Fig. 4.1
Material for transseptal puncture: an SL1 sheath and its dilator equipped with a Brockenbrough needle allows to cross the Fossa ovalis. Shaping of the Brockenbrough needle does allow to negotiate also large atria where there is a difficulty to get close to the septum. For crossing the septum, the Brockenbrough needle is advanced slightly (“puncture”) after tenting of the septum at the correct position with the dilator
4.2 Puncture of the Fossa Ovalis
Advancing the SL1 sheath without a wire in place might be traumatic as the dilator plus needle might easily cross the fragile venous system. Once the SL1 sheath is placed into the superior vena cava and the wire is exchanged for the Brockenbrough needle, a pullback is performed until the systems falls into the fossa ovalis. A mid/posterior and inferior location for transseptal puncture is recommended to facilitate an easy and straight access to the LAA (Fig. 5.4). The system should be pulled back with the needle in a 5 o’clock (to achieve a more posterior location: 7 o’clock) position (Figs. 5.5 and 5.6). Some operators position a pigtail catheter at the aortic valve in the noncoronary cusp – this serves as anatomic landmark where the needle should point to in both a RAO 30° and LAO 40° angiographic view (Fig. 5.7). Echocardiographic control of the location of septal tenting is recommended to verify an optimal position. Next the Brockenbrough needle is advance with a quick “puncture” movement. The sheath/dilator assembly follows; it is important to ensure that the sheath has crossed the interatrial septum prior to pull back the dilator and the needle. Echocardiographic monitoring of this step is highly recommended (Fig. 4.2).
