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Aims A three-dimensional electroanatomic mapping system–guided transseptal puncture (3D-TSP), without fluoroscopy or echocardiography, has been only minimally reported. Indications for 3D-TSP remain unclear. Against this background, this study aims to establish a precise technique and create a workflow for validating and selecting eligible patients for fluoroless 3D-TSP. Methods and results We developed a new methodology for 3D-TSP based on a unipolar electrogram derived from a transseptal needle tip (UEGM tip) in 102 patients (the derivation cohort) with intracardiac echocardiography (ICE) from March 2018 to February 2019. The apparent current of injury (COI) was recorded at the muscular limbus of the foramen ovalis (FO) on the UEGM tip (sinus rhythm: 2.57 ± 0.95 mV, atrial fibrillation: 1.92 ± 0.77 mV), which then disappeared or significantly reduced at the central FO. Changes in the COI, serving as a major criterion to establish a 3D-TSP workflow, proved to be the most valuable indicator for identifying the FO in 99% (101/102) of patients compared with three previous techniques (three minor criteria) of reduction in atrial unipolar or bipolar potential and FO protrusion. A total of 99.9% (1042/1043) patients in the validation cohort underwent successful 3D-TSP through the workflow from March 2019 to July 2023. Intracardiac echocardiography guidance was required for 6.6% (69/1042) of patients. All four criteria were met in 740 patients, resulting in a 100% pure fluoroless 3D-TSP success rate. Conclusion In most patients, fluoroless 3D-TSP was successfully achieved using changes in the COI on the UEGM tip. Patients who met all four criteria were considered suitable for 3D-TSP, while those who met none required ICE guidance. [ABSTRACT FROM AUTHOR]

Aims Common to adult electrophysiology studies (EPSs), intracardiac echocardiography (ICE) use in paediatric and congenital heart disease (CHD) EPS is limited. The purpose of this study was to assess the efficacy of ICE use and incidence of associated complications in paediatric and CHD EPS. Methods and results This single-centre retrospective matched cohort study reviewed EPS between 2013 and 2022. Demographics, CHD type, and EPS data were collected. Intracardiac echocardiography cases were matched 1:1 to no ICE controls to assess differences in complications, ablation success, fluoroscopy exposure, procedure duration, and arrhythmia recurrence. Cases and controls with preceding EPS within 5 years were excluded. Intracardiac echocardiography cases without an appropriate match were excluded from comparative analyses but included in the descriptive cohort. We performed univariable and multivariable logistic regression to assess associations between variables and outcomes. A total of 335 EPS were reviewed, with ICE used in 196. The median age of ICE cases was 15 [interquartile range (IQR) 12–17; range 3–47] years, and median weight 57 [IQR 45–71; range 15–134] kg. There were no ICE-related acute or post-procedural complications. There were 139 ICE cases matched to no ICE controls. Baseline demographics and anthropometrics were similar between cases and controls. Fluoroscopy exposure (P = 0.02), procedure duration (P = 0.01), and arrhythmia recurrence (P = 0.01) were significantly lower in ICE cases. Conclusion Intracardiac echocardiography in paediatric and CHD ablations is safe and reduces procedure duration, fluoroscopy exposure, and arrhythmia recurrence. However, not every arrhythmia substrate requires ICE use. Thoughtful selection will ensure the judicious and strategic application of ICE to enhance outcomes. [ABSTRACT FROM AUTHOR]

Aims This study was performed to compare the usability, efficiency, and safety of a modified angioplasty guidewire-assisted transseptal puncture (TSP) technique vs. the conventional approach in facilitating access into the left atrium during left atrial appendage occlusion (LAAO) procedures for the treatment of atrial fibrillation. Methods and results The ADVANCE-LAAO trial (Angioplasty Guidewire-Assisted vs. Conventional Transseptal Puncture for Left Atrial Appendage Occlusion) was an investigator-initiated, prospective, multicentre, randomized controlled trial (NCT05125159). Patients with atrial fibrillation who underwent LAAO were prospectively enrolled from four centres and randomly assigned to an angioplasty guidewire-assisted TSP group (n = 131) or to a conventional Brockenbrough needle TSP group (n = 132). The primary endpoint was the one-time success rate of TSP. We also analysed the TSP procedure time, failure rate of the assigned TSP type, radiation dose, contrast dose, and procedural complications in both groups. All patients in the guidewire-assisted group underwent successful TSP, whereas five in the standard conventional group switched to the guidewire-assisted approach. The guidewire-assisted puncture improved the one-time success rate (92.4 vs. 77.3%, P = 0.001), shortened the TSP procedure time (109.2 ± 48.2 vs. 120.5 ± 57.6 s, P = 0.023), and tended to have a higher rate of good coaxial orientation of the sheath with the left atrial appendage during the LAAO procedure (66.4 vs. 54.5%, P = 0.059). No TSP-related complications occurred in the guidewire-assisted TSP group, whereas two complications occurred in the conventional TSP group. There was no significant difference in the failure rate of the assigned TSP type, the total procedure time, the total radiation dose, the rate of successful LAAO implantation, or the procedural complication rate between the two groups (all P > 0.05). Conclusion This study confirmed that angioplasty guidewire-assisted puncture can effectively improve the success rate of TSP during LAAO procedures. This novel technique has high potential for application in interventional therapies requiring TSP. [ABSTRACT FROM AUTHOR]

Aims Pulsed field ablation (PFA) for pulmonary vein isolation (PVI) combines the benefits of high procedural efficacy and safety. Transseptal puncture (TSP) to obtain left atrial (LA) access during PVI remains an important source of complications during LA procedures. For PFA procedures, TSP is generally performed using a standard transseptal sheath that is then exchanged over the wire for a dedicated PFA sheath, which might be a potential source for air embolism. We aimed to prospectively evaluate the feasibility and safety of a simplified workflow using the PFA sheath (Faradrive, Boston Scientific) directly for TSP. Methods and Results We prospectively enrolled 100 patients undergoing PVI using PFA at two centres. TSP was performed using the PFA sheath and a standard 98 cm transseptal needle under fluoroscopic guidance. TSP via the PFA sheath was successfully performed in all patients and no complications occurred. The median time from the first groin puncture to the completed LA access was 12 min (IQR 8–16 min). Conclusion An over-the-needle TSP directly with the PFA sheath proved feasible and safe in our study. This simplified workflow has the potential to reduce the risk of air embolism, to shorten procedure time, and to reduce cost. [ABSTRACT FROM AUTHOR]

Aims: Transseptal puncture (TP) for left atrial (LA) catheter ablation procedures is routinely performed under fluoroscopic guidance. To decrease radiation exposure and increase safety alternative techniques are desirable. The aim of this study was to assess whether right atrial (RA) electroanatomic 3D mapping can reliably identify the fossa ovalis (FO) in preparation of TP.Methods and Results: Between May 2019 and August 2019, electroanatomic RA mapping was performed before TP in 61 patients with paroxysmal or persistent atrial fibrillation. Three electroanatomic methods for FO identification, mapping catheter-induced FO protrusion, electroanatomic-guided analysis, and voltage mapping, were evaluated and compared with transoesophageal echocardiography (TOE). Mapping catheter-induced FO protrusion was feasible in 60 patients (98%) with a mean displacement of 6.8 ± 2.5 mm, confirmed by TOE, and proofed to be the most valuable and easiest marker for FO identification. Electroanatomic-guided analysis localized the FO midpoint consistently in the lower half (43 ± 7%) and posterior (18.2 ± 4.4 mm) to a line between coronary sinus and vena cava superior. Analysis of RA voltage maps during sinus rhythm (n = 40, low-voltage cut-off value 1.0 and 1.5 mV) allowed secure FO recognition in 33% and 18%, only. A step-by-step approach, combining FO protrusion (first step) with anatomy criteria in case of protrusion failure (second step) would have allowed for the correct localization of a TP site within the FO in all patients.Conclusion: Right atrial electroanatomic 3D mapping prior to TP proofed to be a simple tool for FO identification and may potentially be of use in the safe and radiation-free performance of TP prior to LA ablation procedures. [ABSTRACT FROM AUTHOR]

Aims: Inadvertent puncture of the aortic root (AR) is a well-known complication of transseptal puncture (TSP). Strategies for handling of this potentially lethal complication have not been identified yet. In this study, we present typical anatomical locations and clinical management of aortic root puncture (ARP) due to TSP.Methods and Results: All patients with ARP were retrospectively collected from seven hospitals. Aortic root puncture was identified and classified regarding angiographical and intraoperative findings in cardiac surgery: (i) TSP from the right atrium (RA) to the non-coronary sinus (NCS), (ii) TSP from RA to the non-coronary sinutubular junction (STJ), and (iii) TSP from RA to the ascending aorta (AA). A total of 24 patients with inadvertent ARP were identified. In 19 patients, penetration of the aorta was accomplished by the inner dilator, in 5 patients by the complete sheath. Previous cardiac surgery had been performed in six patients. There were 13 RA-to-NCS punctures, 2 RA-to-STJ punctures, and 9 RA-to-AA punctures. No cardiac tamponade (CT) occurred in patients with RA-to-NCS and RA-to-STJ punctures. In 8 of 9 patients with RA-to-AA puncture, CT occurred immediately requiring urgent pericardiocentesis and surgical repair. Two patients died after surgical repair. In the 16 patients without surgical therapy, no shunt from the AR to the RA was observed 3 months after the procedure.Conclusion: Aortic root puncture due to mislead TSP via NCS or STJ is usually not associated with a severe clinical course while ARP into the AA via the epicardial space generally leads to CT requiring surgical repair. [ABSTRACT FROM AUTHOR]

Aims: Catheter ablation is underutilized in atrial septal defect (ASD) patients who have undergone implantation of an atrial septal occluder (ASO). This study evaluates the feasibility and safety of catheter ablation of atrial fibrillation (AF) in this subset of patients.Methods and results: Sixteen patients (age 56 ± 12 years, 10 men) with drug-refractory AF (10 paroxysmal and 6 persistent) and previously implanted ASO were enrolled. Balloon dilatation of the closure device was performed if the native septum passage could not be achieved. For paroxysmal AF, the ablation strategy was circumferential pulmonary vein isolation (CPVI), and for persistent AF, additional linear ablation was performed. Transseptal access was achieved through the native septum in 11 patients (Group A) and through the ASO using balloon dilatation in 5 patients (Group B). Circumferential pulmonary vein isolation was achieved in all 16 patients, and linear block was achieved in all persistent patients except for 1 patient who did not achieve mitral isthmus block. The transseptal, total fluoroscopy, and procedural durations were 5 ± 3 vs. 38 ± 8 min, 31 ± 11 vs. 54 ± 15 min, and 165 ± 35 vs. 224 ± 36 min, respectively, in Group A vs. Group B, respectively (all P < 0.05). No shunt at atrial level was detected by transthoracic echocardiography at 3-month follow-up. During a follow-up of 16 ± 6 months, sinus rhythm was maintained in 12 of 16 patients. No severe complications were observed.Conclusion: In ASD patients with ASO, catheter ablation of AF is feasible, safe, and effective. The balloon dilatation technique can facilitate transseptal access through the ASO. [ABSTRACT FROM AUTHOR]

Aims: The transseptal approach is used for left atrial access during the ablation of atrial fibrillation (AF) and other left-sided arrhythmia substrates. Transseptal puncture (TP) is commonly performed with fluoroscopic guidance, contrast injection, and pressure monitoring. In many centres, additional techniques [intracardiac echocardiography (ICE), transoesophageal echocardiography (TEE), radiofrequency needle] are used to facilitate TP but its use adds costs. In this retrospective study, we studied the safety and complication rate when TP was routinely done with fluoroscopic guidance, contrast injection, and pressure monitoring using ICE or TEE only in selected cases.Methods and Results: This study analysed 4690 consecutive TP performed between 2000 and 2015: 3408 (72.6%) were ablation of AF, left-sided atrial flutter, or left-sided atrial tachycardia (non-AP group); 1153 (24.6%) were ablation of left-sided accessory pathway, AP group; and 129 (2.8%) were ablation of ventricular tachycardia. Transseptal puncture was done under fluoroscopy, pressure monitoring, and commonly using contrast media injection. In 27 procedures, ICE or TEE was used to guide the TP. We found 34 tamponades (Tx) that required pericardial drainage of which 28 (0.59%) could possibly be TP related and six could not. The total complication rate for all Tx was 0.72%. A higher rate of tamponades was observed in the AF (non-AP) group than in the AP group (0.88 vs. 0.17%, P < 0.02). The highest rate of tamponades was registered during the operators 51-100 cases, 1.3%, and decreased to 0.4% in cases 101-200, P = 0.04.Conclusion: TP can safely be done under fluoroscopy and pressure monitoring without routine use of additional techniques. With experience, operators should be able to further decrease complication rate. [ABSTRACT FROM AUTHOR]

Aims: We sought to establish the technical feasibility of transseptal puncture and left atrial (LA) ablation through the right internal jugular vein via the superior vena cava (SVC) approach in patients with an interrupted inferior vena cava (IVC).Methods and Results: A 34-year-old man with persistent atrial fibrillation (AF) and polysplenia syndrome (hypoplasia of the left kidney, aplasia of the pancreas tail, bilaterally bilobed lungs, and an interrupted IVC) was referred to our hospital for radiofrequency ablation. Because transseptal puncture and LA ablation would be impossible by a standard IVC approach via the femoral vein, we performed transseptal puncture and LA ablation through the right internal jugular vein via the SVC approach using a manually curved Brockenbrough needle and intracardiac echocardiographic guidance. We accomplished pulmonary vein (PV) isolation using a deflectable guiding sheath and a contact force-sensing ablation catheter to monitor the contact force and the force-time integral of the tip of the ablation catheter. No complications occurred during or after the procedure. The patient was discharged home without recurrence of AF 3 days after the procedure. He had no recurrence of AF and was taking no medication 5 months after ablation.Conclusions: We successfully performed transseptal puncture in a patient with persistent AF, polysplenia syndrome, and complete interruption of the IVC using the superior route through the internal jugular vein. We also accomplished PV isolation using a deflectable guiding sheath and real-time monitoring of the contact force of the ablation catheter. [ABSTRACT FROM AUTHOR]

Aims: Transseptal punctures (TSP) are routinely performed in cardiac interventions requiring access to the left heart. While pericardial effusion/tamponade are well-recognized complications, few data exist on accidental puncture of the aorta and its management and outcome. We therefore analysed our single centre database for this complication.Methods and Results: We assessed frequency and outcome of inadvertent aortic puncture during TSP in consecutive patients undergoing ablation procedures between January 2005 and December 2014. During the 10-year period, two inadvertent aortic punctures occurred among 2936 consecutive patients undergoing 4305 TSP (0.07% of patients, 0.05% of TSP) and in one Mustard patient during attempted baffle puncture. The first two patients required left ventricular access for catheter ablation of ventricular tachycardia. In both cases, an 11.5F steerable sheath (inner diameter 8.5F) was accidentally placed in the ascending aorta just above the aortic valve. In the presence of surgical standby, the sheaths were pulled back with a wire left in the aorta. Under careful haemodynamic and echocardiographic observation, this wire was also pulled back 30 min later. None of the patients required a closing device or open heart surgery. None of the patients suffered complications from the accidental aortic puncture and sheath placement.Conclusion: Inadvertent aortic puncture and sheath placement are rare complications in patients undergoing TSP for interventional procedures. Leaving a guidewire in place during the observation period may allow introduction of sheaths or other tools in order to control haemodynamic deterioration. [ABSTRACT FROM AUTHOR]

Aims The previous literature has suggested that the iatrogenic atrial septal defects (IASDs) may follow left atrial (LA) access by transseptal (TS) puncture, especially in the case of a single TS for more than one catheter. The aim of the present study is to describe the prevalence of patent foramen ovale (PFO) and IASDs in a cohort of atrial fibrillation (AF) patients undergoing redo catheter ablation (CA) procedures in a high-volume centre accessing LA by a standardized single TS puncture. Methods and results Patients (n = 197) who underwent at least one redo AFCA, between 2004 and 2012, were retrospectively enroled. Transoesophageal echocardiography was performed before each procedure during which LA was accessed via a PFO, if present, or by single TS for both the mapping and ablation catheters. At baseline, PFO was detected in 43 (21.8%) patients. Clinical and echocardiographic parameters recorded did not differ within patients presenting with or without PFO. Left atrium was accessed via PFO in 39 (90.7% of those with PFO) patients during the first procedure. New-onset IASD occurred in 11 (5.6%) patients following the first procedure and in 1 (2.2%) patient following the second procedure. The clinical and echocardiographic parameters did not differ within the patients irrespective of whether IASD was reported or not. No TS-related complications occurred. Conclusion In the present cohort, LA access by PFO or single TS for both the mapping and ablation catheters lead to a small risk of asymptomatic IASD, not increased by redo procedures, confirming that it represents a safe approach. No clinical and/or echocardiographic parameters seemed to predict IASD occurrence. [ABSTRACT FROM PUBLISHER]

Aims To compare the safety and efficacy of a new dilator method vs the traditional needle method for transseptal puncture (TSP) in a large cohort study. Methods and results From February 1995 to December 2010, 4443 consecutive patients undergoing TSP done either by a needle method or by a new dilator method were reviewed retrospectively. Data as procedure-related time and complications were evaluated. For the standard needle method, TSP was performed by extending out the needle. In comparison, for the new dilator technique, TSP was performed without an outer sheath and with the needle kept within the dilator; the blunt tip of the dilator was used to help locating the position of the fossa ovalis on purpose. Transseptal puncture was performed by the new dilator method in 2151 patients (48.4%) and by the traditional needle method in 2292 patients (51.6%). The average TSP time needed by the dilator method was longer than that needed by the needle method (5.6 ± 3.9 vs. 3.8 ± 2.9 min, P< 0.05). Additional left atrial angiography was required in seven (0.33%) patients for the dilator and in 39 patients (1.70%) for the needle method (P< 0.05). The total rate of severe complications and obvious TSP-related complications was significantly lower in patients who underwent the dilator method than in those who underwent the needle method (0.33 vs. 1.18%, and 0.20 vs. 1.00%, respectively, P < 0.05). Conclusion Our data suggest that the new dilator technique is much safer than that of the standard needle method. It needs relatively longer procedure time but results in significantly fewer episodes of severe complications. Particularly, the blunt tip of the dilator can be used to help locate the fossa ovalis. Therefore, the new dilator technique might be a better choice for relatively less-experienced operators. [ABSTRACT FROM PUBLISHER]

Aims Transseptal puncture (TP) appears to be safe in experienced hands; however, it can be associated with life-threatening complications. The aim of our study was to demonstrate the added value of routine use of transoesophageal echocardiography (TEE) for the correct positioning of the transseptal system in the fossa ovalis, thus potentially preventing complications during fluoroscopy-guided TP performed by inexperienced operators. Methods and results Two hundred and five patients undergoing pulmonary vein isolation procedure (PVI) for drug-resistant paroxysmal or persistent atrial fibrillation were prospectively included. When the operator (initially blinded to TEE) assumed that the transseptal system was in a correct position according to fluoroscopical landmarks, the latter was then checked with TEE unblinding the physician. If necessary, further refinement of the catheter position was performed. Refinement >10 mm, or in case of catheter pointing directly at the aortic root or posterior wall were considered as major repositioning. Thirty-four patients required major repositioning. Regression analysis revealed age (P: 0.0001, Wald: 12.9, 95% confidence interval: 1.04–1.16), left atrial diameter (P: 0.01, Wald: 6.6, 95% confidence interval: 1.04–1.34), previous PVI (P: 0.01, Wald: 6.3, 95% confidence interval: 1.31–8.76), and atrial septal thickness (P: 0.03, Wald: 4.5, 95% confidence interval: 1.05–3.4) as independent predictors of major revision with TEE. Conclusion Routine 2D TEE in addition to traditional fluoroscopic TP appears to be very useful to guide the TP assembly in a correct puncture position and thus, to avoid TP-related complications. However, further randomized prospective comparative studies are necessary to support these suggestions. [ABSTRACT FROM PUBLISHER]

Aims An increasing number of transseptal punctures (TSPs) are performed worldwide for atrial ablations. Transseptal punctures can be complex and can be associated with potentially life threatening complications. The purpose of the study was to evaluate the safety and efficacy of a novel transseptal guidewire (TSGW) designed to facilitate TSPs. Methods and results Transseptal punctures were performed using a SafeSept™ TSGW passed through a standard TSP apparatus. Transseptal punctures were performed by standard technique with additional use of a TSGW allowing probing of the interatrial septum without needle exposure and penetration of the fossa into the left atrium (LA). Transseptal puncture using the TSGW was performed in 210 patients. Left atrial access was achieved successfully in 205 of 210 patients (97.6%) and in 96.3% of patients undergoing repeat TSP. Left atrial access was achieved with the first pass in 81.2% (mean 1.4 ± 0.9 passes, range 1–6) using the TSGW. No serious complications were attributable to the use of the TSGW, even in cases of failed TSP. Conclusions The TSGW is associated with a high success rate for TSP and may be a useful alternative to transoesophageal or intracardiac echocardiogram-guided TSP. [ABSTRACT FROM PUBLISHER]

Aims Imaging of the left atrium (LA) is mandatory during catheter ablation of atrial fibrillation (AF) and may be achieved by echocardiography. The aim of the present study was to assess the feasibility of using a recently released transoesophageal echocardiography (TEE) microprobe (micro-TEE) in non-sedated adult patients undergoing AF ablation and to directly compare this new technique with intracardiac echocardiography (ICE). Methods and results The study group consisted of 12 consecutive patients (8 males, mean age 49 ± 14 years) who underwent first radiofrequency AF ablation. All patients underwent standard TEE, computed tomography, intraprocedural micro-TEE, and ICE. The easiness of introducing the microprobe in the supine position in non-sedated patients in the electrophysiology laboratory, its tolerability, and quality of obtained images were assessed using a five-point scale. There were no problems with microprobe introduction and obtaining images for a mean of 54 ± 17 min. The microprobe was significantly better tolerated than the standard TEE probe (4.3 ± 0.5 vs. 3.4 ± 0.6 points, P< 0.01). The micro-TEE was scored as significantly better than ICE in the assessment of the LA and LA appendage (LAA) anatomy and function. Both techniques were very useful in guiding transseptal puncture, although micro-TEE images were ranked higher by an echocardiographer than by an electrophysiologist (tenting 4.8 ± 0.6 vs. 4.0 ± 0.6 points, P< 0.01), whereas ICE images were ranked equally excellent by both observers. Conclusion In non-sedated patients undergoing AF ablation, the micro-TEE can be used for the assessment of the LA, LAA, and pulmonary veins anatomy as well as the guidance of transseptal puncture. [ABSTRACT FROM PUBLISHER]

Aims: Although it has been shown that a transseptal (TS) puncture in the electrophysiology laboratory is associated with a high success and a low complication rate, this procedure remains challenging particularly in difficult septum anatomies (aneurismal septum and thick septum) and during repeat TS catheterization. Radiofrequency (RF) electrocautery current delivery through the TS needle has been shown to facilitate the TS puncture. The aim of this study was to verify prospectively the feasibility, safety, and outcome of RF energy delivery associated with the standard TS technique in patients undergoing a challenging TS puncture. [ABSTRACT FROM PUBLISHER]

Aims: Persistent iatrogenic atrial septal defect (iASD) after transseptal puncture for pulmonary vein isolation (PVI) has been described recently as a complication of PVI. No data exists evaluating systematically the incidence and clinical implications of iASDs after PVI using a remote robotic navigation system (RNS) with sheaths with a distinct larger outer diameter. [ABSTRACT FROM PUBLISHER]

Aims: Transseptal (TS) puncture during atrial fibrillation (AF) ablation is a relatively safe procedure in experienced hands. However, major and minor complications cannot be completely ruled out. Real-time three-dimensional transeosophageal echocardiography (RT 3D TEE) is a novel imaging technology that permits direct visualization of the fossa ovalis in a 3D perspective, thereby sensibly lowering the likelihood of potential adverse effects during TS. In our study, we describe the technique and assess the feasibility, advantages, and safety of this novel imaging method in guiding TS puncture in a series of consecutive patients undergoing AF ablation. [ABSTRACT FROM PUBLISHER]