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Techniques of transseptal puncture


Transseptal catherization was first described by Ross, Braunwald, and Morrow in 1959 as a feasible method to obtain direct left atrial (LA) pressure measurements. Although the use of transseptal puncture (TSP) for hemodynamic assessment had since declined due to the wider application of right heart catheterization, TSP is currently considered an essential component of many valvular and nonvalvular structural heart disease (SHD) interventions ( Fig. 5.1 ). This chapter provides an overview of contemporary TSP techniques, with a special emphasis on challenging anatomies and procedural complications.

Fig. 5.1
Illustration of the contemporary applications for transseptal structural heart interventions.
(A) Percutaneous mitral balloon valvuloplasty. (B) Transcatheter mitral valve repair (MitraClip). (C) Mitral valve–in–valve implantation. (D) Transcatheter mitral valve replacement. (E) Mitral paravalvular leak closure. (F) Pulmonary vein isolation. (G) Percutaneous left ventricular assist device placement. (H) Left atrial appendage closure.

(Reprinted with permission from Alkhouli M, Rihal CS, Holmes DR Jr. Transseptal techniques for emerging structural heart interventions. JACC Cardiovasc Interv . 2016:26;9[24]:2465-2480.)

Transseptal puncture toolbox

The basic TSP kit consists of a transseptal sheath and a transseptal needle ( Fig. 5.2 ). However, several ancillary tools can be utilized to increase the safety and success of TSP:

  • 1.

    Transseptal sheaths: Fixed-curve sheaths are usually utilized in the majority of procedures requiring TSP. Steerable sheaths offer superior maneuverability, which facilitates navigating difficult anatomies and achieving site-specific LA access, but they are more expensive than the traditional fixed-curve sheaths. Table 5.1 summarizes the most commonly used transseptal sheaths and their characteristics.

    TABLE 5.1 ■
    Commercially Available Transseptal Sheaths and Their Characteristics
    Transseptal Sheath Manufacturer Steerable Radiopaque Tip Side Holes Sheath Curve Angle (degree) Inner Diameter Usable Length (cm) Guidewire Compatibility (inch)
    Mullins Medtronic No No No 180 (Mullins Style) 7-8F 60 0.032
    Performer Mullins Cook No Yes No 180 (Mullins Style) 4-16F 63-75-85 0.038 (>6F)
    Performer Hausdorf Cook No Yes No 45 double curve 9-12F 75 0.038
    Adelante Breezeway Oscor No Yes Yes 55, 70, 90, 120 8-10F 60-79 0.038
    Fast-Cath St. Jude No Yes No 180 (Mullins style) 8-10F 63 0.032
    Fast-Cath SL series St. Jude No Yes Yes 45, 50, 90 10F 63-81 0.032
    Swartz (SL0-SL4) St. Jude No Yes Yes 45, 50, 90, 135, 180 8-8.5F 63-81 0.032
    Swartz Braided LAMP St. Jude No Yes Yes 45, 90, 135 8-8.5F 63-81 0.032
    Across Interlock System St. Jude No Yes Yes 45, 90 8.5F 63-81 0.032
    TorFlex Baylis Medical No Yes Yes 37, 45, 55, 90, 135 8-8.5F 63-81 0.032
    HeartsSpan Merit No Yes Yes 15, 30, 55, 90, 120, 150 8 5F 60-80-101 0.035
    TSX Boston S No Yes Yes 15, 30, 55, 90, 120, 150 8 5F 60-80-101 0.035
    Preface Biosense No Yes Yes 55, 90, 120, 150 8F 62-77 0.035
    Super Arrow-Flex Teleflex No Yes No 180 (Mullins style) 8F 61 0.035
    Flexcath a Medtronic Yes Yes Yes One Curl 12F 65 0.032, 0.035
    Agilis NxT St. Jude Yes Yes Yes Three Curls (16.8, 22.4, 50 mm) 8.5F 61-71 0.032
    HeartSpan Steerable Merit Yes Yes Yes Three curls (16.4, 22.4, 36 mm) 8.5F 74 0.032
    Dexterity Spirus Yes Yes Yes One curl (two steering locations) 9F, 14F 65-75-105 0.035
    Direx Interlock System Boston S Yes Yes Yes Three curls (17, 22, 50 mm) 9-12F 67-71 0.038
    LAMP, Left atrial multipurpose.

    a 135 maximum deflection.

  • 2.

    Transseptal needles: Stainless steel needles (e.g., Brockenbrough needle, Medtronic, Minneapolis, MN; BRK, St. Jude Medical, St. Paul, MN) are inexpensive and available in multiple lengths and curves, and thus are considered the “work horse” of transseptal needles. Needles utilizing radiofrequency energy (e.g., Baylis, Montreal, Canada) allow controlled puncture and may enhance the safety and efficacy of TSP in patients with fibrotic or thickened fossa ovalis (FO) ( Fig. 5.3 ). Commercially available transseptal needles and their features are listed in Table 5.2 .

    Fig. 5.3, Ancillary tools for difficult-to-navigate transseptal puncture.

    TABLE 5.2 ■
    Commercially Available Transseptal Needles and Their Characteristics
    Transseptal Needle Manufacturer Length (mm) Needle Curve Angle (degree) Distal Tip (Gauge) Proximal Tip (Gauge) Special Feature
    Brockenbrough Medtronic 56, 71 30 21 18
    BRK Series St. Jude 71, 89, 98 BRK, BRK1 (30, 55) a 21 18 Bevel angle 50 degrees
    BRK XS Series St. Jude 71, 89, 98 BRK, BRK1 (30, 55) 21 18 Bevel angle 30 degrees b
    TSX Boston S 71, 89, 98 50, 86 21 18 Transparent handle c
    Heart Span Biosense 56, 71, 89 50, 86 21, 22 18 Transparent handle c
    Cook TSN Cook 56, 71 30 21 18
    NRG RF Baylis 71, 89, 98 C0, C1 (30, 60) 21 18 Radiofrequency energy

    a Steeper primary bevel angle and two back bevels that combine to form a distinct point at the tip of the needle.

    b Pediatric curves are BRK and BRK2.

    c Allows direct visualization of bubbles before they travel distally.

  • 3.

    Ancillary tools: In patients with a fibrotic, thickened, or aneurysmal intraatrial septum (IAS), needle-wire systems (e.g., Safesept wire, Pressure Products, San Pedro, CA) allow safe traversing into the LA. The Safesept is a 120-cm, 0.014″ Nitinol guidewire that has a sharp but floppy tip, which prolapses immediately into a “J” shape upon entry into the LA (see Fig. 5.3 ). The wire can be then advanced safely into a pulmonary vein, and the transseptal sheath/needle assembly is railed over the wire into the LA. If upon advancing the Safesept wire, an undesirable puncture is recognized (e.g., into the pericardium), the wire can be safely retracted without sequelae. Pigtail wire systems can be utilized to achieve and maintain stable access into the LA. A major advantage of these wires is the avoidance of stiff wire placement in the pulmonary vein during sheath exchanges, eliminating the small but significant risk of pulmonary vein injury/bleeding. These wires are available in a 0.025″ platform (e.g., TorayGuide, Toray, Tokyo, Japan; Protrack pigtail wire, Baylis, Montreal, Canada), but comparable 0.035″ wire systems can be used off-label for the same purpose (e.g., Confida wire, Medtronic; Safari wire, Boston Scientific, Marlborough, MA).

Fig. 5.2, Commonly used transseptal sheaths and needles.

Transseptal catheterization step by step

Simple TSPs

Transseptal catheterization is preferably performed via a right transfemoral venous access. After that, partial anticoagulation with 2000 to 5000 IU of intravenous heparin is administered. The transseptal sheath (most commonly the Mullins sheath or the SL-1 sheath) is then advanced over a wire into the superior vena cava (SVC) in the anterior-posterior (AP) fluoroscopic projection. Although some transseptal sheaths are compatible with 0.035″ wires, the majority require a 0.032″ guidewire (see Table 5.1 ). The transseptal needle is then advanced inside the sheath but kept ≈ 1 to 2 cm proximal to its distal tip. The sheath and dilator are grasped with the index finger and thumb and the needle is grasped with the remaining fingers to ensure a constant relationship between the needle and sheath. The orientation of the needle and sheath must be maintained by matching the metal arrow on the needle’s hub to the direction of the sheath’s sidearm. The sheath/needle assembly is then retracted to the junction of the SVC/right atrium (RA) as a single unit with a slight clockwise rotation, such that system is pointing toward 3- or 4-o’clock. Two characteristic “jumps” of the dilator tip are usually appreciated by the operator: one as the tip passes under the aortic knob and one as the tip passes under the muscular septum into the FO. The location of the transseptal sheath dilator on the FO can be confirmed either with fluoroscopy (AP, lateral projections), transesophageal echocardiography (TEE; bicaval and short-axis views), or intracardiac echocardiography (ICE; septal view). The needle tip is then advanced into the LA, and an LA position can be verified before advancing the sheath by aspirating oxygenated blood, measuring LA pressure, injecting contrast into the LA, or advancing a coronary or a Safesept wire into a pulmonary vein. The sheath/dilator apparatus is then advanced over the needle into the LA in two steps: first, the dilator is advanced over the needle; and second, the sheath is advanced over the needle/dilator assembly into the LA. If two LA accesses are needed, two wires can be advanced inside the sheath into the LA; J-shaped wires (e.g., Amplatz Extra-stiff) need to be advanced into a pulmonary vein to provide adequate support for sheath advancement, whereas pigtail wires (e.g., Protrack) can be kept in the body of the LA. The sheath is removed, and the two desired LA sheaths are advanced side to side over the two wires into the LA. Alternatively, a dedicated puncture via a separate venous access can be obtained for the second LA access to minimize the size of the resultant atrial septal defect. The FO often requires balloon dilation to facilitate crossing of large sheaths/guiding catheters, such as during transcatheter mitral valve repair or transseptal mitral valve–in–valve procedures. Peripheral angioplasty balloons (7 to 10 mm × 40 mm) are usually utilized for this purpose.

Challenging TSPs

Patients referred for SHD interventions often have an extremely challenging IAS to cross. Those patients may have had prior transcatheter or surgical interventions involving the intraatrial septum, which as a result can be patched, oversewn, fibrotic, or calcified. , In addition, venous tortuosity, congenital anomalies or occlusions, and extreme rotation of the heart can lead to significant challenges at different stages of the TSP procedure.

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