The Detrimental Impact of Chronic Renal Insufficiency

The Detrimental Impact of Chronic Renal Insufficiency

Transseptal Puncture Technique Saibal Kar, MD, FACC, FAHA, FSCAI Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA Disclosure Statement of Financial Interest Saibal Kar, MD, FACC Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship

Company Grant/Research Support Abbott Vascular,Boston Scientific, St Jude Medical, Circulite, Coherex, Gore, Biotronics

Consulting Fees/Honoraria Abbott Vascular, Boston Scientific, St Jude Medical, Gore Other Financial Benefit

Coherex, Biosensors International Introduction Transseptal access of the left atrium, was initially developed to directly measure pressures of the left atrium and ventricle In the present era, transseptal access of the left atrium is critical step for a wide variety of electrophysiological and interventional

procedures Accurate and safe transseptal puncture is therefore important for the success of these procedures Transseptal interventions Electrophysiological procedures Pulmonary vein isolation Mitral valve interventions Valvuloplasty, Repair, replacement, paravalvular leak closure

Left atrial appendage closure Left sided support systems: Tandom Heart Equipment for Transseptal Puncture 71cm BRK/BRK1 & 67cm SL1 Equipment for Transseptal Puncture Dilator

Ross needle Sheath Sheath NRG Radiofrequency Needle( Baylis Medical) Image guidance for successful transseptal puncture Fluoro :

Two views : AP and lateral or RAO and LAO Echo guidance Transesophageal echo or intracardiac echo Combined fluoro and echo Accurate location of TS puncture based on pathology and procedure Can be used to guide the rest of procedure Early detection of complications Fluoroscopy: Two orthogonal views should be used:

Antero posterior View G. Joseph CCVD 42:138,1997 Fluoroscopy: Two orthogonal views should be used: Lateral View 90 degree lateral Basic TEE views for optimal Transseptal puncture Bicaval view:

LA RA Short axis view SVC 4 chamber view LA

LA AO RA SVC LV RV Technique in different

procedures Mitral valve interventions Left atrial appendage closure Closure of paravalvular leak Mitral Valvuloplasty Posterior and superior Anterior puncture : Difficulty to advancing Stiff balloon catheter in LV

MitraClip System Steerable Guide Catheter Clip Delivery System Stabilizer MitraClip Transseptal puncture during MitraClip Procedure

Too close to MV Too posterior from MV Correct TS for MitraClip; 4.0 - 4.5 cm away from MV Transseptal puncture during MitraClip Procedure Appropriate location determines the success of the procedure Short axis: Posterior

Bicaval view: Superior 4 chamber view: Distance From Puncture to point of coaptation 4 to 4.5 cm Special situation MitraClip for Flail leaflet 4 chamber view: Distance From Puncture to point of coaptation 4 to 4.5 cm

Bicaval view: Superior Short axis: Posterior Special situation Functional MR with very large left atrium 4 chamber view: Distance From Puncture to point of coaptation 4 to 4.5 cm

Bicaval view: Low Short axis: Mid or anterior TS puncture location : determining factors Left atrial size Type of pathology Functional Flail/Prolapse

Region of MV involvement Medial aspect ( A3P3) Lateral aspect (A1P1) Optimal location for TS puncture for left atrial appendage occlusion Low Posterior Posterior

Puncture LAA Use of Fluoro and TEE for Transseptal puncture Appropriate location and prevention of tamponade Bicaval view (90 to 100) Short axis view ( 35 to 50) LA

LA RA Mid Fossa SVC RA AO

Mid Fossa / Posterior Advantages of TEE guided Transseptal puncture Accurate localisation Avoid Puncture of the posterior wall or roof of LA Early detection of pericardial effusion Posterior

Puncture Anterior puncture LAA Other Important Tips during Transseptal Puncture Avoid excessive tenting of septum Protect Needle tip with wire Use of stylet through needle to puncture septum

Use of radiofrequency needle, Optimal TS: Avoid/treat complications Cardiac perforation/cardiac tamponade Prevent it Early recognition Treatment Thrombus formation Prevention Treatment

Conclusion Trans-septal access is a critical step to several structural procedures Echo and Fluoro guidance is essential Puncture is dependent on Procedure Location of the pathology Size of the Left atrium Be vigilent about potential complications

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