Angio Landmarks for Transseptal CRT 2017 Washington, DC, Feb 18 – 21, 2017 10min + .... min Angio Landmarks for Transseptal 7:45 PM – 7:55 PM . Horst Sievert, Ilona Hofmann, Laura Vaskelyte, Sameer Gafoor, Stefan Bertog, Predrag Matić, Markus Reinartz, Bojan Jovanovic, Kolja Sievert,, Nalan Schnelle CardioVascular Center Frankfurt - CVC, Frankfurt, Germany

Disclosures Physician name Company Relationship Horst Sievert Abbott, Ablative Solutions, Acoredis, Atrium, Biosense Webster, Bioventrix, Boston Scientific, Carag, Cardiac Dimensions, CardioKinetix, Celonova, Cibiem, CGuard, Coherex, Comed B.V., Contego, CSI, CVRx, ev3, FlowCardia, Gardia, Gore, GTIMD Medical, Guided Delivery Systems, Hemoteq, InspireMD, Kona Medical, Lumen Biomedical, Lifetech, Medtronic, Occlutech, pfm Medical, Recor, SentreHeart, Svelte Medical Systems, Terumo, Trivascular, Valtech, Vascular Dynamics, Venus Medical, Veryan Consulting fees, Travel expenses, Study honoraria Cardiokinetix, Access Closure, Coherex, SMT Stock options

The left atrium is located below, lateral and posterior of the aortic root Frontal Lateral Silva GV, Palacios IF, Percutaneous Interventions for Congenital Heart Disease, 2014

Most angio landmarks are based on two lines Frontal "Mid-line" in the middle of the septum "M-line" in the middle of the mitral valve The best puncture site is usually at the crossing of these two lines Silva GV, Palacios IF, Percutaneous Interventions for Congenital Heart Disease, 2014

Inoue's mid-line T* = upper end of the tricuspid valve L = lateral border of the left atrium

Inoue's Landmarks T RA angiogram Mark the tricuspid valve (T) on the screen Wait for LA angiogram Mark the lateral border of the LA Horizontal line from T to LA border T Mid-line Mark the mitral valve Horizontal line in the middle of the mitral valve (M line) Puncture at the crossing of the M-Line with the mid-line

Definition of the Horizontal "M-line" Hung, Cath Cardiovasc Diag 26:275, 1992

Inoue's modified technique without using the M-line Define the mid-line Mark the inferior border of the LA 2/3 of a vertebra above this border

Hung's Landmarks without RA angiogram This "mid-line" is usually identical to that from the Inoue's angiographic method The aortic valve instead of the tricuspid valve is used as a landmark Hung Cath Cardiovasc Diag 26:275, 1992

Hung's Landmarks Stain technique Hung, Cath Cardiovasc Diag 26:275, 1992

Hieu's # landmark

Very large LA The border of the LA may be more lateral than the border of the RA Septum is only in the area where LA and RA are overlapping Therefore, the mid-line has to be determined using the RA border RA border LA border

Sheath position in typical anatomy Lateral projection The needle looks posteriorly towards the spine. AP projection The tip of the needle looks away from the operator.

Most important The jump into the fossa

The dot shows the position of the sheath Clinical practice confirms Inoue

Summary and conclusions Multiple angiographic landmarks have been defined for transseptal puncture All require a pigtail in the aortic root and/or opacification of the LA (spontaneous or after contrast injection) Medial and posterior position of the needle is important Most important is the jump of the needle into the fossa In difficult anatomy  use TEE or ICE

Thank you