1. 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

2. 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

3. 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

4. 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

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

6. 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

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

8. 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

9. 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

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

11. Hieu's # landmark

12. 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

13. 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.

14. Most important
The jump into the fossa

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

16. 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

17. Thank you