1. TRANS-SEPTAL PUNCTURE
Dr.GOPIDI APARANJI
SRI JAYADEVA INSTITUTE OF CARDIOVASCULAR SCIENCES &
RESEARCH, BANGALORE

2. Outline
• Introduction
• Indications
• Contraindications
• Technique of transseptal puncture (TSP)
• Difficult situations
– Access to right atrium
– Engaging Fossa Ovalis
– Needle advancement
– Sheath and Guide advancement
• Complications and management

3. History

4. INDICATIONS
• Diagnostic -
– LA/ LV hemodynamic assessment
– Diagnostic EP study LA & LV arrhythmias
• Therapeutic
– PTMC
– PV isolation , PV balloon dilation
– LAA closure
– LVAD
– Paravalvular leak repair
– Mitra Clip
– Mitral Valve in Valve
– TMVR

6. Contraindications
• Absolute C/I – LA cavity / Septal thrombus or Tumor
• Relative
– Distorted Anatomy – Severe Kyphoscoliosis
– Huge LA / RA
– Aortic root aneurysm
– Interrupted IVC

7. Transeptal Puncture (TSP)
• We need three things
– HARDWARE
– ANATOMICAL LANDMARKS
– IMAGING GUIDANCE

8. HARDWARE

9. TSP – Hardware
• Needle with Stylet
– Classic Brockenbrough Needle (Medtronic)
– BRK , BRK-1 & 2 (St Jude)
– NRG RF – Baylis

10. TSP – Hardware
• Sheath with Dilator
– Fixed – Mullins
– Steerable – Agilis – 5-6 times expensive

13. ANATOMICAL LANDMARKS
AND
IMAGING GUIDANCE

20. RAO

24. Procedure
• 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

25. PROCEDURE
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 –
SEPTAL STAIN
6. Confirm LA entry
7. Dilator followed by Sheath are advanced
8. Removal of Dilator assembly – Slowly
9. Definitive procedure performed

26. PIG TAIL CATHETER IN AORTIC ROOT(NCC)
0.032 WIRE IN INNOMINATE VEIN

27. SHEATH DILATOR ASSEMBLY IN INNOMINATE
VEIN

28. TRACKING BROCKENBROUGH NEEDLE WITH TIP
JUST INSIDE DILATOR

29. DESCENT FROM SVC – RA
RA – FOSSA

30. CHECK IN RAO
(check needle tip away from Aorta and CS

31. CHECK IN LAO/LATERAL
(check needle tip away from Aorta and in
inferoposterior third

32. PUSH ASSEMBLY/ NEEDLE PUNCTURE
(If satisfied by anatomical landmarks and/or pulsation

34. CHECK IN AP/RAO VIEW BY ANGIO / PRESSURE /
SATURATION
(If SATISFIED – advance dilator/sheath)

35. LA WIRE ENTRY

36. Special situations

38. Complications
• Cardiac Perforation & Tamponade
– <1% in diagnostic hemodynamic studies,
– 1% to 2% in PBMV, and
– 2% to 3% in PVI and LAA closure
• Thromboembolism
– 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
effusion!
• (Puncture- RA free wall -
PERICARDIAL SPACE – LA
lateral wall) Needs emergency
surgery!

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)
• Autotransfusion24

41. AORTIC ROOT STAIN
• Abandon procedure
• Observe for
hemodynamics/effusion
• Only a needle puncture -
wait and watch.
• defer the procedure and
repeat echo in regular
intervals