0. Transseptal Puncture Technique
Saibal Kar, MD, FACC, FAHA, FSCAI
Heart Institute, Cedars-Sinai Medical Center,
Los Angeles, CA

1. 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
Consulting Fees/Honoraria
Other Financial Benefit
Abbott Vascular,Boston Scientific, St Jude Medical, Circulite, Coherex, Gore, Biotronics
Abbott Vascular, Boston Scientific, St Jude Medical, Gore
Coherex, Biosensors International

2. 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

3. 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

4. Equipment for Transseptal Puncture
71cm BRK/BRK1 & 67cm SL1

5. Equipment for Transseptal Puncture
Dilator
Ross needle
Sheath
Sheath

6. NRG® Radiofrequency Needle( Baylis Medical)

7. 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

8. Fluoroscopy: Two orthogonal views should be used:
Antero posterior View
G. Joseph CCVD 42:138,1997

9. Fluoroscopy: Two orthogonal views should be used:
Lateral View
90 degree lateral

10. Basic TEE views for optimal Transseptal puncture
Bicaval view:
SVC LA RA
Short axis view LA RA AO
4 chamber view
SVC LV RV LA

11. Technique in different procedures
Mitral valve interventions
Left atrial appendage closure
Closure of paravalvular leak

12. Mitral Valvuloplasty Posterior and superior Anterior puncture :
Difficulty to advancing
Stiff balloon catheter in LV

13. MitraClip System Steerable Guide Catheter Stabilizer MitraClip
Clip Delivery System
Steerable Guide Catheter
Stabilizer
MitraClip

14. Transseptal puncture during MitraClip Procedure
Too close to MV
Too posterior from MV
Correct TS for MitraClip;
cm away from MV

15. Appropriate location determines the success of the procedure
Transseptal puncture during MitraClip Procedure
Appropriate location determines the success of the procedure
Bicaval view: Superior
Short axis: Posterior
4 chamber view:
Distance From Puncture
to point of coaptation 4 to 4.5 cm

16. 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

17. 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

18. TS puncture location : determining factors
Left atrial size
Type of pathology
Functional
Flail/Prolapse
Region of MV involvement
Medial aspect ( A3P3)
Lateral aspect (A1P1)

19. Optimal location for TS puncture for left atrial appendage occlusion
Low Posterior
LAA
Posterior
Puncture

20. Use of Fluoro and TEE for Transseptal puncture Appropriate location and prevention of tamponade
Short axis view ( 35 to 50º)
Bicaval view (90 to 100º) LA LA RA AO RA
SVC
Mid Fossa
Mid Fossa / Posterior

21. 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

22. 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,

23. Optimal TS: Avoid/treat complications
Cardiac perforation/cardiac tamponade
Prevent it
Early recognition
Treatment
Thrombus formation
Prevention

24. 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