle tip away from Aorta and CS) Trans Septal Puncture(TSP) in Cardiology

52. Check in LAO/lateral ( check needle tip away from Aorta and in inferoposterior third) Trans Septal Puncture(TSP) in Cardiology

53. 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. Trans Septal Puncture(TSP) in Cardiology

54. Heart 2009; 95 :85–92. doi:10.1136/hrt.2007.135939 Trans Septal Puncture(TSP) in Cardiology

55. Confirm in LAO: needle should be directed posterior. Advance needle into LA. Confirm by pressure, LA injection of contrast by fluoroscopy. Advance sheath/dilator into LA. Careful about tenting septum and not pushing needle too far into LA. Remove dilator and needle. Transseptal Procedure Steps Trans Septal Puncture(TSP) in Cardiology

56. Push assembly/ needle puncture ( If satisfied by anatomical landmarks and/or pulsation) Trans Septal Puncture(TSP) in Cardiology

57. Check in AP/RAO view by angio / pressure / saturation ( If satisfied – advance dilator/sheath) Trans Septal Puncture(TSP) in Cardiology

58. 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. Trans Septal Puncture(TSP) in Cardiology

59. 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 Trans Septal Puncture(TSP) in Cardiology

60. ICE & TEE The use of Intra-Cardiac E chocardiography (ICE) can also facilitate double TSP when the use of multiple sheaths in the LA is required. Both Transesophageal E chocardiography (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 Trans Septal Puncture(TSP) in Cardiology

61. TEE Should Make it Safer and Easier than Fluoro Guided Puncture Trans Septal Puncture(TSP) in Cardiology

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

63. TEE G uided: T enting A trial S eptum Trans Septal Puncture(TSP) in Cardiology

64. 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. Trans Septal Puncture(TSP) in Cardiology

65. Thick Atrial Septum Trans Septal Puncture(TSP) in Cardiology

66. ICE I ntracardiac 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. Trans Septal Puncture(TSP) in Cardiology

67. 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. Trans Septal Puncture(TSP) in Cardiology

68. ICE Trans Septal Puncture(TSP) in Cardiology

69. R a diofrequency Perforation of LA Septum Trans Septal Puncture(TSP) in Cardiology

70. Alternate T echniques Application of Bovie electrocautery at hub of BRK Puncture septum with stiff end of 0.014 guidewire SafeSept Guidewire Trans Septal Puncture(TSP) in Cardiology

71. 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 Trans Septal Puncture(TSP) in Cardiology

72. SafeSept trans-septal guidewire World J Cardiol 2015 August 26; 7(8): 499-503 ISSN 1949-8462 Trans Septal Puncture(TSP) in Cardiology

73. SafeSept trans-septal guidewire World J Cardiol 2015 August 26; 7(8): 499-503 ISSN 1949-8462 Trans Septal Puncture(TSP) in Cardiology

74. Trans Septal Puncture(TSP) in Cardiology

75. (A) Fixed-curve sheath. (B) Steerable sheath ( Agillis ). (C) BRK ( Brockenbrough ) transseptal needle. (D) SafeSept wire. (E) NRG radiofrequency needle. Trans Septal Puncture(TSP) in Cardiology

76. Complications of TSP Pericardial Effusion Tamponade RA and LA needle puncture Aortic Puncture/Perforation Death Air Embolism or TIA Transient ST Elevation Persistent ASD Trans Septal Puncture(TSP) in Cardiology

77. Overall Mortality <1% MUST LEARN PERICARDIOCENTASIS BEFORE SEPTAL PUNCTURE Echo must be readily available Trans Septal Puncture(TSP) in Cardiology

78. Pericardial Tamponade Reverse Anticoagulation Heparin : Protamine Coumadin : FFP Pericardiocentesis and placement of pericardial drain Trans Septal Puncture(TSP) in Cardiology

79. 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! Trans Septal Puncture(TSP) in Cardiology

80. 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 Trans Septal Puncture(TSP) in Cardiology

81. 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 Trans Septal Puncture(TSP) in Cardiology

82. Aortic root perforation Trans Septal Puncture(TSP) in Cardiology

83. Transcatheter Repair of Aortic Perforation Webber MR et al. J Invasive Cardiol 2013 May;25(5):E10-13 Trans Septal Puncture(TSP) in Cardiology

84. 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 Trans Septal Puncture(TSP) in Cardiology

85. 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. Trans Septal Puncture(TSP) in Cardiology

86. 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. Trans Septal Puncture(TSP) in Cardiology

87. 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. Trans Septal Puncture(TSP) in Cardiology

88. IATROGENIC ATRIAL SEPTAL DEFECT N ot 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, E lective closure of the iatrogenic septal defect should be considered in selected patients Trans Septal Puncture(TSP) in Cardiology

89. Rare complications Vena cava perforation C oronary artery dissection D etachment of the tip of the transseptal sheath Acute pericarditis Trans Septal Puncture(TSP) in Cardiology

90. Complications of Transseptal Puncture De Ponti et al. JACC 2006;47:1037-1042 Italian Multicenter Survey: 5520 procedures over 12 years Trans Septal Puncture(TSP) in Cardiology

91. Emerging techniques requiring TSP Trans Septal Puncture(TSP) in Cardiology

92. 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. Trans Septal Puncture(TSP) in Cardiology

93. TS catheterization in electrophysiology (EP) 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 . Trans Septal Puncture(TSP) in Cardiology

94. TS catheterization in electrophysiology (EP) 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. Trans Septal Puncture(TSP) in Cardiology

95. TS catheterization in electrophysiology (EP) 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 Trans Septal Puncture(TSP) in Cardiology

96. (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. Trans Septal Puncture(TSP) in Cardiology

97. TS catheterization in electrophysiology (EP) 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. Trans Septal Puncture(TSP) in Cardiology

98. 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. Trans Septal Puncture(TSP) in Cardiology

99. 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. Trans Septal Puncture(TSP) in Cardiology

100. 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 Trans Septal Puncture(TSP) in Cardiology

101. 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 Trans Septal Puncture(TSP) in Cardiology

102. 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. Trans Septal Puncture(TSP) in Cardiology

103. 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. Trans Septal Puncture(TSP) in Cardiology

104. 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) Trans Septal Puncture(TSP) in Cardiology

105. 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. Trans Septal Puncture(TSP) in Cardiology

106. 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. Trans Septal Puncture(TSP) in Cardiology

107. 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

108. 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. Trans Septal Puncture(TSP) in Cardiology

109. 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. Trans Septal Puncture(TSP) in Cardiology

110. Different sites of TSP Mitra clip or paravalvular leak closure Trans septal PFO closure Percutaneous LV assist device placement LAA closure Pulmonary vein interventions Trans Septal Puncture(TSP) in Cardiology

111. Difficult tsp Trans Septal Puncture(TSP) in Cardiology

112. 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 Trans Septal Puncture(TSP) in Cardiology

113. 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 Trans Septal Puncture(TSP) in Cardiology

114. 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 Trans Septal Puncture(TSP) in Cardiology

115. 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 Trans Septal Puncture(TSP) in Cardiology

116. 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 Trans Septal Puncture(TSP) in Cardiology

117. 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. Trans Septal Puncture(TSP) in Cardiology

118. 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) Trans Septal Puncture(TSP) in Cardiology

119. 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 Trans Septal Puncture(TSP) in Cardiology

120. THANK YOU Trans Septal Puncture(TSP) in Cardiology