TRANS-SEPTAL PUNCTURE in Interventional Cardiology

various methods and techniques for transseptal puncture for accessing LA via RA in interventional cardiology.

1. TRANS-SEPTAL PUNCTURE Dr. Durvesh Bhangale 3 rd year DM Cardiology SJICR, Bangalore Chairpersons: Dr K SATHISH Dr. SHILPA Dr. DISHA

2. Anatomy of Interatrial septum

3. Borders of Inter-Atrial septum

4. Traditionally comprehended Inter-atrial septum is a large area. However, for purposes of TRANS-SEPTAL PUNCTURE ,

5. True inter-atrial septum: corresponds to the fossa ovalis and its antero-inferior rim. Other rims are not true inter-atrial septum . A puncture at these sites will end up outside the heart. Fossa Ovalis is a relatively small area that is only 20% of the total IAS area. 40 mm²to 240 mm² in adults

6. Trans-septal puncture

7. Red : MitraClip , paravalvular leak closure (a higher crossing site is recommended for medial leaks, and a lower crossing site is recommended for lateral leaks; dashed red circles). Yellow: transseptal patent foramen ovale closure. Blue: percutaneous left ventricular assist device placement,hemodynamic studies. Green : left atrial appendage closure. Orange : pulmonary vein interventions.

8. Contraindications for Trans-septal puncture

9. Hardware Needle: The initial needle used by Ross had a curved distal end to allow controlled movements of the tip and an arrow-shaped proximal handle to define needle orientation. Brockenbrough modified the Ross needle by reducing the caliber of the distal 1.5 cm of the needle from 18 to 21 gauge.

10. Safety Feature: The original Ross Needle was modified to have the distal 1.5 cm of smaller calibre The needle at its hub has a direction arrow that corresponds to the needle curve. The Brockenbrough Needle is used with Mullin’s Sheath that has a more tapered tip without side holes. It allows the distal 1 cm of the needle to protrude out.

11. Methods of puncture Fluoroscopic Method (Landmark guided) Trans- Esophageal echo guided (TEE) Intra-Cardiac Echo guided (ICE) MDCT guided

12. ICE and TEE Both ICE and TEE have benefits over fluoroscopic method, especially when double septal punctures are required. ICE has an advantage over TEE of not requiring assistant during procedure for TEE probe manipulations.

13. TEE guided Trans-septal puncture

14. Trans-septal puncture pressure monitoring As the needle is pulled down from SVC RAFOSSA OVALIS, the pressure gradually dampens until you get a straight line. This indicates the dilator is abutting the septum. Once the puncture is made, there is sudden elevation of pressure and you get a LA waveform.

15. Landmark guided Methods Venous only transeptal puncture Bloomfield-Sinclair-Smith Method

16. 0.032’’ wire into the innominate vein

17. Sheath and dilator assembly is passed over the wire

18. Track the BRK needle to the innominate vein

19. Start descent SVC RA 2. RA fossa ovalis

20. Imaginary midline between Ao and right lateral border of LA. Take RA + PA angiogram if not visible

21. RAO Check Needle tip is away from the Aorta

22. LAO/Lateral- Check needle away from aorta and in infero -posterior third

23. SEPTAL FLUSH METHOD For atrial septal outline Best appreciated in the lateral view Continuous flushing of the posteromedially directed dilator/needle with contrast medium as it is withdrawn caudally. outlines the RA aspect of the septum and its orientation. Differentiated between high septum dissection or needle entanglement in thick portion of IAS. (in high septum dissection, it appears stained in vertical fashion.)

24. If satisfied with position, push the assembly

25. Check in AP & RAO- Pressure waveform, saturation and angio

26. Other techniques Left femoral Trans-Jugular (LA cross system) Trans-Hepatic Safe-Sept Wire Electrocautery RFA (Toronto RF catheter) LASER

27. Complications Cardiac Perforation & Tamponade 1-2% in BMV 2-3% in PVI and LAA closure Thromboembolism (Highest for PVI - 5%) Air Embolism Iatrogenic ASD

28. Stitch Phenomenon

29. AORTIC ROOT STAIN

30. Challenges to septal puncture Giant LA- Use of straighter needle, imaging, needle indicator @6-7o’clock position, probe the fossa ovalis may be useful. Giant RA- IAS is bulged towards left, make the needle acutely bent. Needle indicator @ 3-4’o clock position. IVC anomalies- use of transjugular route. Use of 56cm BRK needle or Endry’s septal puncture needle. High puncture is preferred. Kyphoscoliosis - relative contraindication, use TEE guidance Aneurysmally dilated Coronary sinus- take CS injection shoot.

31. Familiarise with HARDWARE

32. Familiarise with ANATOMY

33. Be Watchful for complications And keep an eye on HEMODYNAMICS

34. Be prepared to manage complications PERICARDIOCENTESIS CTVS BACKUP

35. Thank you