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. 2021 Oct 20;17(9):720-727.
doi: 10.4244/EIJ-D-20-00454.

Transseptal puncture: procedural guidance, challenging situations and management of complications

Giulio Russo  1 , Maurizio Taramasso, Francesco Maisano
Affiliations

Transseptal puncture: procedural guidance, challenging situations and management of complications

Giulio Russo et al. EuroIntervention. .

Abstract

A number of interventional procedures based on the transseptal puncture (TSP) have been developed in recent years. The increasing number of interventional procedures, as well as the use of large-bore sheaths and complex devices, has led to improvements in technique and equipment. The combined use of fluoro-scopy and of transoesophageal echocardiography (TEE) has increased safety and precision. However, TSP still represents a tricky procedure, which may become even more difficult in cases of challenging interatrial septa, and life-threatening complications may occur. Consequently, an in-depth knowledge of procedural steps, equipment, echocardiographic views, fossa ovalis anatomy and how to manage the most frequent complications is critical to performing a successful TSP.

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Conflict of interest statement

F. Maisano is a consultant for Abbott Vascular, Medtronic, Edwards Lifesciences, Perifect, Xeltis, Transseptal Solutions, Magenta and Cardiovalve, has received grant support from Abbott Vascular, Medtronic, Edwards Lifesciences, Biotronik, Boston Scientific, NVT, and Terumo, has royalty income/IP rights from Edwards Lifesciences and 4Tech, and is co-founder/shareholder of Transseptal Solutions, 4Tech, Cardiovalve, Magenta, Perifect, Coregard and SwissVortex. G. Russo has received a fellowship training grant from the EAPCI, sponsored by Edwards Lifesciences. M. Taramasso reports consultancy fees from Abbott Vascular, Edwards Lifesciences, 4Tech, Boston Scientific, CoreMedic, Mitraltech, and SwissVortex, outside the submitted work.

Figures

Figure 1
Figure 1
Transseptal kits. A) Swartz SL transseptal sheaths. B) St. Jude transseptal kit. C) NRG radiofrequency transseptal needle (Baylis Medical).
Central illustration
Central illustration
Fossa ovalis anatomy from the RA view and its schematic division into four parts (A). Three-dimensional models showing the IS from the right side (B) and the left side (C) and its relationship with the mitral valve plane.
Figure 2
Figure 2
Echo-guided femoral punctures. A) Short-axis view. B) Operative field setting. DFA: deep femoral artery; FV: femoral vein; SFA: superficial femoral artery
Figure 3
Figure 3
Correct handling (A) and orientation (B) of the Mullins/SL sheath and Brockenbrough needle during the pullback manoeuvres.
Figure 4
Figure 4
Views during the pullback phase of TSP. A) TEE bicaval view. B) SAX at the base. C) Four-chamber view. D) Schematic view of the three main TEE projections used during TSP in relation to the anatomic structures they show. 4ch: four chamber; ANT: anterior; Ao: aorta; AV valve: atrioventricular valve; INF: inferior; IVC: inferior vena cava; LA: left atrium; LV: left ventricle; PV: pulmonary vein; RA: right atrium; RV: right ventricle; SUP: superior; SAX: short axis; SVC: superior vena cava
Figure 5
Figure 5
Posterior TSP through the pericardial space (A) causing atrial haematoma (B) and delayed cardiac tamponade.
See this image and copyright information in PMC

References

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