Techniques of transseptal puncture





Transseptal catherization was first described by Ross, Braunwald, and Morrow in 1959 as a feasible method to obtain direct left atrial (LA) pressure measurements. Although the use of transseptal puncture (TSP) for hemodynamic assessment had since declined due to the wider application of right heart catheterization, TSP is currently considered an essential component of many valvular and nonvalvular structural heart disease (SHD) interventions ( Fig. 5.1 ). This chapter provides an overview of contemporary TSP techniques, with a special emphasis on challenging anatomies and procedural complications.




Fig. 5.1


Illustration of the contemporary applications for transseptal structural heart interventions.

(A) Percutaneous mitral balloon valvuloplasty. (B) Transcatheter mitral valve repair (MitraClip). (C) Mitral valve–in–valve implantation. (D) Transcatheter mitral valve replacement. (E) Mitral paravalvular leak closure. (F) Pulmonary vein isolation. (G) Percutaneous left ventricular assist device placement. (H) Left atrial appendage closure.

(Reprinted with permission from Alkhouli M, Rihal CS, Holmes DR Jr. Transseptal techniques for emerging structural heart interventions. JACC Cardiovasc Interv . 2016:26;9[24]:2465-2480.)


Transseptal puncture toolbox


The basic TSP kit consists of a transseptal sheath and a transseptal needle ( Fig. 5.2 ). However, several ancillary tools can be utilized to increase the safety and success of TSP:



  • 1.

    Transseptal sheaths: Fixed-curve sheaths are usually utilized in the majority of procedures requiring TSP. Steerable sheaths offer superior maneuverability, which facilitates navigating difficult anatomies and achieving site-specific LA access, but they are more expensive than the traditional fixed-curve sheaths. Table 5.1 summarizes the most commonly used transseptal sheaths and their characteristics.



    TABLE 5.1 ■

    Commercially Available Transseptal Sheaths and Their Characteristics












































































































































































































    Transseptal Sheath Manufacturer Steerable Radiopaque Tip Side Holes Sheath Curve Angle (degree) Inner Diameter Usable Length (cm) Guidewire Compatibility (inch)
    Mullins Medtronic No No No 180 (Mullins Style) 7-8F 60 0.032
    Performer Mullins Cook No Yes No 180 (Mullins Style) 4-16F 63-75-85 0.038 (>6F)
    Performer Hausdorf Cook No Yes No 45 double curve 9-12F 75 0.038
    Adelante Breezeway Oscor No Yes Yes 55, 70, 90, 120 8-10F 60-79 0.038
    Fast-Cath St. Jude No Yes No 180 (Mullins style) 8-10F 63 0.032
    Fast-Cath SL series St. Jude No Yes Yes 45, 50, 90 10F 63-81 0.032
    Swartz (SL0-SL4) St. Jude No Yes Yes 45, 50, 90, 135, 180 8-8.5F 63-81 0.032
    Swartz Braided LAMP St. Jude No Yes Yes 45, 90, 135 8-8.5F 63-81 0.032
    Across Interlock System St. Jude No Yes Yes 45, 90 8.5F 63-81 0.032
    TorFlex Baylis Medical No Yes Yes 37, 45, 55, 90, 135 8-8.5F 63-81 0.032
    HeartsSpan Merit No Yes Yes 15, 30, 55, 90, 120, 150 8 5F 60-80-101 0.035
    TSX Boston S No Yes Yes 15, 30, 55, 90, 120, 150 8 5F 60-80-101 0.035
    Preface Biosense No Yes Yes 55, 90, 120, 150 8F 62-77 0.035
    Super Arrow-Flex Teleflex No Yes No 180 (Mullins style) 8F 61 0.035
    Flexcath a Medtronic Yes Yes Yes One Curl 12F 65 0.032, 0.035
    Agilis NxT St. Jude Yes Yes Yes Three Curls (16.8, 22.4, 50 mm) 8.5F 61-71 0.032
    HeartSpan Steerable Merit Yes Yes Yes Three curls (16.4, 22.4, 36 mm) 8.5F 74 0.032
    Dexterity Spirus Yes Yes Yes One curl (two steering locations) 9F, 14F 65-75-105 0.035
    Direx Interlock System Boston S Yes Yes Yes Three curls (17, 22, 50 mm) 9-12F 67-71 0.038

    LAMP, Left atrial multipurpose.

    a 135 maximum deflection.



  • 2.

    Transseptal needles: Stainless steel needles (e.g., Brockenbrough needle, Medtronic, Minneapolis, MN; BRK, St. Jude Medical, St. Paul, MN) are inexpensive and available in multiple lengths and curves, and thus are considered the “work horse” of transseptal needles. Needles utilizing radiofrequency energy (e.g., Baylis, Montreal, Canada) allow controlled puncture and may enhance the safety and efficacy of TSP in patients with fibrotic or thickened fossa ovalis (FO) ( Fig. 5.3 ). Commercially available transseptal needles and their features are listed in Table 5.2 .




    Fig. 5.3


    Ancillary tools for difficult-to-navigate transseptal puncture.

    (A) Safesept needle-wires system. (B) Radiofrequency transseptal needle.

    (Reprinted with permission from Alkhouli M, Rihal CS, Holmes DR Jr. Transseptal techniques for emerging structural heart interventions. JACC Cardiovasc Interv . 2016:26;9[24]: 2465-2480.)


    TABLE 5.2 ■

    Commercially Available Transseptal Needles and Their Characteristics




































































    Transseptal Needle Manufacturer Length (mm) Needle Curve Angle (degree) Distal Tip (Gauge) Proximal Tip (Gauge) Special Feature
    Brockenbrough Medtronic 56, 71 30 21 18
    BRK Series St. Jude 71, 89, 98 BRK, BRK1 (30, 55) a 21 18 Bevel angle 50 degrees
    BRK XS Series St. Jude 71, 89, 98 BRK, BRK1 (30, 55) 21 18 Bevel angle 30 degrees b
    TSX Boston S 71, 89, 98 50, 86 21 18 Transparent handle c
    Heart Span Biosense 56, 71, 89 50, 86 21, 22 18 Transparent handle c
    Cook TSN Cook 56, 71 30 21 18
    NRG RF Baylis 71, 89, 98 C0, C1 (30, 60) 21 18 Radiofrequency energy

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Jan 3, 2021 | Posted by in CARDIOLOGY | Comments Off on Techniques of transseptal puncture

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