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Background: Intracardiac echocardiography (ICE) has been widely used in the catheter ablation of atrial fibrillation (AF). However, the value of ICE in the training of transseptal puncture (TSP) is unclear. Methods: ICE‐Training Study was a single‐center, parallel‐group, unmasked, randomized controlled trial registered in ChineseClinicalTrials.gov. Participants were randomly assigned (1:1) to different groups (1) the ICE simulator training group (ICE‐ST), in which TSP was trained and performed under the guidance of both ICE and x‐ray; and (2) the conventional simulator training group (Con‐ST), in which TSP was trained and performed only under the guidance of x‐ray. The trainees need to undergo the training stage and the evaluation stage. Results: From October 2022 to December 2022, 18 consecutive fellows (age 32.4 ± 4.4 years, 12 males) without experience of TSP were included. The training period (16.9 ± 6.6 vs. 29.6 ± 8.7 times, p = 0.003) and the fluoroscopy time (120.3 ± 25.3 vs. 189.3 ± 40.2 s, p < 0.001) of the ICE‐ST group was significantly shorter than that of the Con‐ST group. No significant difference was found in the comprehensive performance of TSP in the ICE‐ST group (composite score 96.7 ± 5.7) and the Con‐ST group (composite score 95.9 ± 6.3, p = 0.62), but the selection of TSP sites in the ICE‐ST group was commonly better than that in the Con‐ST group. Conclusions: ICE could improve the efficiency of TSP training and optimize the site of TSP to facilitate catheter manipulation in the ablation. Trial Registration: ChineseClinicalTrials.gov identifier: ChiCTR2200058377 [ABSTRACT FROM AUTHOR]

Background: Transseptal puncture (TSP) is a critical step in electrophysiological (EP) procedures, as a misdirected TSP can result in life-threatening complications. Although TSP is predominantly performed under fluoroscopic guidance in EP procedures, transesophageal echocardiography (TEE) offers more precision and certainty in the localization of the transseptal needle at the interatrial septum. Despite the widespread use of TSP, evidence supporting the added value of TEE-guided TSP in EP procedures remains limited. This study evaluates the impact of additional TEE guidance on TSP-associated complications during EP procedures. Methods: This study enrolled patients who underwent left atrial or left ventricular procedures with TSP, performed either without (fluoroscopy group) or with additional TEE guidance (TEE group), at the University Heart Center Ulm, Germany. Results: A total of 932 patients were included: 443 in the TEE group (mean age 68.1 ± 11.8 years, 40.6% female) and 489 in the fluoroscopy group (mean age 68.8 ± 11.0 years, 38.2% female). The mean number of transseptal accesses per patient was 1.18 ± 0.38 in the TEE group and 1.14 ± 0.34 in the fluoroscopy group (p = 0.101). Pericardial tamponade occurred significantly less in the TEE group (0.5%) than in the fluoroscopy group (1.8%; p = 0.046). Logistic regression revealed a 91.8% lower risk of pericardial tamponade with TEE-guided TSP compared to fluoroscopy guidance alone. The overall TEE complication rate was low (0.9%). Conclusions: TEE guidance during TSP significantly reduces the risk of pericardial tamponade in EP procedures, indicating that TSP should be performed with additional sonographic guidance to increase patient safety. [ABSTRACT FROM AUTHOR]

Background: Transseptal puncture (TSP) is a critical prerequisite for left-sided cardiac interventions, such as atrial fibrillation (AF) ablation and left atrial appendage closure. Despite its routine nature, TSP can be technically demanding and carries a risk of complications. This study presents a novel, patient-specific, anthropomorphic phantom for TSP simulation training that can be used with X-ray fluoroscopy and ultrasound imaging. Methods: The TSP phantom was developed using additive manufacturing techniques and features a replaceable fossa ovalis (FO) component to allow for multiple punctures without replacing the entire model. Four cardiologists and one cardiology trainee performed TSP on the simulator, and their performance was assessed using four metrics: global isotropy index, distance from the centroid, time taken to perform TSP, and a set of 5-point Likert scale questions to evaluate the clinicians' perception of the phantom's realism and utility. Results: The results demonstrate the simulator's potential as a training tool for interventional cardiology, providing a realistic and controllable environment for clinicians to refine their TSP skills. Experienced cardiologists tended to cluster their puncture points closer to regions of the FO associated with higher global isotropy index scores, indicating a relationship between experience and optimal puncture localization. The questionnaire analysis revealed that participants generally agreed on the phantom's realistic anatomical representation and ability to accurately visualize the TSP site under fluoroscopic guidance. Conclusions: The TSP simulator can be incorporated into training programs, offering trainees the opportunity to improve tool handling, spatial coordination, and manual dexterity prior to performing the procedure on patients. Further studies with larger sample sizes and longitudinal assessments are needed to establish the simulator's impact on TSP performance and patient outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Transseptal puncture (TSP) is a critical prerequisite for left-sided cardiac interventions, such as atrial fibrillation (AF) ablation and left atrial appendage closure. Despite its routine nature, TSP can be technically demanding and carries a risk of complications. This study presents a novel, patient-specific, anthropomorphic phantom for TSP simulation training that can be used with X-ray fluoroscopy and ultrasound imaging. Methods The TSP phantom was developed using additive manufacturing techniques and features a replaceable fossa ovalis (FO) component to allow for multiple punctures without replacing the entire model. Four cardiologists and one cardiology trainee performed TSP on the simulator, and their performance was assessed using four metrics: global isotropy index, distance from the centroid, time taken to perform TSP, and a set of 5-point Likert scale questions to evaluate the clinicians’ perception of the phantom’s realism and utility. Results The results demonstrate the simulator’s potential as a training tool for interventional cardiology, providing a realistic and controllable environment for clinicians to refine their TSP skills. Experienced cardiologists tended to cluster their puncture points closer to regions of the FO associated with higher global isotropy index scores, indicating a relationship between experience and optimal puncture localization. The questionnaire analysis revealed that participants generally agreed on the phantom’s realistic anatomical representation and ability to accurately visualize the TSP site under fluoroscopic guidance. Conclusions The TSP simulator can be incorporated into training programs, offering trainees the opportunity to improve tool handling, spatial coordination, and manual dexterity prior to performing the procedure on patients. Further studies with larger sample sizes and longitudinal assessments are needed to establish the simulator’s impact on TSP performance and patient outcomes.

Purpose of the Review: Intracardiac echocardiography (ICE) provides real-time, fluoroless imaging of cardiac structures, allowing optimal catheter positioning and energy delivery during ablation procedures. This review summarizes the use of ICE in catheter ablation of atrial fibrillation (AF). Recent Findings: Growing evidence suggests that the use of ICE improves procedural safety and facilitates radiofrequency and cryoballoon AF ablation. ICE-guided catheter ablation is associated with reduced procedural duration and fluoroscopy use. Recent studies have examined the role of ICE in guiding novel ablation techniques, such as pulsed field ablation. Finally, the use of ICE allows for early detection and timely management of potentially serious procedural complications. Summary: Intracardiac echocardiography offers significant advantages during AF ablation procedures and its use should be encouraged to improve procedural safety and efficacy. [ABSTRACT FROM AUTHOR]

BackgroundIn the era of fluoroless catheter ablation (CA), achieving a successful transseptal puncture (TSP) presents a significant challenge. We introduce a novel technique for zero-fluoroscopy and cost-effective needle-free TSP.Case summaryWe describe two cases where a GMS-1 guidewire (0.025 inch, pigtail configuration; Toray Medical Co., Ltd., Japan) was utilized for TSP. This technique was performed using either fluoroscopy or intracardiac echocardiography (ICE). The procedure was completed successfully in both cases, with no complications reported.ConclusionThe use of a 0.025 inch GMS-1 guidewire with an electrocautery technique enables effective transseptal puncture without the need for a needle or fluoroscopy. This novel approach offers a safe, efficient, and zero-fluoroscopic alternative for TSP.

BackgroundThe closure of a patent foramen ovale (PFO) using transseptal puncture has particular advantages and disadvantages. Thus, transseptal puncture should be re-evaluated in detail.AimsWe aimed to assess the effectiveness of the detailed transseptal puncture technique in patients who underwent PFO closure due to cryptogenic stroke or transient ischemic attack in terms of residual shunts and atrial fibrillation.MethodsWe prospectively analyzed 144 consecutive patients who underwent PFO closure by the detailed transseptal puncture technique between February 2013 and April 2023 in two centers. All of the patients had a >10 mm long-tunnel PFO.ResultsThe procedural success rate was 100%. However, after the procedure, moderate pericardial effusion developed in one patient (0.7%) and an acute pulmonary embolism related to femoral vein thrombosis was observed in one patient (0.7%) during the first month. Complications related to the procedure were noted in two patients (1.4%) during the first month of follow-up. Residual shunts were observed in 1.4% of cases after PFO closure.ConclusionWe demonstrated that the detailed transseptal technique is safe and effective for PFO closure. The detailed transseptal PFO closure technique significantly reduced the risk of atrial fibrillation, and the occurrence of residual shunts was significantly low following the closure.

Pulmonary vein isolation is a primary therapeutical option for controlling atrial fibrillation, particularly in cases complicated with heart failure or previously ineffective pharmacological antiarrhythmic treatment. Different techniques share the punction of the femoral vein followed by the insertion of endocardial catheters through the inferior vena cava. When an interrupted vena cava inferior is present, another approach is needed to reach the target area for ablation. We present a case and the circumstances of a 48-year-old female, when transjugular pulmonary vein isolation was performed due to persistent atrial fibrillation.

Introduction: In cryoballoon ablation (CBA) procedures, transseptal access (TSA) is generally achieved using a standard sheath and needle system that is exchanged for the cryoballoon delivery sheath and dilator over a long wire. Sheath exchange has been related with air embolic events. Recently, an integrated dilator‐needle system assembled to the cryoballoon sheath was introduced. We aimed to evaluate the efficacy and safety of an integrated TSA tool compared with the traditional approach in atrial fibrillation CBA procedures. Methods: Patients scheduled for CBA procedures were randomized 1:1 to traditional TSA (t‐TSA) or integrated TSA (i‐TSA). TSA time was defined as time from superior vena cava to LA insertion of the cryoballoon delivery sheath, after sheath exchange (t‐TSA) or directly (i‐TSA). Results: Ninety‐seven patients (76 males, mean age 59 ± 10 years) were randomized, 48 patients underwent t‐TSA, and 49 i‐TSA. Mean TSA time was 5 min 59 s ± 5 min 36 s in the t‐TSA group and 2 min 59 s ± 2 min 14 s in the i‐TSA group (p <.001). Total fluoroscopy time, skin‐to‐skin procedure time, and LA dwell time were respectively 15 ± 6, 69 ± 16, and 44 ± 12 min in the t‐TSA group and 13 ± 6, 65 ± 15, and 43 ± 11 min in the i‐TSA group (p = ns). No clinically significant acute complications related to TSA were noted in both cohorts. Conclusion: This is the first randomized study comparing both TSA approaches. TSA in CBA procedures using this integrated tool enables a safe and efficient workflow, reducing TSA time and avoiding sheath exchange. [ABSTRACT FROM AUTHOR]

Background: Complex arrhythmias often arise from the left side of the heart, necessitating established electrophysiological (EP) procedures like 3D-mapping-assisted radiofrequency (RF) ablations or pulmonary vein isolation (PVI). These procedures typically require transseptal access, emphasizing the critical role of achieving an optimal catheter position through a precise transseptal puncture (TSP). Commonly employed imaging methods for TSP guidance include fluoroscopy and interventional echocardiography. Despite their routine use, there is limited evidence on which imaging modality offers superior catheter positioning for EP procedures, and safety concerns regarding transseptal punctures with imaging remain underexplored. This study aims to systematically evaluate the feasibility, safety, and accuracy of echo-guided TSP compared to fluoroscopy-guided TSP. Methods: In this prospective study, 150 consecutive patients undergoing left atrial EP procedures were enrolled between October 2023 and February 2024 at the Ulm University Heart Center. Following optimal fluoroscopy-guided transseptal needle positioning at the interatrial septum, the catheter placement was further verified using transesophageal echocardiography (TEE). Adjustments were made in cases of suboptimal needle positioning observed in TEE. The fluoroscopically achieved septal positions were categorized based on TEE images as optimal, suboptimal, poor, or dangerous. Results: Among the 150 patients included (58.0% male), fluoroscopy achieved optimal, suboptimal, and poor/dangerous positions in 32.7%, 43.3%, and 24.0%, respectively. After TEE-guided adjustments, optimal and suboptimal positions were achieved in 59.3% and 40.7% of patients, respectively. No instances of poor or dangerous transseptal needle positions were observed under TEE guidance. Conclusions: TEE-guided TSP emerges as a feasible, more accurate, and safer imaging method for transseptal punctures in EP procedures. [ABSTRACT FROM AUTHOR]

Background: Transseptal puncture (TSP) performed with the Brockenbrough (BRK) needle is technically demanding and carries potential risks. The back end of the percutaneous transluminal coronary angioplasty (PTCA) guidewire is blunt and flexible, with good support, it can puncture the right ventricle-free wall, which is thicker than the atrial-septum. The guidewire is thin and easy to manipulate. This study evaluated the performance of TSP with a PTCA guidewire and microcatheter without a needle. Methods: The back end of a PTCA guidewire was advanced into the Tiger (TIG) catheter, within the SL1 sheath, to puncture the fossa ovalis (FO) under fluoroscopy. Subsequently, the microcatheter was inserted into the left atrium (LA) above the guidewire, and the front end of the guidewire was exchanged in the LA. After the puncture site was confirmed by contrast, the TIG catheter and a 0.032 inch wire were advanced into the LA. Finally, the sheath, with the dilator, was advanced over the wire into the LA. The safety margin of this method was tested in a pig model. Results: The puncture was successful in all seven pigs tested with a puncture-to-sheath entry time of <20 minutes and no procedure-related complications. The method was successfully used to perform a difficult TSP in a patient with an extremely tortuous inferior vena cava, in whom puncture with a BRK needle had repeatedly failed. Conclusions: Cardiologists may use the PTCA guidewire and microcatheter as an alternative to the needle while performing TSP in special conditions, such as an extremely tortuous inferior vena cava. [ABSTRACT FROM AUTHOR]

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]

Abstract Background Transseptal puncture (TSP) is a crucial technique for catheter ablation of atrial fibrillation (AF). Although intracardiac echo (ICE) facilitates a safe and accurate TSP, it is not widely used in developing countries because of the expense. This study evaluated the efficiency and safety of a novel cardiac multidetector computed tomography (MDCT)‐guided TSP during AF catheter ablation. Methods The study consisted of two cohorts. In the index cohort, TSP procedure was performed under the guidance of ICE, and we recorded the angulation of right anterior oblique of X‐ray projection. In the validation cohort, we compared the efficiency and safety of TSP guided by MDCT‐calculated angulation with propensity‐score‐matched patients who underwent TSP guided by ICE. Results We included 50 patients in the index cohort, and the mean angles of interatrial septum (IAS) measured from MDCT and ICE were 34.8 ± 6.3 and 35.1 ± 6.5, respectively. In the validation cohort, 376 patients were enrolled in the MDCT‐guided group and ICE‐guided group. Both groups had 1 case of cardiac tamponade. The mean axial plane angle was 35.46 ± 6.17 degrees, which was not influenced by age, gender, BMI, and LA size, while a moderate positive linear correlation between EF and the axial plane angle (R2 = 0.14, p = .006). Conclusion Cardiac MDCT can provide a clear vision of IAS orientation, and provide the appropriate RAO angle and height for TSP. The efficiency and safety of our MDCT‐guided TSP were comparable to ICE‐guided TSP, which may serve as an alternative method for TSP with ICE unavailable.

Background: While steerable sheaths are widely used to improve catheter stability and contact force during radiofrequency (RF) catheter ablation in patients with atrial fibrillation (AF), steerable sheaths are less commonly used during transseptal puncture. This study evaluated whether left atrial catheterization efficiency can be improved using the VersaCross combined steerable sheath and transseptal system compared to previous standard workflow. Methods: This study retrospectively analyzed AF ablation performed using the VersaCross Workflow consisting of VersaCross steerable sheath and RF wire for transseptal puncture and catheter ablation (VCW) to the standard workflow using a fixed curve sheath with RF needle followed by exchange for an Agilis steerable sheath for catheter ablation (STW). Results: Thirty patients underwent RF ablation for paroxysmal or persistent AF, 15 using the VCW and 15 using the STW. Transseptal puncture time was 10.8 mins faster with the VCW compared to the standard workflow (20.9 ± 5.9 min vs. 31.7 ± 15.1 min; p = 0.024). Time to left atrial catheterization was 40% faster with the VCW compared to the STW (21.3 ± 5.8 min vs. 35.2 ± 14.4 min; p = 0.003). Overall procedure time was 14.2 min faster in the VCW compared to the STW (86.3 ± 16.1 min vs. 100.5 ± 19.3 min; p = 0.044). Conclusions: Use of the VersaCross steerable system significantly reduced time to transseptal puncture, time to left atrial catheterization, and overall RF ablation time.

Background: Transseptal puncture (TSP) is a critical step in electrophysiological (EP) procedures, as a misdirected TSP can result in life-threatening complications. Although TSP is predominantly performed under fluoroscopic guidance in EP procedures, transesophageal echocardiography (TEE) offers more precision and certainty in the localization of the transseptal needle at the interatrial septum. Despite the widespread use of TSP, evidence supporting the added value of TEE-guided TSP in EP procedures remains limited. This study evaluates the impact of additional TEE guidance on TSP-associated complications during EP procedures. Methods: This study enrolled patients who underwent left atrial or left ventricular procedures with TSP, performed either without (fluoroscopy group) or with additional TEE guidance (TEE group), at the University Heart Center Ulm, Germany. Results: A total of 932 patients were included: 443 in the TEE group (mean age 68.1 ± 11.8 years, 40.6% female) and 489 in the fluoroscopy group (mean age 68.8 ± 11.0 years, 38.2% female). The mean number of transseptal accesses per patient was 1.18 ± 0.38 in the TEE group and 1.14 ± 0.34 in the fluoroscopy group (p = 0.101). Pericardial tamponade occurred significantly less in the TEE group (0.5%) than in the fluoroscopy group (1.8%; p = 0.046). Logistic regression revealed a 91.8% lower risk of pericardial tamponade with TEE-guided TSP compared to fluoroscopy guidance alone. The overall TEE complication rate was low (0.9%). Conclusions: TEE guidance during TSP significantly reduces the risk of pericardial tamponade in EP procedures, indicating that TSP should be performed with additional sonographic guidance to increase patient safety.

Zero-X-ray is a common ablation approach, mostly employed for right atrial procedures. The need of fluoroscopy in left atrial ablation procedures is mainly linked to transseptal puncture. Our aim, in this case-report, is to illustrate a zero-X-ray transseptal approach with a novel transseptal access system, AcQCrossTM (Medtronic), which has an integrated needle-dilator design. [ABSTRACT FROM AUTHOR]

Background: Transseptal puncture (TSP) is a crucial technique for catheter ablation of atrial fibrillation (AF). Although intracardiac echo (ICE) facilitates a safe and accurate TSP, it is not widely used in developing countries because of the expense. This study evaluated the efficiency and safety of a novel cardiac multidetector computed tomography (MDCT)‐guided TSP during AF catheter ablation. Methods: The study consisted of two cohorts. In the index cohort, TSP procedure was performed under the guidance of ICE, and we recorded the angulation of right anterior oblique of X‐ray projection. In the validation cohort, we compared the efficiency and safety of TSP guided by MDCT‐calculated angulation with propensity‐score‐matched patients who underwent TSP guided by ICE. Results: We included 50 patients in the index cohort, and the mean angles of interatrial septum (IAS) measured from MDCT and ICE were 34.8 ± 6.3 and 35.1 ± 6.5, respectively. In the validation cohort, 376 patients were enrolled in the MDCT‐guided group and ICE‐guided group. Both groups had 1 case of cardiac tamponade. The mean axial plane angle was 35.46 ± 6.17 degrees, which was not influenced by age, gender, BMI, and LA size, while a moderate positive linear correlation between EF and the axial plane angle (R2 = 0.14, p =.006). Conclusion: Cardiac MDCT can provide a clear vision of IAS orientation, and provide the appropriate RAO angle and height for TSP. The efficiency and safety of our MDCT‐guided TSP were comparable to ICE‐guided TSP, which may serve as an alternative method for TSP with ICE unavailable. [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]

Background: Percutaneous radiofrequency catheter ablation (RFA) in hypertrophic obstructive cardiomyopathy (HOCM) with intracardiac echocardiography (ICE) guidance is a novel method that has been proven to be safe and effective in a small sample size study. RFA of the interventricular septum through a trans-atrial septal approach in HOCM patients with a longer follow-up has not been reported. Methods: 62 consecutive patients from March 2019 to February 2022 were included in this study. The area between the hypertrophied septum and anterior mitral valve (MV) leaflet was established using the three-dimensional system (CARTO 3 system), and all patients received atrial septal puncture under the guidance of intracardiac echocardiography (ICE). Point-by-point ablation was performed to cover the contact area. After ablation, the patients were followed up for 1, 3, 6, and 12 months. Transthoracic echocardiography was performed at 1, 3, 6, and 12 months, and resting and exercise-provoked left ventricular outflow tract (LVOT) gradients were obtained. Results: During the 1-year follow-up, most patients' symptoms improved. The NYHA grading of the patient decreased from 2 (2, 3) at baseline to 2 (1, 2) (p < 0.001). LVOT peak gradient at rest was decreased from 59 (±27) mmHg to 30 (±24) mmHg (p < 0.001), and the provoked peak gradient was decreased from 99 (±33) mmHg to 59 (±34) mmHg (p < 0.001). The average maximum septal thickness was reduced from 21 (±4) mm to 19 (±4) mm (p < 0.001). Conclusions: After a 1-year follow-up, ice-guided radiofrequency ablation for HOCM might be a safe, accurate, and effective method. The catheter might be reliably attached to the ablation target area via trans-atrial septal access. [ABSTRACT FROM AUTHOR]

Introduction: Mechanical force to achieve transseptal puncture (TSP) using a standard needle may lead to overshooting and injury, and can potentially be avoided using a radiofrequency (RF)‐powered needle or wire. Applying electrocautery to needles and guidewires as an alternative to purpose‐built RF systems has been associated with safety risks, such as tissue coring and thermal damage. The commercially available AcQCross needle‐dilator system (Medtronic) features a sharp open‐ended needle for mechanical puncture, as well as a built‐in connector to enable energy delivery for RF puncture. This investigation compares the safety and efficacy of the AcQCross needle to the dedicated VersaCross RF wire system and generator (Baylis Medical/Boston Scientific). Methods: In an ex vivo porcine model, VersaCross wire punctures were performed using 1 s, constant mode (approx. 10 W) with maximum two attempts. AcQCross punctures were performed by applying energy for 2 s using a standard electrosurgical generator at 10 W (max. five attempts), 20 W (max. two attempts), and 30 W (max. two attempts). Efficacy was assessed in terms of puncture success and a number of energy applications required for TSP. Safety was assessed quantitatively as force required for TSP, energy required to puncture, and incidence of tissue coring, as well as by qualitative assessment of puncture sites. Additional qualitative observation of tissue cores and debris were obtained from TSP performed in live swine. Results: RF TSP was 100% successful using the VersaCross wire with 1.0 ± 0.0 attempts. When power was used with the AcQCross needle, it failed to puncture at low (10 and 20 W) power settings; TSP was achieved with 30 W of energy with 91% success using 1.53 ± 0.51 attempts (p <.05 vs. VC) with greater variability (F1,33 = 9223.5, p <.0001). Compared to RF puncture using the VersaCross system, mechanical puncture, alone, using the AcQcross needle required six times more force (8 mm additional forward device displacement) to perforate the septum. Qualitative assessment of puncture sites revealed larger defects and more tissue charring with the AcQCross needle at 30 W compared to punctures with VersaCross wire. Tissue coring with the open‐ended AcQCross needle was observed in vivo and measured to occur in 57% of punctures using the ex vivo model; no coring was observed with the closed‐tip VersaCross wire. Conclusions: The AcQCross needle frequently required higher energy of 30 W to achieve RF TSP and was associated with tissue coring and charring, which have been, previously, reported when electrifying a standard open‐ended mechanical needle or guidewire. These findings may limit safety and effectiveness compared to the VersaCross system. [ABSTRACT FROM AUTHOR]

Background Patients with atrial fibrillation (AF) have a five-fold increase in stroke events, and ∼90% of the thrombi develop in the left atrial appendage (LAA). Left atrial appendage occlusion (LAAO) has emerged as a safe and feasible alternative to oral anticoagulation (OAC) for stroke prevention in selected patients with non-valvular AF and contraindications to OAC. Atrial fibrillation is closely associated with mitral disease, and there is a growing interest in combined procedures. More than half of patients undergoing a mitral transcatheter edge-to-edge repair (M-TEER) suffer of AF and many have high or unacceptable bleeding risk. Case summary We present a case of an 80-year-old woman suffering from paroxysmal AF, right carotid siphon aneurysm, and primary mitral regurgitation, with a high bleeding risk, who underwent a combined intervention of M-TEER and LAAO. Discussion The combination of these two procedures is a logical step once the access to the left atrium is obtained with a transseptal puncture (TSP) and a transesophageal echocardiography (TEE) is in place to guide both procedures. The turning point in LAAO procedure is a correct TSP allowing coaxial alignment of the sheath with the LAA neck. Steerable delivery sheaths are promising dedicated tools, particularly in challenging anatomy or during combined procedures requiring different TSP positions. [ABSTRACT FROM AUTHOR]

Introduction. The use of high-power radiofrequency current is considered to be a promising alternative to the currently used technique of catheter ablation of atrial fibrillation (AF) with radiofrequency current of normal power. To date, there are no studies on the application of this technique using catheters without external irrigation. The aim. To study direct results of application of high-power radiofrequency current in AF catheter ablation using non-irrigated catheters. Materials and methods. We analyzed 30 consecutive patients who underwent primary catheter ablation (12 women and 18 men, mean age of the patients was 57.6 ± 11.7 years). Concomitant pathology (coronary heart disease, hypertension, diabetes mellitus) was observed in 19 (63.3%) patients. Wide isolation of pulmonary veins was performed, and in nonparoxysmal forms, applications were added in the places where fragmented activity was registered or in the line of applications between ipsilateral pulmonary veins and inferior left pulmonary vein and mitral valve annulus. The applications were made with a 4 mm electrode without irrigation function with wiping it after every 30 applications. Application parameters were 40-45 Watt power, application time 10 seconds, target temperature 55°C. Results. The mean left atrial catheter dwelling time was 1.6 ± 0.3 hours. The mean time of X-ray exposure was 8.2 ± 2.3 minutes. The average number of applications was 127.8 ± 23.6. It was not possible to isolate 3 pulmonary veins in three patients: one superior left pulmonary vein and two inferior right pulmonary veins (2.5% of all pulmonary veins). No complications related to the procedure were observed. The occurrence of AF in the early postoperative period was observed in 4 (13.3%) patients. Conclusions. The immediate results of applying the radiofrequency current of 40-45 W with the application duration of 10 seconds and the target temperature of 55°C during AF catheter ablation using non-irrigated catheters indicate the safety of this technique. It is necessary to study a larger contingent of patients and long-term results.

A 74-year-old man after multiple mitral valve surgeries underwent catheter ablation of a bi-atrial tachycardia (BiAT). Ultra-high resolution activation mapping exhibited a reentrant circuit propagating around the inferior to anterior mitral annulus and right atrial (RA) septum with two interatrial connections. At the transeptal puncture site, continuous fractionated electrograms were recorded during the BiAT, and entrainment pacing revealed a post-pacing interval similar to the tachycardia cycle length, which suggested that the interatrial conduction from the RA to the left atrium (LA) was located just at the transseptal puncture site. A radiofrequency application inside the transseptal puncture hole could successfully eliminate the BiAT. The ablation target for BiATs propagating around the mitral annulus and RA septum is generally the anatomical mitral isthmus (MI). Since the present case had multiple incisions on both the RA and LA septum due to mitral valve surgeries, there was the possibility of the occurrence of a BiAT including the RA and LA septum after performing an MI linear ablation. Therefore, the preferable ablation target for the BiAT in the present case appeared to be the interatrial connection. Ultra-high resolution detailed mapping not only on the atrial endocardium but also in the transseptal puncture hole may be useful for identifying a critical interatrial connection of BiAT circuits.

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]

Purpose: Percutaneous closure of the left atrial appendage (LAA) reduces the risk of embolic stroke in patients with atrial fibrillation. Thereby, the optimal transseptal puncture (TSP) site differs due to the highly variable anatomical shape of the LAA, which is rarely considered in existing training models. Based on non-contrast-enhanced magnetic resonance imaging (MRI) volumes, we propose a training model for LAA closure with interchangeable and patient-specific LAA enabling LAA-specific identification of the TSP site best suited. Methods: Based on patient-specific MRI data, silicone models of the LAAs were produced using a 3D-printed cast model. In addition, an MRI-derived 3D-printed base model was set up, including the right and left atrium with predefined passages in the septum, mimicking multiple TSP sites. The various silicone models and a tube mimicking venous access were connected to the base model. Empirical use of the model allowed the demonstration of its usability. Results: Patient-specific silicone models of the LAA could be generated from all LAA patient MRI datasets. The influence of various combinations regarding TSP sites and LAA shapes could be demonstrated as well as the technical functionality of the occluder system. Via the attached tube mimicking the venous access, the correct handling of the deployment catheter even in case of not optimal puncture site could be practiced. Conclusion: The proposed contrast-agent and radiation-free MRI-based training model for percutaneous LAA closure enables the pre-interventional assessment of the influence of the TSP site on the access of patient-specific LAA shapes. A straightforward replication of this work is measured by using clinically available imaging protocols and a widespread 3D printer technique to build the model. [ABSTRACT FROM AUTHOR]

Patients with atrial fibrillation who take a high bleeding risk and are not candidates for oral anticoagulation therapy are increasingly being referred for left atrial appendage closure (LAAC) as an alternative method of stroke prevention. However, certain manipulations performed during the LAAC procedure, such as transseptal puncture (TSP), may potentially result in vessel injury and lead to cardiac tamponade or even fatality. Clinical significance and management strategies associated with these complications remain controversial. A 74-year-old female patient with atrial fibrillation was referred for left atrial appendage occlusion. During the puncture of the atrial septum, the catheter sheath inadvertently exited through the roof of the right atrium and continued to advance, resulting in pulmonary artery perforation. The patient underwent immediate pericardiocentesis and drainage, followed by surgical exploration for suturing the tear in the pulmonary artery and ligation of the left atrial appendage. This represents the first reported case of a pulmonary artery perforation occurring during a transseptal puncture procedure for left atrial appendage closure. The case exemplifies the feasibility of emergency cardiac surgery as a therapeutic intervention.

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Introduction: Transseptal puncture (TSP) to allow for large delivery sheath left atrial (LA) access remains a challenging aspect of LA appendage closure (LAAC) in patients with prior history of TSP, thick or lipomatous septum, atrial septal aneurysms, or other complex cardiac anatomies. This study investigates the use of the VersaCross large access (VLA) system (Baylis Medical/Boston Scientific) to improve procedural efficiency of LAAC compared to the standard needle workflow. Methods and Results: Fifty LAAC procedures using WATCHMAN FLX between November 2021 and September 2022 were retrospectively analyzed comparing the VLA workflow (n = 25) to the standard needle workflow (n = 25). Study primary endpoint was time to procedural efficiency, and secondary endpoints included TSP time, acute LAAC success, fluoroscopy use, device recaptures, and periprocedural complications. Acute LAAC was successfully completed in all cases with no intraprocedural complications. TSP time was faster, but not significant, using the VLA workflow compared to the standard RF needle workflow (2.6 ± 1.1 min vs. 3.0 ± 1.8 min, p = 0.38). Time to WATCHMAN sheath in LA from TSP was 27% faster (1.5 ± 0.8 min vs. 2.1 ± 0.9 min; p = 0.03), and time to WATCHMAN release from TSP was 19% faster (10.5. ± 2.5 min vs. 13.0 ± 3.7 min; p = 0.01) with the VLA workflow. Overall procedure time was 15% faster (30.4 ± 5.1 min vs. 36.0 ± 6.6 min; p = 0.003) using VLA. Fluoroscopy time was 25% lower (4.0 ± 2.2 min vs. 5.5 ± 2.3 min; p = 0.003) and fluoroscopy dose was 60% lower (97.0 ± 91.7 mGy vs. 241.8 ± 240.6 mGy; p = 0.01) and more consistent [F‐test, p ˂ 0.0001] using the VLA workflow compared to the needle workflow. Conclusion: The VLA system streamlines LAAC procedures, improving LAAC efficiency and reducing fluoroscopy use by allowing for de novo dilation of the septum for large‐bore delivery sheaths, and reducing device exchanges and delivery sheath manipulation. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Three‐dimensional multiplanar analysis and real‐time three‐dimensional guidance using transesophageal echocardiography can help to identify and access the ideal position for transseptal puncture even in the presence of atrial septal occluders. Transseptal puncture (TSP) for the percutaneous mitral valve edge‐to‐edge repair (PMVR) after percutaneous atrial septal defect (ASD) closure is a rare and challenging issue. Here, we present a case illustrating the feasibility of real‐time three‐dimensional transesophageal echocardiographic guidance for TSP without ASD closure device injury. [ABSTRACT FROM AUTHOR]

Aims: The widespread use of three-dimensional (3D) mapping systems and echocardiography in the field of cardiac electrophysiology has made it possible to perform transseptal punctures (TSP) with low or no fluoroscopy. However, such attempts in adults with congenital heart disease (ACHD) who have previously undergone surgical or interventional treatment are limited. Therefore, we sought to explore the feasibility and safety of an approach to perform zero- or low-fluoroscopy TSP in ACHD patients undergoing left atrial cardiac ablation procedures. Methods and results: This study included 45 ACHD patients who underwent TSP for ablation of left-sided tachycardias (left atrium or pulmonary venous atrium). Computed tomography (CT) of the heart was performed in all patients prior to ablation. 3D mapping of the right-sided heart chambers before TSP was used to superimpose the registered anatomy, which was subsequently used for the mapping-guided TSP technique. TSP was performed with zero-fluoroscopy in 27 patients, and the remaining 18 patients had a mean fluoroscopy exposure of 315.88 ± 598.43 μGy.m2 and a mean fluoroscopy duration of 1.9 ± 5.4 min. No patient in this cohort experienced TSP-related complications. Conclusion: Our study describes a fluoroscopy-free or low-dose fluoroscopy approach for TSP in ACHD patients undergoing catheter ablation of left-sided tachyarrhythmias who had been previously treated surgically or interventionally due to congenital heart defects. By superimposing 3D electroanatomic mapping with cardiac CT anatomy, this protocol proved to be highly effective, feasible and safe. [ABSTRACT FROM AUTHOR]

Transseptal puncture is an increasingly common procedure undertaken to gain access to the left side of the heart during structural heart disease interventions. Precision guidance during this procedure is paramount to ensure success and patient safety. As such, multimodality imaging, such as echocardiography, fluoroscopy, and fusion imaging, is routinely used to guide safe transseptal puncture. Despite the use of multimodal imaging, there is currently no uniform nomenclature of cardiac anatomy between the various imaging modes and proceduralists, and echocardiographers tend to use imaging modality-specific terminology when communicating among the various imaging modes. This variability in nomenclature among imaging modes stems from differing anatomic descriptions of cardiac anatomy. Given the required level of precision in performing transseptal puncture, a clearer understanding of the basis of cardiac anatomic nomenclature is required by both echocardiographers as well as proceduralists; enhanced understanding can help facilitate communication across specialties and possibly improve communication and safety. In this review, the authors highlight the variation in cardiac anatomy nomenclature among various imaging modes. [ABSTRACT FROM AUTHOR]

We present the case of a patient with risk factors and a noninvasive evaluation that suggested postcapillary pulmonary hypertension, but in fact had invasive hemodynamics consistent with precapillary pulmonary hypertension. A thorough hemodynamic evaluation of pulmonary hypertension must be performed, as treatment is linked to the underlying physiology. (Level of Difficulty: Advanced.)

Key Clinical Message Three‐dimensional multiplanar analysis and real‐time three‐dimensional guidance using transesophageal echocardiography can help to identify and access the ideal position for transseptal puncture even in the presence of atrial septal occluders. Abstract Transseptal puncture (TSP) for the percutaneous mitral valve edge‐to‐edge repair (PMVR) after percutaneous atrial septal defect (ASD) closure is a rare and challenging issue. Here, we present a case illustrating the feasibility of real‐time three‐dimensional transesophageal echocardiographic guidance for TSP without ASD closure device injury.

Introduction: Transseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three‐dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system‐guided TSP and ICE‐guided TSP techniques. Methods: We conducted a prospective observational study of patients undergoing TSP for left atrial catheter ablation procedures (mostly atrial fibrillation ablation). Propensity scoring was used to match patients undergoing 3D‐guided TSP with patients undergoing ICE‐guided TSP. Logistic regression was used to compare the clinical data, procedural data, fluoroscopy time, success rate, and complications between the groups. Results: Sixty‐five patients underwent 3D‐guided TSP, and 151 propensity score‐matched patients underwent ICE‐guided TSP. The TSP success rate was 100% in both the 3D‐guided and ICE‐guided groups. Median needle time was 4.00 min (interquartile range [IQR]: 2.57–5.08) in patients with 3D‐guided TSP compared to 4.02 min (IQR: 2.83–6.95) in those with ICE‐guided TSP (p =.22). Mean fluoroscopy time was 0.2 min (IQR: 0.1–0.4) in patients with 3D‐guided TSP compared to 1.2 min (IQR: 0.7–2.2) in those with ICE‐guided TSP (p <.001). There were no complications related to TSP in both group. Conclusions: Three‐dimensional mapping‐guided TSP is as safe and effective as ICE‐guided TSP without additional cost. [ABSTRACT FROM AUTHOR]

Background Transient ST-segment elevation or coronary artery spasm during transseptal catheterization has been previously described. Most cases were either reversible or asymptomatic. Case summary We present a case of severe multiple coronary artery spasms with advanced atrioventricular block and ventricular fibrillation during compression of the fossa ovalis by a sheath catheter, before the performance of the transseptal puncture procedure for mitral transcatheter edge-to-edge-repair. Discussion The mechanical effects of forward tension from transseptal puncture on the interatrial vagal network could be the most possible explanation for the occurrence of this phenomenon. [ABSTRACT FROM AUTHOR]

Abstract Introduction Cryoballoon (CB) guided pulmonary vein isolation (PVI) is an established procedure in the treatment of atrial fibrillation (AF). Transseptal access is an indispensable step during PVI and may be associated with severe complications. For specific interventions, specific puncture sites of the fossa ovalis are advantageous. Here, we analyzed the potential impact of a transesophageal echocardiography (TOE) guided transseptal puncture on nadir temperatures in CB PVI. Methods and Results We retrospectively analyzed 209 patients undergoing CB PVI in our hospital. The use of TOE had been at the operator’s discretion. No TOE‐related complications such as perforation of the pharynx or esophagus or loss of teeth were noted. Concerning the applied freezes, we found significantly lower nadir temperatures in all PVs in the TOE group than in the non‐TOE group. Procedure time and fluoroscopy time and complications were similar in both groups. Conclusion TOE‐guided TSP in CB PVI is safe and feasible. Our study found significantly lower nadir temperatures of CB freezes after TOE‐guided TSP which potentially underscores the value of a more infero‐anterior puncture site.

AimTo propose a standardized workflow for 3D-electroanatomical mapping guided pulmonary vein isolation in pigs.Materials and methodsDanish female landrace pigs were anaesthetized. Ultrasound-guided puncture of both femoral veins was performed and arterial access for blood pressure measurement established. Fluoroscopy- and intracardiac ultrasound-guided passage of the patent foramen ovale or transseptal puncture was performed. Then, 3D-electroanatomical mapping of the left atrium was conducted using a high-density mapping catheter. After mapping all pulmonary veins, an irrigated radiofrequency ablation catheter was used to perform ostial ablation to achieve electrical pulmonary vein isolation. Entrance- and exit-block were confirmed and re-assessed after a 20-min waiting period. Lastly, animals were sacrificed to perform left atrial anatomical gross examination.ResultsWe present data from 11 consecutive pigs undergoing pulmonary vein isolation. Passage of the fossa ovalis or transseptal puncture was uneventful and successful in all animals. Within the inferior pulmonary trunk 2–4 individual veins as well as 1–2 additional left and right pulmonary veins could be cannulated. Electrical isolation by point-by-point ablation of all targeted veins was successful. However, pitfalls including phrenic nerve capture during ablation, ventricular arrhythmias during antral isolation close to the mitral valve annulus and difficulties in accessing right pulmonary veins were encountered.ConclusionFluoroscopy- and intracardiac ultrasound-guided transseptal puncture, high-density electroanatomical mapping of all pulmonary veins and complete electrical pulmonary vein isolation can be achieved reproducibly and safely in pigs when using current technologies and a step-by-step approach.

Three-dimensional electroanatomical mapping (3D EAM) has expanded radiofrequency catheter ablation applications in humans to almost all complex arrhythmias and has drastically reduced fluoroscopy use, yet its potential in dogs is poorly investigated. The objectives of the current study were to assess the feasibility and safety of 3D EAM of all four heart chambers, 3D EAM-guided biopsies and transseptal puncture in dogs. Eight healthy purpose-bred Beagle dogs. Electroanatomical mapping was performed under general anaesthesia during sinus rhythm using a 22-electrode mapping catheter. Left heart catheterisation was achieved by either retrograde transaortic access (n = 4) or transseptal puncture (n = 4). Successful 3D EAM of the right atrium and ventricle was achieved in all dogs at a median time of 33 (13–40) min and 17 (3–52) min, respectively. Left atrial and ventricular 3D EAM was successful in six and seven dogs, at a median time of 17 (4–27) min and 8 min (4–19 min), respectively. Complications requiring intervention occurred in one dog only and were a transient third degree atrioventricular block and pericardial effusion following transseptal puncture, which was treated by pericardiocentesis. All dogs recovered uneventfully. Fluoroscopy time was limited to a median of 7 min (0–45 min) and almost exclusively associated with transseptal puncture. Three-dimensional EAM of all cardiac chambers, including mapping-guided biopsy and transseptal puncture is feasible in small dogs. Complications are similar to those reported in human patients. This suggests a potential added value of 3D EAM to conventional electrophysiology in dogs with arrhythmias. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the feasibility and safety of an innovative "all in one" integrated transseptal crossing device to achieve transseptal puncture (TSP). Methods: Twenty patients (10 males, mean age 65.65 ± 9.25 years), indicated to supraventricular left side tachyarrhythmia ablation, underwent TSP using a new-generation integrated crossing device, and a control cohort of twenty patients (10 males, mean age 65.5 ± 10.12 years) underwent TSP using the traditional TSP system. Results: In all the study patients, the novel TSP device led to a successful and safe access to the left atrium (LA). The mean transseptal time, defined as the time occurring between the groin puncture and the advancing of the guidewire into the left superior pulmonary vein (PV), was 3 min 33 s ± 44 s, 7 min 5 s ± 36 s in the control cohort. Additionally, we compared the cost of the two systems. No acute complications related to the TSP were noted in both cohorts. Conclusions: TSP performed with the new integrated transseptal system is feasible and safe. [ABSTRACT FROM AUTHOR]

Background: Although fluoroless transseptal puncture (TSP) guided by intracardiac echocardiography (ICE) has been used for many years, there are no reports of an accurate site-specific method for TSP in detail, especially about the safety and efficiency of the method. This study aimed to compare the efficacy and safety of TSP guided by three-dimensional ICE using a fluoroless site-specific method with that of the conventional fluoroless method in patients with atrial fibrillation (AF). Methods: This prospective study included 60 patients with AF scheduled for radiofrequency ablation who were assigned to undergo modified fluoroless site-specific TSP (SS-ICE group, n = 30) or conventional fluoroless TSP (C-ICE group, n = 30). TSP was guided by three-dimensional ICE in both study groups. Results: All fluoroless TSP were performed successfully in both groups. There were no significant differences in patient characteristics, Pre-TSP time (11.3 ± 1.7 min vs. 11.1 ± 1.6 min, P = 0.822) and TSP time (3.4 ± 0.9 min vs. 3.5 ± 1.1 min, P = 0.772) between the SS-ICE group and the C-ICE group. The distance between the actual traversing point and the presetting point in the fossa ovalis was less than 5 mm in 87% of patients (26/30, 3.1 ± 1.2 mm) in the SS-ICE group. There were no TSP-related complications in either group. Conclusion: SS-ICE method is a simple, safe, and effective approach for fluoroless site-specific TSP. [ABSTRACT FROM AUTHOR]

Background: Recently, a novel integrated dilator-needle system (AcQCross Qx, Acutus Medical) was introduced to reduce the number of exchanges for a transseptal access. This system can be used in combination with large bore sheaths. In this pilot study, we evaluated the safety and efficacy of a zero-exchange approach with the AcQCross system in cryoballoon procedures.Methods: In this retrospective single-center study, we included 40 patients (AcQCross: n = 20; control group: n = 20) who underwent a cryoballoon procedure for the treatment of atrial fibrillation. In the AcQCross and control group, patients underwent ablation with POLARx (Boston Scientific) and Arctic Front Advance Pro (AFA-Pro, Medtronic) in equal numbers (n = 10). In the AcQCross group, the AcQGuide Max sheath (Acutus Medical) was used in all POLARx cases.Results: The baseline characteristics of the study population were comparable between groups. In the AcQCross group, there was a reduction in procedure time (49.7 ± 9.0 min vs. 59.6 ± 8.1 min, P < 0.001) and time from puncture until balloon delivery (15.5 ± 6.8 min vs. 21.5 ± 7.4 min, P = 0.01) in comparison with the control group. The balloon in body time, fluoroscopy time, number of cryoapplications, and biophysical parameters were similar between groups. There was one temporary phrenic nerve injury in the AcQCross group. Importantly, no signs of air embolism were noted with the AcQGuide Max sheath.Conclusions: The use of the novel AcQCross system improves procedural efficacy in cryoballoon procedures by reducing the number of exchanges. [ABSTRACT FROM AUTHOR]

Background: Transseptal puncture to achieve left atrial access is necessary for many cardiac procedures, including atrial fibrillation ablation. More recently, there has been an increasing need for left atrial access using large caliber sheaths, which increases risk of perforation associated with the initial advancement into the left atrium. We compared the effectiveness of a radiofrequency needle-based transseptal system versus conventional needle for transseptal access.Methods: This prospective controlled trial randomized 161 patients with symptomatic paroxysmal atrial fibrillation undergoing cryoballoon pulmonary vein isolation to transseptal access with a commercially available transseptal system (radiofrequency needle plus stiff pigtail wire; RF + Pigtail group) versus conventional transseptal access (standard group). The primary outcome was time required for left atrial access. Secondary outcomes included failure of the assigned transseptal system, radiation exposure, and complications.Results: The median transseptal puncture time was significantly shorter using the radiofrequency needle plus stiff pigtail wire transseptal system compared with conventional transseptal (840 ± 323 vs. 956 ± 407 s, P = 0.0489). Compared to conventional transseptal puncture, fewer transseptal attempts were required (1.0 ± 0.5 RF applications vs. 1.3 ± 0.8 mechanical punctures, P = 0.0123) and the fluoroscopy time was significantly shorter (72.0 [IQR 48.0, 129.0] vs. 93.0 [IQR 60.0, 171.0] s, P = 0.0490) with the radiofrequency needle plus stiff pigtail wire transseptal system. Failure to achieve transseptal LA access with the assigned system was rarely observed (1.3% vs. 5.7%, P = 0.2192). There were no procedural complications observed with either system.Conclusions: The use of a radiofrequency needle plus stiff pigtail wire resulted in shorter time to left atrial access and reduced fluoroscopy time compared to left atrial access using conventional transseptal equipment.Trial Registration: ClinicalTrials.gov identifier NCT03199703. [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve-in-valve implantation is a preferred treatment for degenerating mitral bioprosthetic valves in high-risk surgical patients. A balloon-expandable transcatheter heart valve delivered through a postero-inferior transseptal puncture is deployed within the prosthesis over a guidewire secured in the left ventricle. Patients with aneurysmal left atrium and altered angulation between the planes of atrial septum and mitral prosthesis have unstable position of the guidewire that flips out of the left ventricle into the left atrium when the valve delivery system is advanced. Instead of a transapical access to snare the guidewire and create a railroad in such instances, we report a new technique of transarterial retrograde snaring of the guidewire in the left ventricle for stabilization., (© 2024 Wiley Periodicals LLC.)