TRANS-SEPTAL PUNCTURESATYAM RAJVANSHI
Dr John Ross
Ross J Jr. Trans-septal left heart catheterization: a new method of left atrial puncture.
Ann Surg 1959;149:395– 401.
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)
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)
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
CONTRAINDICATIONS
• Absolute!
LA cavity or septal thrombus/tumour
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
AnatomicalLandmarks
Hardware
Imaging Guidance
WE NEED 3 THINGS
AnatomicalLandmarks
HARDWARE
Imaging Guidance
21 gauge
18 gauge
270° curve
71 cm
67 cm59 cm
MULLINS SHEATH AND DILATOR SYSTEM (Medtronic Inc.)Size Sheath length Dilator length Wire size max.
ADULT8 Fr +/- hemostatic valve
59 cm 67 cm .032 in
PEDIATRIC8 Fr 44 cm 52 cm .025 in6 Fr 44 cm 52 cm .025 in
BROCKENBROUGH NEEDLE (Medtronic Inc.)Shaft Size Tip Size Length
ADULT18 gauge 21 gauge 71 cm
PEDIATRIC19 gauge 22 gauge 56 cm
WE NEED 3 THINGS
ANATOMICALLANDMARKS
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
12
9 3
6
Huge LA with Bulging septum – Fossa ovalis shifts inferiorly and posteriorlyto 7’ or even 8’ o clock
12
9 3
6
Small LA with inward septum – Fossa ovalis shifts more anteriorly3’ to 4’ o clock
RAO
AP
LAT
WE NEED 3 THINGS
AnatomicalLandmarks
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
Cath Cardiovasc Diagn. 1993;28:119-25.
INUOE ANGIOGRAPHIC METHOD
Cath Cardiovasc Diagn. 1993;28:119-25.
HUNG’S MODIFIED METHOD(no Angio – only aortic root pigtail)
Cath Cardiovasc Diagn. 1992;26:275-84.
Cath Cardiovasc Diagn. 1992;26:275-84.
HUNG’S MODIFIED METHOD(no Angio – only aortic root pigtail)
TRANS-SEPTAL PUNCTURE
0.032 WIRE IN INNOMINATE
VEIN
SHEATH DILATOR ASSEMBLY IN
INNOMINATE VEIN
TRACKING BROCKENBROUGH NEEDLE WITH TIP JUST INSIDE DILATOR
DESCENT FROM SVC – RA
RA – FOSSA
IMAGINARY MID-LINE
(If LA silhouette not visible – Take RA ± PA angiogram for
LA)
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)
PUSH ASSEMBLY/NEEDLE PUNCTURE
(If satisfied by anatomical landmarks
and/or pulsation)
CHECK IN AP/RAO VIEWBY ANGIO / PRESSURE / SATURATION
(If SATISFIED – advance dilator/sheath)
LA WIRE ENTRY
SPECIAL SITUATIONS
Giant RASmall LA Normal LA
Septal bulge Giant
RA
Forceful torque to middle of IAS
Enlarged LA6’ or 7’o clock
Enlarged RABend the needle
No jumps/pulsationAnatomic landmarks
PROCEDURE SPECIFIC PUNCTURE SITE
OTHER APPROACHES/TECHNIQUES
• Left Femoral• Transjugular (LA-crosse system)• Transhepatic
• TTE/TEE/ICE guidance
• Safe-sept wire• Electrocautery• RFA (Toronto RF catheter)• Laser
COMPLICATIONS
• Overall Mortality <1%
• MUST LEARN PERICARDIOCENTASIS BEFORE SEPTAL PUNCTURE
• Echo must be readily available
STITCH PHENOMENAIn 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
THINK BEFORE PULLING OUT!After septal puncture – always wait for 2 minutes, watch hemodynamics/echo, then give heparin
MANAGEMENT OF STITCH/EFFUSIONOnly 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
HOW TO SUCCESSFULLY PUNCTURE SEPTUM
The take-home points
FAMILIARISE WELL WITH HARDWARE
RAO
LATAP
FAMILIARISE WELL WITH ANATOMY
BE WATCHFUL FOR COMPLICATIONS