Transseptal puncture for left atrial ablation: risk factors for cardiac tamponade and a proposed causative classification system

Abstract

Background Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). Purpose We examined the associations of TSP-related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our centre from 2016–2020. Methods Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinised to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. Results 3,239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP-related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above-median age (OR 2.4 (1.19–4.2), p=0.006) and those undergoing re-do procedures (OR 1.95 (1.29–3.43, p=0.042) were at higher risk of TRCT. Of the operator-dependent variables, choice of transseptal needle (Endrys vs Brockenbrough, p>0.1) or puncture sheath (Swartz vs Mullins vs Agilis vs Vizigo vs Cryosheath, all p>0.1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk (OR 4.42 (2.45–8.2), p=0.001), whilst top quartile operator experience (OR 0.4 (0.17–0.85, p=0.002), transoesophageal echocardiogram (TOE prevalence: 26%, OR 0.51 (0.11–0.94), p=0.023), and use of the SafeSept guidewire (OR 0.22 (0.08–0.62), p=0.001) reduced TRCT risk. An increase in SafeSept wire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R2=0.72, p<0.001) and was associated with a relative risk reduction of 70%. Conclusions During left atrial ablation, the independent predictors of TRCT were patient age, re-do procedure, operator experience, unsuccessful first pass, TOE-guidance, and use of the SafeSept wire. A novel classification system for the causes of cardiac tamponade is proposed (table 1); this may be of interest to clinical trialists or auditors evaluating patient safety. Funding Acknowledgement Type of funding sources: None.