Transseptal left heart catheterization: Usefulness of the intracavitary electrocardiogram in the localization of the fossa ovalis

One of the major difficulties in left heart Catheterization through the interatrial septum is to ensure that the Brockenbrough needle tip is correctly laid on the fossa ovalis floor (FOF), which is the only area where the puncture must be done. The difficulties may be enhanced in patients with atrial enlargement and subsequent distortion of the anatomical structures. In order to reduce the hazards of the septal puncture, an electrocardiographic mapping of the right atrial endocardium was performed using the Brockenbrough needle as an exploratory electrode in a group of 20 patients. When the tip of the needle was laid against the FOF, the endoatrial electrocardiogram (EAE) registered a slight or no injury curve, even when the pressure was tight enough to perforate the septum. On the contrary, the pressure on any other area of the muscular septum or atrial walls elicited a bizarre monophasic injury curve. The peculiar electrocardiographic response of the FOF to the pressure exerted by the Brockenbrough needle tip was a valuable aid to identify the area where the transseptal puncture must be done. In addition, the sudden changes in the P wave morphology immediately after the septal perforation, provided the first clue that the left atrium has been reached.     

Value of CT localization of the fossa ovalis prior to transseptal left heart catheterization for left atrial ablation.

AIMS: Transseptal puncture (TP) can be a difficult procedure and is not without risk of complications. The purpose of this study was to evaluate the use of three-dimensional multi-detector row computed tomography (MDCT) to localize the fossa ovalis (FO) and facilitate TP in patients undergoing left atrial catheter ablation. METHODS AND RESULTS: Fourteen consecutive patients were studied. Thirteen patients underwent pulmonary vein isolation and one patient had ablation for left atrial flutter. All patients underwent cardiac MDCT imaging pre-ablation for use in conjunction with electroanatomic mapping. Prior to puncturing the interatrial septum, standard fluoroscopic views of the transseptal sheath were compared with corresponding MDCT images tagging the FO. Successful, uncomplicated TP was achieved in all 14 patients. The mean duration of TP was 15.6 +/- 10.0 min. The average fluoroscopy time was 8.5 +/- 7.4 min. The MDCT images were deemed helpful in facilitating TP in 13 patients (93%). CONCLUSION: This study demonstrates the feasibility of MDCT to localize the FO and aid TP. For patients undergoing left atrial ablation in whom MDCT imaging is undertaken pre-ablation, tagging the FO can be easily performed and is a novel tool for guiding transseptal catheterization without additional risk.     

Shifting of puncture site in the fossa ovalis during radiofrequency catheter ablation: intracardiac echocardiography-guided transseptal left heart catheterization

Intracardiac echocardiography (ICE) serves as an adjunct to fluoroscopy for electrophysiological procedures by identifying critical anatomic landmarks and confirming catheter-endocardial contact. In the present study, we investigated the usefulness of ICE for radiofrequency catheter ablation. ICE was utilized to guide transseptal puncture in 19 patients undergoing radiofrequency catheter ablation. The fossa ovalis, which was one critical anatomic landmark, had an average vertical diameter of 18.5 +/- 6.9 mm and an average horizontal diameter of 10.0 +/- 2.4 mm, as measured by ICE and fluoroscopy. Although there was only a small shift of the puncture site in the horizontal direction, the puncture site shifted towards the upper edge of the fossa ovalis for 17 patients (89%). Furthermore, we could verify that the distance between the apex of the tent-shape formed by the pressure of the puncture needle in the fossa ovalis and the left atrial wall opposing it was sufficient to carry out the procedure safely. Confirming the puncture site using ICE is useful in carrying out transseptal left heart catheterization safely.     

Transseptal left heart catheterization: Utility of a sheath technique

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.     

Transseptal left heart catheterization a 50-year odyssey

Development in the 1950s of the transseptal technique for left heart catheterization is described. Initial studies in animals and human cadavers were followed up by left atrial puncture with measurements of left atrial and left ventricular (LV) pressure (the latter using a small plastic catheter) in patients with cardiac disease. Many such procedures were performed safely without complications. Subsequent modification of the original technique for percutaneous catheter insertion allowed placement of a larger taper-tipped catheter in the LV chamber for selective LV angiography. Early clinical research studies at the National Heart Institute were performed using the transseptal method; these included investigation of the effects of increasing afterload on the normal and failing left ventricle by means of a graded angiotensin infusion to induce a progressive increase in aortic pressure. A marked decrease in the stroke volume occurred with increased afterload in the failing heart. This finding later led to the concept of afterload mismatch with limited pre-load reserve. Another early transseptal catheterization study in which measurements of LV pressure were made at different locations within the left ventricle as well as in the left atrium confirmed the presence of cavity obliteration in some patients and true obstruction in the LV outflow tract in many others. In addition, left ventriculography showed that obstruction was caused by abnormal anterior position during systole of the anterior mitral valve leaflet. With growing acceptance of retrograde catheterization of the left ventricle, the use of the transseptal technique for diagnostic purposes declined. However, in recent years, substantial renewed application of the transseptal method has occurred for special diagnostic and therapeutic purposes, including balloon valvuloplasties and electrophysiologic ablation procedures within the left heart.     

Transseptal left heart catheterization: a review of 278 studies

In our laboratory, we performed 278 transseptal left heart catheterizations in adult patients over a period of 13 years. The left atrium was entered in 91.4% of the intended left heart catheterizations. Of 252 attempts, the left ventricle was entered in 96.1%. Major complications were aortic puncture (0.7%), pericardial puncture/suspected tamponade (3.2%), systemic arterial embolism (1.1%), and suspected perforation of the inferior vena cava (0.4%). There were no deaths. Although less frequently performed during the last decade, the transseptal catheterization technique has a complication rate of the same magnitude as during periods when this method was more commonly applied.     

Transseptal catheterization of the left heart in infants and children: experience in a small volume catheterization laboratory

During a five-and-one-half year period, the transseptal technique was used for left heart catheterization in 37 patients with a variety of congenital heart disease. The age of the patients ranged from four months to 21 years and weights ranged from 6.6 to 65 kg. Access to the left heart cavities and ascending aorta was achieved in all but two patients. There were no complications. Even when used infrequently, the transseptal technique allows rapid and safe entry to the left heart cavities in infants and children.     

Transseptal left heart catheterization and the incidence of persistent iatrogenic atrial septal defects

Introduction: Access to the left atrium for invasive and interventional cardiac procedures requires a transseptal (TS) puncture that creates an iatrogenic atrial septal defect (iASD). The utilization of TS access is increasing in cardiology, and the frequency of iASD is, therefore, likely to increase as well. Here, we discuss the TS technique, review existing series of iASD with regard to incidence and clinical significance of residual iASD, and present emerging techniques utilizing TS access where iASD may result. Methods and Results: A PubMed search for “iatrogenic atrial septal defects” was performed to identify prospective series addressing the incidence of iASDs after TS procedures. We identified 10 series with primary attention to iASD. Cases involving TS access included electrophysiology ablation procedures, atrial appendage closure, and percutaneous balloon mitral valvuloplasty. Immediate postprocedural incidence of iASD was as high as 87%, with decreased incidence of residual iASD detected over time. At 18 months of follow‐up, up to 15% of iASD cases persisted. Residual iASDs were not associated with clinical sequelae of embolism, cyanosis, or right heart failure. Conclusions: iASDs are frequent following TS access and a majority resolve over time. Available evidence suggests iASDs are well tolerated but late term follow‐up is limited. With the increased utilization of TS transcatheter procedures, the frequency and size of iASDs may rise. Understanding the rare but serious clinical implications of iASD and the need for systematic surveillance in the future is warranted. (J Interven Cardiol 2011;24:254–263)     

Transseptal left heart catheterization with a Swan-Ganz flow-directed catheter: review of 173 studies

Of 178 transseptal left heart catheterizations performed, 173 successful cases are reported, with the use of a Swan-Ganz, flow-directed, balloon-tipped catheter. By means of a modified Brockenbrough technique, which is described in detail, a 10F Teflon tube (3.3 mm outside diameter) was inserted into the left atrium. Through the tube, which was continuously flushed with saline solution, a 5F Swan-Ganz catheter was introduced into the left atrium. In all cases where left atrial puncture was possible (n = 173), the left ventricle was easily entered, even in the presence of mitral stenosis. Two major complications with signs of cerebral embolism occurred in this series. The method is technically reliable and acceptably safe in cases where the transseptal route of left heart catheterization is required.     

Morphometric analysis of fossa ovalis in rheumatic heart disease

BACKGROUND: Rheumatic heart disease is an important cause of valvular disease in India, with resultant alterations in the interatrial septum and fossa ovalis. Morphometric details of fossa ovalis may help in its localization during transseptal catheterization so as to prevent complications. METHODS AND RESULTS: Autopsy heart specimens of rheumatic heart disease (n=30) and non-cardiac death (n=30) patients between 15-45 years of age were studied as case and control group, respectively. The dimensions of fossa ovalis and interatrial septum were measured. The ratio of area of fossa ovalis to septum was calculated. Case group showed a significant increase in surface area of septum and fossa as compared to control group. The septal area was significantly increased in 15-30 years and 31-45 years groups, specially females in the former group. The fossa area was increased only in 31-45 years age group. The ratio of area of fossa to septum was not statistically altered in cases versus controls. Case group, specially females of 15-30 years, showed a significant horizontal orientation of fossa as compared to controls. Cases having both mitral and aortic stenosis showed highest increase in the areas of fossa and septum, as also the most horizontal orientation of fossa. CONCLUSIONS: The enlargement of the septal area begins at an early age in rheumatic heart disease along with initial hemodynamic and valvular alterations. There is a categorical horizontal orientation of fossa ovalis in these cases. Varying dynamics in stenotic and regurgitant valves leads to varying morphological changes in dimensions of fossa ovalis and septum.     

Transseptal puncture guided by intracardiac echocardiography during percutaneous transvenous mitral commissurotomy in patients with distorted anatomy of the fossa ovalis.

Positioning of the transseptal needle during percutaneous transvenous mitral commissurotomy (PTMV) can become a difficult and risky procedure when distortion of the interatrial septum exists. We present two cases where intracardiac echocardiography (ICE) facilitated the transseptal puncture in the presence of bulging of the fossa ovalis into the right atrium.     

Clinical significance of different atlas of intracavitary electrocardiogram for PICC localization in 961 cases

PurposeTo explore the application of ECG‐guided localization technology in PICC catheterization and the clinical significance of different maps of intracavitary ECG in PICC tip localization.MethodsIn the process of catheter placement under the guidance of ultrasound, the technique of intracavitary ECG location was used. The length of the catheter was measured on the body''s surface. The amplitude of the P‐wave and the QRS‐wave groups of electrocardiograms before and during catheter placement was recorded. Nine hundred sixty‐one patients who underwent X‐ray chest film examination after catheterization were imaged on the chest film at the tip of the catheter.ResultsEight hundred four cases had a characteristic P wave, 83.66%, of which, 331 cases (50% < P/R ≤80%) had 99.09%; 425 cases (80% < P/R ≤100%) had 99.29%; 48 cases (P/R >100%) had 100%. One hundred eighteen cases of non‐specific P wave accounted for 12.28% and 79.66% of chest radiographs, of which 72 cases of P/R <50% were 100%; 46 cases of unchanged P wave were 47.83%; 34 cases of special cases accounted for 3.54% and 55.88% of chest radiographs; five cases of interference wave accounted for 0.25%, and the chest radiographs were self‐control. The in‐place rate of the body contrast catheter was 80%.ConclusionsThe accuracy of the ECG characteristic map in guiding the location of the PICC tip is higher than that of the non‐characteristic P wave, and it has more clinical significance in locating the best position of the PICC tip.