55
TRANS-SEPTAL PUNCTURE SATYAM RAJVANSHI

Trans septal puncture

Embed Size (px)

Citation preview

Page 1: Trans septal puncture

TRANS-SEPTAL PUNCTURESATYAM RAJVANSHI

Page 2: Trans septal puncture

Dr John Ross

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

Ann Surg 1959;149:395– 401.

Page 3: Trans septal puncture

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)

Page 4: Trans septal puncture

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)

Page 5: Trans septal puncture

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

Page 6: Trans septal puncture

CONTRAINDICATIONS

• Absolute!

LA cavity or septal thrombus/tumour

Page 7: Trans septal puncture

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!

Page 8: Trans septal puncture

WE NEED 3 THINGS

AnatomicalLandmarks

Hardware

Imaging Guidance

Page 9: Trans septal puncture

WE NEED 3 THINGS

AnatomicalLandmarks

HARDWARE

Imaging Guidance

Page 10: Trans septal puncture

21 gauge

18 gauge

270° curve

71 cm

67 cm59 cm

Page 11: Trans septal puncture

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

Page 12: Trans septal puncture
Page 13: Trans septal puncture
Page 14: Trans septal puncture

WE NEED 3 THINGS

ANATOMICALLANDMARKS

Hardware

Imaging Guidance

Page 15: Trans septal puncture
Page 16: Trans septal puncture

12

9 3

6

Page 17: Trans septal puncture

12

9 3

6

IAS plane in supine patient

From 2’ to 7’ o clock

Page 18: Trans septal puncture

12

9 3

6

Normal Fossa ovalis plane

4’ to 6’ o clock

Page 19: Trans septal puncture

12

9 3

6

Page 20: Trans septal puncture

12

9 3

6

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

Page 21: Trans septal puncture

12

9 3

6

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

Page 22: Trans septal puncture

RAO

Page 23: Trans septal puncture

AP

Page 24: Trans septal puncture

LAT

Page 25: Trans septal puncture

WE NEED 3 THINGS

AnatomicalLandmarks

Hardware

IMAGING GUIDANCE

Page 26: Trans septal puncture

IMAGING GUIDANCE

• FLUOROSCOPY• TTE• TEE

• ICE

• CT• MRI• ECG

Page 27: Trans septal puncture

INUOE ANGIOGRAPHIC METHOD

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

Page 28: Trans septal puncture

INUOE ANGIOGRAPHIC METHOD

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

Page 29: Trans septal puncture

INUOE ANGIOGRAPHIC METHOD

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

Page 30: Trans septal puncture

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

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

Page 31: Trans septal puncture

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

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

Page 32: Trans septal puncture

TRANS-SEPTAL PUNCTURE

Page 33: Trans septal puncture

0.032 WIRE IN INNOMINATE

VEIN

Page 34: Trans septal puncture

SHEATH DILATOR ASSEMBLY IN

INNOMINATE VEIN

Page 35: Trans septal puncture

TRACKING BROCKENBROUGH NEEDLE WITH TIP JUST INSIDE DILATOR

Page 36: Trans septal puncture

DESCENT FROM SVC – RA

RA – FOSSA

Page 37: Trans septal puncture

IMAGINARY MID-LINE

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

LA)

Page 38: Trans septal puncture

CHECK IN RAO

(check needle tip away from Aorta and CS)

Page 39: Trans septal puncture

CHECK IN LAO/LATERAL

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

Page 40: Trans septal puncture

PUSH ASSEMBLY/NEEDLE PUNCTURE

(If satisfied by anatomical landmarks

and/or pulsation)

Page 41: Trans septal puncture

CHECK IN AP/RAO VIEWBY ANGIO / PRESSURE / SATURATION

(If SATISFIED – advance dilator/sheath)

Page 42: Trans septal puncture

LA WIRE ENTRY

Page 43: Trans septal puncture

SPECIAL SITUATIONS

Page 44: Trans septal puncture

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

Page 45: Trans septal puncture

PROCEDURE SPECIFIC PUNCTURE SITE

Page 46: Trans septal puncture

OTHER APPROACHES/TECHNIQUES

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

• TTE/TEE/ICE guidance

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

Page 47: Trans septal puncture

COMPLICATIONS

Page 48: Trans septal puncture

• Overall Mortality <1%

• MUST LEARN PERICARDIOCENTASIS BEFORE SEPTAL PUNCTURE

• Echo must be readily available

Page 49: Trans septal puncture

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

Page 50: Trans septal puncture

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

Page 51: Trans septal puncture

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

Page 52: Trans septal puncture

HOW TO SUCCESSFULLY PUNCTURE SEPTUM

The take-home points

Page 53: Trans septal puncture

FAMILIARISE WELL WITH HARDWARE

Page 54: Trans septal puncture

RAO

LATAP

FAMILIARISE WELL WITH ANATOMY

Page 55: Trans septal puncture

BE WATCHFUL FOR COMPLICATIONS