Fluoroscopy-free Atrial Transseptal Puncture

Abstract

Introduction: Fluoroscopy is traditionally used in atrial transseptal puncture (TSP); however fluoroscopy exposes patient and physician to excess radiation. Here, we describe a feasibility study of a zero-fluoroscopy transseptal puncture (ZFTSP) technique utilising electroanatomical mapping (EAM) and intracardiac echo (ICE) in a small case series of patients undergoing ablation for atrial fibrillation (AF). We then compare this technique to other established ZFTSP techniques for paroxysmal AF ablation.

Methods: Seven patients received ZFTSP. An Acunav™ ICE catheter (Biosense Webster Inc., California, US) was placed in the right atrium, then an Agilis™ sheath (St. Jude Medical, Saint Paul, Minnesota, US) was established into the inferior vena cava. A ThermoCool^® SmartTouch™ catheter (Biosense Webster Inc., California, US) was inserted through the Agilis to map the fossa ovalis. Mapping catheter exchange for dilator and needle allowed for facile ZFTSP. AF outcome, fluoroscopy times, and procedure times were compared with eight age-matched control patients.

Results: There were no significant differences in age, body mass index (BMI) or AF duration between the two groups and no immediate complications. ZFTSP procedure time was 183.9±33.7 minutes versus 293.13±129.9 minutes for TSP-only controls (p=0.05). Fluoroscopy time was 17.5±14.1 minutes in ZFTSP patients versus 73.4±50.3 minutes in controls (p=0.01). AF recurrence in ZFTSP patients was 14% versus 25% in controls.

Conclusion: ZFTSP utilising ICE and EAM is safe, effective, and time-efficient. There is a small but significant reduction in radiation exposure to patient and physician by the use of this technique.

Keywords: Atrial fibrillation; electro-anatomical mapping; intracardiac echocardiography; transseptal puncture; zero-fluoroscopy.

Figure 1. Procedure for setting the transseptal puncture sheath

(A) vascular access, (B) placement of intracardiac echocardiographic catheter (left) and 0.032″ J-wire (right), (C) over-wire exchange of right 8-Fr sheath for the 8.5-Fr Agilis sheath, and (D) exchange of Agilis dilator and J-wire for ablation catheter, which is advanced to the fossa ovalis. (E) Electroanatomical mapping of the atrial septal fossa ovalis yields a targeted map for placement of the mapping catheter just inferior to the fossa, and is confirmed by (F) intracardiac echocardiography (ICE).

Figure 2. Zero-fluoroscopy atrial septal puncture

(A) Cartoon diagram of Agilis sheath being advanced over the mapping catheter to the atrial septum. (B) Disappearance of the mapping catheter by electroanatomical mapping (EAM) corresponds to proximity of the Agilis to the atrial septum (left), and is confirmed by ICE (right). (C) Cartoon diagram of Agilis sheath crossing the atrial septum, (D) with corresponding EAM (left) and ICE (right) images. (E) Insertion of the mapping catheter can be used to confirm LA placement, (F) as well as injection of agitated saline through the catheter.