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Review
. 2015 Jan-Feb;67(1):70-6.
doi: 10.1016/j.ihj.2015.02.024. Epub 2015 Mar 12.

How to perform transeptal puncture

Nitish Naik  1
Affiliations
Review

How to perform transeptal puncture

Nitish Naik. Indian Heart J. 2015 Jan-Feb.
No abstract available

PubMed Disclaimer

Figures

Fig. 1
Fig. 1
a: Mullins sheath with dilator. b: Transeptal needles: The needle on the left is the Brockenbrough needle. The one in the middle is BRK needle from St Jude Medical while the needle on the right is the BRK1 needle.
Fig. 2
Fig. 2
AP fluoroscopic view with a Mullins sheath and Brockenbrough needle in the SVC. Pigtail catheter is placed in the aorta with the loop of the pigtail resting in the non-coronary cusp.
Fig. 3
Fig. 3
Brockenbrough needle inserted into the Mullins sheath with the needle flange pointing at 3 o' clock position.
Fig. 4
Fig. 4
AP fluoroscopic view with the Mullins sheath and Brockenbrough needle now at the level of the aortic valve.
Fig. 5
Fig. 5
AP fluoroscopic view with the Mullins sheath and Brockenbrough needle positioned at the expected area of the fossa ovalis.
Fig. 6
Fig. 6
RAO projection with the Mullins sheath and Brockenbrough needle at the expected area of fossa ovalis. Note that the tip of the needle looks away from the operator.
Fig. 7
Fig. 7
Lateral projection at the same position as in Figs. 5 and 6. The needle looks posteriorly towards the spine.
Fig. 8
Fig. 8
Radiographic contrast injection in the left atrium through the Mullins sheath.
Fig. 9
Fig. 9
Hemodynamic trace obtained from the Mullins sheath at the fossa ovalis. The pressure recording is at 25 mm paper speed and on a 0–50 mmHg scale with each line representing 5 mmHg. The patient is in sinus rhythm. When the Mullins sheath reaches the fossa ovalis the pressure trace becomes a straight line as it abuts the septum. Once the septal puncture is performed the pressure trace and waveform of the left atrium is seen.
Fig. 10
Fig. 10
LAO fluoroscopic view with the needle in the same position as in Figs. 5–7. Note the slight overlap of the Brockenbrough needle with the pigtail catheter in the aorta.
Fig. 11
Fig. 11
a and b, AP and RAO fluoroscopic projection with a decapolar catheter positioned in the coronary sinus and the Mullins sheath with Brockenbrough needle at the fossa ovalis. Note that the needle is posterior to the os of the coronary sinus in the RAO view.
Fig. 12
Fig. 12
RAO projection in a patient who underwent concomitant mitral valvuloplasty and ablation of a left free wall pathway. Pigtail catheter in the aorta, decapolar catheter in the coronary sinus and Brocekenbrough needle at fossa ovalis. The needle lies approximately a centimeter below the aortic valve (line A) and posterior to both the aorta and the coronary sinus os (line B), which mark the anterior boundary of the interatrial septum. The puncture needle should not dip below coronary sinus os which also marks the anteroinferior margin of the interatrial septum (line C). The posterior margin of the left atrium is visible on the RAO projection (line D) though this overlaps with the pulmonary vein antrum and the right atrium. Septal puncture is best performed in the center of this “box” that is so formed. Entry into the left ventricle (LV) is most easily achieved if the entry is made in between lines B and D. The closer the needle is to line B, the puncture becomes more anterior and closer to the mitral annulus. This may impede easy LV entry; in difficult cases, a retro loop along the posterior wall of LA may facilitate LV entry. A high and anterior puncture risks entry into the aorta which may be catastrophic. A very posterior puncture is associated with the risk of pericardial tamponade; in some cases although the needle may enter the left atrium, it may have “stitched” the posterior walls of the right atrium and left atrium.
Fig. 13
Fig. 13
a and b, LAO and lateral fluoroscopic projections with the needle in the same position as Fig. 9.
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References

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