Transseptal catheterization 1992: It is here to stay

Abstract

Attempts to measure left atrial (LA) pressure date back to the early days of cardiac catheterization when congenital and rheumatic heart disease attracted the greatest clinical interest. In some instances, investigators found it was possible to pass a catheter through an atrial septal defect or, if no shunt was present, through a foramen ovale that would permit passage of a probing catheter. Techniques involving needle puncture of the right (RV) and left ventricles (LV) had been explored since Reboul and Racine [I] used an intercostal anterior parasternal route in dogs in 1933. Reports of direct intercostal, subxiphoid and apical ventricular puncture became frequent beginning with Ponsdomenech and Nunez [2] in 1951. Exploration of entry into the LA by needle puncture paralleled the ventricular experience.The first systematic clinically useful approach to LA puncture, at least from a chronological standpoint, involved posterior puncture through a rigid bronchoscope. Once the bronchoscope had reached the canna, a long needle with suitable distal bend was advanced through the device to puncture both the trachea and the LA. Introduced by Facquet et al. [3] in Europe in 1952, use of the method was continued in the United States by Allison and Linden [4] in 1953 and Morrow et al. [5] in 1957. At approximately the same time, in 1954, Radner [6] described an extension of his practice of suprasternal aortic puncture. When the aorta was small, the puncture needle could be passed more deeply and enter the LA selectively. When the aorta was moderate in size or when more physiologic data were desired, measurements from the LA, pulmonary artery and aorta could be obtained in sequence simply by withdrawing the puncture needle. Also at this time, in 1953, Bjork et al. [7] introduced direct posterior paravertebral LA puncture as an alternative to other techniques for measurement of LA pressure. Fischer and McCaffrey [8], in 1956, modified the original method by utilizing a prone position instead of the lateral decubitus, and adding flouroscopic control. Wood et al. [9], in 1956, modified the equipment to allow simultaneous recording of LV and LA pressures. Indeed, most of these techniques were refined, revised, or modified to suit the needs of many investigators [ 101. And while they did allow relatively accurate assessment of pressure, they had the potential for significant complications and were not used as widely as needed.The clinical need to assess LA pressure in the setting of mitral valve disease or pulmonary hypertension and the need to enter the LV in an antegrade fashion in selected patients with aortic valve disease fostered the development of transseptal catheterization by Ross [ 1 11 and Cope [ 121 in 1959. The orig-inal method required that a cutdown be made on the saphenous vein so that an 1 1 F catheter could be introduced and passed to the right atrium. Once this was accomplished, a long largebore (usually 16 gauge) needle was passed through the sheath, positioned against the atrial septum and then pushed throu...

Emergency surgery after percutaneous transmitral commissurotomy: Operative versus echocardiographic findings, mechanisms of complications, and outcomes

“…In patients with MS, in whom the normal geometry is lost because of biatrial enlargement, septal puncture should be undertaken with extreme caution. 14 TEE-guided septal puncture can be helpful in this situation. 15…”

Lessons learned during 26 years as editor

“…What they do not know how to do, they defer to echocardiography, computerized tomography or other non-invasive technique whose limitations they do not fully understand. We have been told in published articles that transseptal catheterization is a dying art [3]. I suspect that competent complete diagnostic catheterization of congenital, valvular or non-coronary disease is also a sick art if not yet terminal.…”