Trans septal puncture

TRANS-SEPTAL PUNCTURESATYAM RAJVANSHI

Dr John Ross

Ross J Jr. Trans-septal left heart catheterization: a new method of left atrial puncture.

Ann Surg 1959;149:395– 401.

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)

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)

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

CONTRAINDICATIONS

• Absolute!

LA cavity or septal thrombus/tumour

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!

WE NEED 3 THINGS

AnatomicalLandmarks

Hardware

Imaging Guidance

WE NEED 3 THINGS

AnatomicalLandmarks

HARDWARE

Imaging Guidance

21 gauge

18 gauge

270° curve

71 cm

67 cm59 cm

MULLINS SHEATH AND DILATOR SYSTEM (Medtronic Inc.)Size Sheath length Dilator length Wire size max.

ADULT8 Fr +/- hemostatic valve

59 cm 67 cm .032 in

PEDIATRIC8 Fr 44 cm 52 cm .025 in6 Fr 44 cm 52 cm .025 in

BROCKENBROUGH NEEDLE (Medtronic Inc.)Shaft Size Tip Size Length

ADULT18 gauge 21 gauge 71 cm

PEDIATRIC19 gauge 22 gauge 56 cm

WE NEED 3 THINGS

ANATOMICALLANDMARKS

Hardware

Imaging Guidance

12

9 3

6

12

9 3

6

IAS plane in supine patient

From 2’ to 7’ o clock

12

9 3

6

Normal Fossa ovalis plane

4’ to 6’ o clock

12

9 3

6

12

9 3

6

Huge LA with Bulging septum – Fossa ovalis shifts inferiorly and posteriorlyto 7’ or even 8’ o clock

12

9 3

6

Small LA with inward septum – Fossa ovalis shifts more anteriorly3’ to 4’ o clock

RAO

AP

LAT

WE NEED 3 THINGS

AnatomicalLandmarks

Hardware

IMAGING GUIDANCE

IMAGING GUIDANCE

• FLUOROSCOPY• TTE• TEE

• ICE

• CT• MRI• ECG

INUOE ANGIOGRAPHIC METHOD

Cath Cardiovasc Diagn. 1993;28:119-25.

INUOE ANGIOGRAPHIC METHOD

Cath Cardiovasc Diagn. 1993;28:119-25.

INUOE ANGIOGRAPHIC METHOD

Cath Cardiovasc Diagn. 1993;28:119-25.

HUNG’S MODIFIED METHOD(no Angio – only aortic root pigtail)

Cath Cardiovasc Diagn. 1992;26:275-84.

Cath Cardiovasc Diagn. 1992;26:275-84.

HUNG’S MODIFIED METHOD(no Angio – only aortic root pigtail)

TRANS-SEPTAL PUNCTURE

0.032 WIRE IN INNOMINATE

VEIN

SHEATH DILATOR ASSEMBLY IN

INNOMINATE VEIN

TRACKING BROCKENBROUGH NEEDLE WITH TIP JUST INSIDE DILATOR

DESCENT FROM SVC – RA

RA – FOSSA

IMAGINARY MID-LINE

(If LA silhouette not visible – Take RA ± PA angiogram for

LA)

CHECK IN RAO

(check needle tip away from Aorta and CS)

CHECK IN LAO/LATERAL

(check needle tip away from Aorta and in inferoposterior third)

PUSH ASSEMBLY/NEEDLE PUNCTURE

(If satisfied by anatomical landmarks

and/or pulsation)

CHECK IN AP/RAO VIEWBY ANGIO / PRESSURE / SATURATION

(If SATISFIED – advance dilator/sheath)

LA WIRE ENTRY

SPECIAL SITUATIONS

Giant RASmall LA Normal LA

Septal bulge Giant

RA

Forceful torque to middle of IAS

Enlarged LA6’ or 7’o clock

Enlarged RABend the needle

No jumps/pulsationAnatomic landmarks

PROCEDURE SPECIFIC PUNCTURE SITE

OTHER APPROACHES/TECHNIQUES

• Left Femoral• Transjugular (LA-crosse system)• Transhepatic

• TTE/TEE/ICE guidance

• Safe-sept wire• Electrocautery• RFA (Toronto RF catheter)• Laser

COMPLICATIONS

• Overall Mortality <1%

• MUST LEARN PERICARDIOCENTASIS BEFORE SEPTAL PUNCTURE

• Echo must be readily available

STITCH PHENOMENAIn 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

THINK BEFORE PULLING OUT!After septal puncture – always wait for 2 minutes, watch hemodynamics/echo, then give heparin

MANAGEMENT OF STITCH/EFFUSIONOnly 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

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

HOW TO SUCCESSFULLY PUNCTURE SEPTUM

The take-home points

FAMILIARISE WELL WITH HARDWARE

RAO

LATAP

FAMILIARISE WELL WITH ANATOMY

BE WATCHFUL FOR COMPLICATIONS