Special Techniques

7 Special Techniques

Transseptal Heart Catheterization

Retrograde left-sided heart catheterization for aortic or mitral stenosis or prosthetic valve dysfunction may not be suitable for or provide accurate hemodynamic data in all patients. Retrograde crossing of the minor orifice of a tilting disk-type prosthetic valve in the aortic position with plastic catheters has been performed with varying success, although death from entrapped catheters has been reported. Retrograde passage of 0.014-inch pressure wire to obtain hemodynamics has been reported in bi-leaflet tilting disk aortic valves. Alternatively, transseptal access to the left atrium and ventricle, by passing a catheter across the thin atrial septal membrane usually at the fossa ovalis, is an established technique.

Procedural Highlights

The Equipment

Figure 7-1 shows the curved long catheter (Fig. 7-1, A) and long hollow needle (Fig. 7-1, C) used to cross the atrial septum. A long sheath with an extending curved obturator that accepts a 0.032-inch guidewire has now replaced the straight stylet that was used for insertion of the curved transseptal catheter from the femoral vein into the right atrium. The modified transseptal needle has a 21-gauge needle tip to reduce hazard from accidental puncture of the aorta or atrial wall, and the catheter has side holes (to enhance injection of contrast medium) and a tapered tip to facilitate entry into the femoral vein and traversal of the atrial septum. Detail of transseptal needle tip is shown in Figure 7-1, D. Several methods exist to cross the atrial septum. Intracardiac echocardiography is popular among electrophysiologists to guide their approach. Using angiographic landmarks alone is commonly used by seasoned operators and is described here. The transseptal Mullen’s catheter and sheath system or Brockenbrough catheter with large or small curves are the catheter systems most commonly used (Fig. 7-2). The transseptal needle system is gently curved and attached to a pressure transducer with a rotating adaptor for free movement of the long needle within the catheter as it travels up to the heart.

Steps to perform transseptal catheterization are as follows

(Note for imaging- Views of the initial placement of pigtail, guidewires, and transseptal system are obtained in the AP projection. To estimate anterior or posterior placement of catheter in the atrial septum, RAO angulation is used. Transseptal puncture is performed in the AP projection to see needle entry in atrium.):

7. The positioning technique described by Croft and others is used to precisely localize the point of puncture on the interatrial septum (Fig. 7-4). This technique uses the right anterior oblique angulation. Using the lower edge of the pigtail catheter within the sinus of Valsalva and right atrial (RA) posterior wall, a horizontal line is drawn from the lower end of the pigtail catheter intersecting with the vertical line of the RA border. The operator moves the needle to 1 cm below the line. The needle tip should bisect this line at the midpoint. This point usually is centered within the fossa ovale.

Preparatory Notes

1. The transseptal catheter must be measured against the transseptal needle to identify the position at which the needle extends outside the catheter (Fig. 7-2). This measurement is done on the back table before insertion of the catheter-needle assembly. The operator places the catheter over the needle, notes at what point the needle leaves the catheter end, and marks this distance with a fingertip. Keeping the needle inside the catheter protects the wall of the atrium from inadvertent needle damage.

Direct Transthoracic Left Ventricular Puncture

The development of retrograde arterial catheterization and transseptal catheterization has enabled clinicians to obtain hemodynamic data without direct transthoracic puncture techniques except in unusual situations. This technique carries a high potential of risk and should be performed only by experienced operators.


Transthoracic LV puncture is required to measure LV pressure or to perform LV angiography when no other access is available. This occurs mainly in patients who have had combined mitral and aortic valve replacement with mechanical tilting disk prostheses. Although several investigators report techniques for crossing mechanical tilting disks, retrograde complications have been reported involving catheter entrapment and occlusion of the ball valves or tilting disks with disastrous results. When ventricular pressure and angiography are required in a patient who has had double-valve replacement, direct puncture with echocardiographic guidance can be performed at relatively low risk.

Before the procedure, two-dimensional echocardiography from the apical window is helpful in locating the true LV apex and determining the direction of the long axis of the left ventricle. After the arterial and right-sided heart catheters have been placed, an 18-gauge, 4.25-inch–long needle with a Teflon sheath connected to a pressure transducer is inserted at the apical area through the intercostal space close to the upper border of the lower rib in this space. It is directed posteriorly toward the right shoulder. The pressure tracing is continuously monitored while the needle is advanced. After the needle enters the ventricle, it is removed, leaving the Teflon sheath in place through which pressure recordings and angiography are performed. Alternatively a guidewire can be inserted and a 4 F pigtail catheter can be advanced into the left ventricle for hemodynamic and angiographic data. Figures 7-5 and 7-6 illustrate a typical case of direct LV puncture and associated hemodynamics.

Jun 5, 2016 | Posted by in CARDIAC SURGERY | Comments Off on Special Techniques

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