Fluoroscopy-free Atrial Transseptal Puncture

Abstract

Introduction Fluoroscopy is traditionally used in atrial transseptal puncture (TSP); however fluoroscopy exposes patient and physician to excess radiation. Here, we describe a feasibility study of a zero-fluoroscopy transseptal puncture (ZFTSP) technique utilising electroanatomical mapping (EAM) and intracardiac echo (ICE) in a small case series of patients undergoing ablation for atrial fibrillation (AF). We then compare this technique to other established ZFTSP techniques for paroxysmal AF ablation. Methods Seven patients received ZFTSP. An Acunav™ ICE catheter (Biosense Webster Inc., California, US) was placed in the right atrium, then an Agilis™ sheath (St. Jude Medical, Saint Paul, Minnesota, US) was established into the inferior vena cava. A ThermoCool® SmartTouch™ catheter (Biosense Webster Inc., California, US) was inserted through the Agilis to map the fossa ovalis. Mapping catheter exchange for dilator and needle allowed for facile ZFTSP. AF outcome, fluoroscopy times, and procedure times were compared with eight age-matched control patients. Results There were no significant differences in age, body mass index (BMI) or AF duration between the two groups and no immediate complications. ZFTSP procedure time was 183.9±33.7 minutes versus 293.13±129.9 minutes for TSP-only controls (p=0.05). Fluoroscopy time was 17.5±14.1 minutes in ZFTSP patients versus 73.4±50.3 minutes in controls (p=0.01). AF recurrence in ZFTSP patients was 14% versus 25% in controls. Conclusion ZFTSP utilising ICE and EAM is safe, effective, and time-efficient. There is a small but significant reduction in radiation exposure to patient and physician by the use of this technique.

Safety and Effectiveness of a Novel Fluoroless Transseptal Puncture Technique for Lead-free Catheter Ablation: A Case Series

“…28 Limited visualization of the transseptal apparatus has been associated with reduced transseptal puncture success, requiring a switch over to fluoroscopic guidance in 30% to 60% of cases. 26,29 Although EAM-guided transseptal puncture has also been reported, 30,31 data on the safety and effectiveness of these techniques as well as the ability to visualize the transseptal needle in the superior vena cava (SVC) during dropdown and while positioning the transseptal needle on the interatrial septum are limited. Therefore, in the absence of precise three-dimensional visualization of a transseptal needle, fluoroscopy continues to be used during transseptal puncture and remains the last barrier to completely fluoroless cardiac ablations.…”

Electroanatomic guidance versus conventional fluoroscopy during transseptal puncture for atrial fibrillation ablation

“…In the present study, we evaluated the feasibility and safety of EA 12 Recent descriptions of TSP guided by combination EA mapping and ICE are a promising option when the cost is justified. [4][5][6] The progressive improvement of 3D mapping systems over the last decade now allows operators to visualize the real-time manipulation and placement of catheters during cardiac procedures with hybrid technology that combines magnetic resonance and current-based data, ensuring high accuracy and shorter fluoroscopy times. 7,[13][14][15] Our approach is based on a knowledge of right atrium anatomy and embryology.…”

“…Although ICE represents another possibility for limiting fluoroscopic use, the technique is cost‐prohibitive and routine use is not economically sustainable in some countries 12 . Recent descriptions of TSP guided by combination EA mapping and ICE are a promising option when the cost is justified 4–6 …”

“…Accordingly, there is a need for strategies to reduce X‐ray exposure during procedures such as AF ablation. Recently, fluoroscopy has been accompanied by two‐ and three‐dimensional (3D) transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) for challenging cases to increase safety and minimize fluoroscopy exposure 3–7 . Unfortunately, the use of TEE during ablation procedures is limited by a need for general anesthesia, which is otherwise unnecessary for AF ablation.…”

“…Recently, fluoroscopy has been accompanied by two-and threedimensional (3D) transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) for challenging cases to increase safety and minimize fluoroscopy exposure. [3][4][5][6][7] Unfortunately, the use of TEE during ablation procedures is limited by a need for general anesthesia, which is otherwise unnecessary for AF ablation. On the contrary, the widespread use of ICE, in some regions, is limited by its prohibitive cost.…”