• Femoral approach.
• 8F sheath in vein, 6F sheath in the artery.
• Bolus administration of 1000U Heparin.
• Right heart catheterisation is performed.
• Pig tail catheter in Aortic root.
• Prepare Sheath assembly and check Needle compatibility
1. Pass 0.032” wire into Left innominate Vein over which
Sheath & Dilator assembly is advanced
2. Wire is removed – Careful not to pull too fast – air
3. Needle with Stylet introduced just distal to the dilator tip
4. Begin Descent of the entire “assembly”
5. Confirm position in RAO ; Puncture to be done LAO –
6. Confirm LA entry
7. Dilator followed by Sheath are advanced
8. Removal of Dilator assembly – Slowly
9. Definitive procedure performed
• Cardiac Perforation & Tamponade
– <1% in diagnostic hemodynamic studies,
– 1% to 2% in PBMV, and
– 2% to 3% in PVI and LAA closure
– Highest for PVI ~ 5 % (Clincal & subclinical)
• Air Embolism
• Iatrogenic ASD
– Hypoxemia resulting from large right-to-left shunt can occur
after withdrawal of the transseptal sheath but is rare
39. STITCH PHENOMENA
• In large LA - no septum
beyond or near the right
lateral and inferior border of
LA - Overlapping walls of RA
and LA form this region
• If this region punctured - both
RA and LA get involved in
• (Puncture- RA free wall -
PERICARDIAL SPACE – LA
lateral wall) Needs emergency
40. THINK BEFORE PULLING OUT!
• After septal puncture – always wait for 2 minutes, watch
hemodynamics/echo, then give heparin
• MANAGEMENT OF STITCH/EFFUSION
• Only a needle puncture-wait and watch.defer the procedure and repeat
echo in regular intervals
• If effusion is small and Balloon in left atrium - do BMV as reduction in LA
pressure will decreases the leak
• If septum is dilated, don’t remove the dilator - Pigtail insertion and SHIFT
TO CTVS with dilator in situ
• Reverse Heparin (1 mg protamine per 100 U of UFH)
41. AORTIC ROOT STAIN
• Abandon procedure
• Observe for
• Only a needle puncture -
wait and watch.
• defer the procedure and
repeat echo in regular