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A 74-year-old man with symptomatic premature ventricular contractions (PVCs) with a right bundle branch block and right inferior axis QRS morphology underwent electrophysiologic testing. During the PVCs, coronary sinus mapping revealed ventricular prepotentials with the earliest activation in the distal great cardiac vein (GCV) where the local ventricular electrograms were smaller in amplitude than the atrial electrograms. The transaortic approach could not reach the earliest activation site within the GCV, but the transseptal catheter ablation successfully eliminated the PVCs on the mitral valve. With catheter ablation of ventricular arrhythmias with pure mitral annular origins, a transseptal approach may be necessary.

In summary, I think it is important to state that transseptal left heart catheterization is a safe procedure when the operator pays meticulous attention to detail. Potential complications can be avoided if the operator: (1) heparinizes the sheath prior to catheterization, (2) fully heparinizes the patient when the catheter and sheath are across the septum, and (3) remembers that the left atrium in these patients is quite small and can be perforated easily by the tapered tip of the transseptal catheter. Transesophageal cardiac ultrasound makes this latter point very clear to anyone doing this procedure.

The incidence of mitral regurgitation and intramyocardial injection of contrast material during left heart catheterization in normal dogs has been investigated, comparing the transseptal with the retrograde aortic approach. A transseptal catheter passed through the mitral valve into the left ventricle almost always caused some regurgitation during injection of contrast material, even in the absence of premature ventricular contractions. There was a 33 per cent incidence of intramyocardial injection when the transseptal catheter was employed. Retrograde aortic catheterization was associated at times with minimal mitral regurgitation when premature ventricular contractions occurred during injection, but significant mitral regurgitation was never produced. In the absence of premature contractions, regurgitation did not occur. Intramyocardial injection of contrast material was not observed in this series when the retrograde aortic catheter was employed.

1. Teflon tubing is ideally suited for transseptal catheterization because of its low coefficient of friction. 2. Catheterization of the left ventricle can be easily performed with a maneuverable spring guide. 3. A Teflon-tipped cannula and a tough, flexible, Teflon guide are used for percutaneous catheter insertions. 4. Safety measures used in transseptal puncture are described. 5. Simultaneous percutaneous insertion of a retrograde Teflon aortic catheter and the transseptal catheter permit transvalvular gradients to be obtained even when a diseased mitral or aortic valve cannot be crossed.

A method is described for obtaining left and right ventricular endocardial biopsies repeatedly over a period of 3–6 mo in the dog. The left ventricular endocardial biopsy technique consists of the placement of a catheter via the venous route across the atrial septum and into the left ventricle. The biopsy catheter is in turn placed within this transseptal catheter. Tissues obtained by this method were satisfactory for both light and electron microscopic examination. At postmortem examination, only minimal and insignificant damage existed at the biopsy site. Consequently, we recommend this technique for the study of progressive pathologic changes in the endocardium that occur during the course of an experiment which can be identified and quantified in comparison to the control state.

This report describes our experience with a modified sheath transseptal catheter system. The sheath technique allows for introduction of various catheters into the left heart, including a uniquely designed pigtail catheter intended for use with this system. Fifty-three patients underwent successful transseptal catheterization, 44 of whom had severe native aortic valve stenosis and seven with suspected prosthetic aortic valve dysfunction. The technique provides optimal ventriculographic and hemodynamic information as well as improved access to the left heart in patients with aortic valve disease.