Trans interatrial septal puncture technique under fluoroscopy guidance - basics and beyond

1. TRANS-SEPTAL PUNCTURE
SATYAM RAJVANSHI

2. Dr John Ross
Ross J Jr. Trans-septal left heart catheterization: a new
method of left atrial puncture.
Ann Surg 1959;149:395– 401.

3. EVOLVING INDICATIONS FOR
TRANS-SEPTAL CATHETERIZATION
• BMV
• Edge-to-edge MV repair
• PFO/ASD closure
• Antegrade BAV
• LAA occlusion
• Paravalvular leak closure
• Percutaneous LVAD (Tandem Heart)

4. EVOLVING INDICATIONS FOR
TRANS-SEPTAL CATHETERIZATION
• BMV
• Edge-to-edge MV repair
• PFO/ASD closure
• Antegrade BAV
• LAA occlusion
• Paravalvular leak closure
• Percutaneous LVAD (Tandem Heart)
• EP – LA and LV arrhythmias
• Dilation/Stenting of PV stenosis (post-ablation)

5. EVOLVING INDICATIONS FOR
TRANS-SEPTAL CATHETERIZATION
• BMV
• Edge-to-edge MV repair
• PFO/ASD closure
• Antegrade BAV
• LAA occlusion
• Paravalvular leak closure
• Percutaneous LVAD (Tandem Heart)
• EP – LA and LV arrhythmias
• Dilation/Stenting of PV stenosis (post-ablation)
• Left heart hemodynamics
• Rarely Aortic stent grafts
• Historically Transeptal TAVI

6. CONTRAINDICATIONS
• Absolute!
LA cavity or septal thrombus/tumour

7. CONTRAINDICATIONS
• Absolute!
LA cavity or septal thrombus/tumour
• Relative
• Distorted anatomy – heart/thorax/spine
• Huge LA/RA enlargement
• Enlarged aortic root
• Interrupted IVC
• Post ASD patch repair
Experts can find a way around!

8. WE NEED 3 THINGS
Anatomical
Landmarks
Hardware
Imaging Guidance

9. WE NEED 3 THINGS
Anatomical
Landmarks
HARDWARE
Imaging Guidance

10. 21 gauge
18 gauge
270° curve
71 cm
67 cm
59 cm

11. MULLINS SHEATH AND DILATOR SYSTEM (Medtronic Inc.)
Size Sheath length Dilator length Wire size max.
ADULT
8 Fr +/- hemostatic valve 59 cm 67 cm .032 in
PEDIATRIC
8 Fr 44 cm 52 cm .025 in
6 Fr 44 cm 52 cm .025 in
BROCKENBROUGH NEEDLE (Medtronic Inc.)
Shaft Size Tip Size Length
ADULT
18 gauge 21 gauge 71 cm
PEDIATRIC
19 gauge 22 gauge 56 cm

14. WE NEED 3 THINGS
ANATOMICAL
LANDMARKS
Hardware
Imaging Guidance

16. 12
9 3
6

17. 12
9 3
6
IAS plane in supine patient
From 2’ to 7’ o clock

18. 12
9 3
6
Normal Fossa ovalis plane
4’ to 6’ o clock

19. 12
9 3
6

20. 1
2
9 3
6
Huge LA with Bulging septum –
Fossa ovalis shifts inferiorly and posteriorly
to 7’ or even 8’ o clock

21. 1
2
9 3
6
Small LA with inward septum –
Fossa ovalis shifts more anteriorly
3’ to 4’ o clock

22. RAO

23. AP

24. LAT

25. WE NEED 3 THINGS
Anatomical
Landmarks
Hardware
IMAGING
GUIDANCE

26. IMAGING GUIDANCE
• FLUOROSCOPY
• TTE
• TEE
• ICE
• CT
• MRI
• ECG

27. INUOE ANGIOGRAPHIC METHOD
Cath Cardiovasc Diagn. 1993;28:119-25.

28. INUOE ANGIOGRAPHIC METHOD
Cath Cardiovasc Diagn. 1993;28:119-25.

29. INUOE ANGIOGRAPHIC METHOD
Cath Cardiovasc Diagn. 1993;28:119-25.
PM=1.2 times vertebral width

30. HUNG’S MODIFIED METHOD
(no Angio – only aortic root pigtail)
Cath Cardiovasc Diagn. 1992;26:275-84.

31. Cath Cardiovasc Diagn. 1992;26:275-84.
HUNG’S MODIFIED METHOD
(no Angio – only aortic root pigtail)

32. TRANS-SEPTAL PUNCTURE

33. 0.032 WIRE IN
INNOMINATE
VEIN

34. SHEATH DILATOR
ASSEMBLY IN
INNOMINATE VEIN

35. TRACKING BROCKENBROUGH NEEDLE WITH
TIP JUST INSIDE DILATOR

36. DESCENT FROM
SVC – RA
RA – FOSSA

37. IMAGINARY MID-LINE
(If LA silhouette not visible –
Take RA ± PA angiogram for LA)

38. CHECK IN RAO
(check needle tip away from
Aorta and CS)

39. CHECK IN LAO/LATERAL
(check needle tip away from Aorta
and in inferoposterior third)

40. PUSH ASSEMBLY/
NEEDLE PUNCTURE
(If satisfied by anatomical
landmarks and/or
pulsation)

41. CHECK IN AP/RAO VIEW
BY ANGIO / PRESSURE / SATURATION
(If SATISFIED – advance dilator/sheath)

42. LA WIRE ENTRY

43. SPECIAL SITUATIONS

44. Giant RASmall LA Normal LA
Septal
bulge Giant
RA
Forceful torque
to middle
of IAS
Enlarged LA
6’ or 7’o clock
Enlarged RA
Bend the needle
No jumps/pulsation
Anatomic landmarks

45. PROCEDURE
SPECIFIC
PUNCTURE SITE

46. OTHER APPROACHES/TECHNIQUES
• Left Femoral
• Transjugular (LA-crosse system)
• Transhepatic
• TTE/TEE/ICE guidance
• Safe-sept wire
• Electrocautery
• RFA (Toronto RF catheter)
• Laser

47. COMPLICATIONS

48. • Overall Mortality <1%
• MUST LEARN
PERICARDIOCENTASIS
BEFORE SEPTAL
PUNCTURE
• Echo must be readily
available

49. STITCH PHENOMENA
In large LA - no septum beyond or near the
right lateral and inferior border of LA -
Overlapping walls of RA and LA form this
region - If this region punctured - both RA
and LA get involved in effusion!
(Puncture- RA free wall - PERICARDIAL
SPACE – LA lateral wall)
Needs emergency surgery!
Case report of injecting
cyanoacrylate glue in the
perforation site
Indian Heart Journal 2004:56;328-332

50. THINK BEFORE PULLING OUT!
After septal puncture – always wait for 2 minutes, watch hemodynamics/echo, then give heparin
MANAGEMENT OF STITCH/EFFUSION
Only a needle puncture-wait and watch.defer the procedure and repeat echo in regular intervals
If effusion is small and Balloon in left atrium - do BMV as reduction in LA pressure will decreases the
leak
If septum is dilated, don’t remove the dilator - Pigtail insertion and SHIFT TO CTVS with dilator in
situ
Reverse Heparin (1 mg protamine per 100 U of UFH)
Autotransfusion

51. AORTIC ROOT STAIN
• Abandon procedure
• Observe for
hemodynamics/effusion
• Only a needle puncture - wait
and watch.defer the
procedure and repeat echo in
regular intervals

52. HOW TO SUCCESSFULLY PUNCTURE
SEPTUM
The take-home points

53. FAMILIARISE WELL WITH HARDWARE

54. RAO
LAT
AP
FAMILIARISE WELL WITH ANATOMY

55. BE WATCHFUL FOR COMPLICATIONS