Rhea Verma
Heart Rhythm Center, USA
Title: Relationship of transeptal puncture (TSP) site to the non-coronary cusp of aortic valve
Biography
Biography: Rhea Verma
Abstract
Background: Methods for performing TSP have evolved over time. Intracardiac echo (ICE) is standard in most practices for TSP during atrial fibrillation (AF) ablation. However, this has added significant cost to the procedure. We studied the feasibility of using aortic root angiography, specifically the relationship of TSP site to non-coronary cusp (NCC) of aortic valve to help facilitate needle localization prior to TSP.
Methods: One hundred and eleven (111) consecutive patients undergoing AF ablation were enrolled. Aortic root angiography was performed by placing an angled pigtail catheter in the NCC. Images were taken in the RAO 45° and LAO 30°. The Brockenbrough needle was introduced in the SL1 sheath and retracted until it fell in the fossa ovalis (FO). Relationship of TSP site to NCC was recorded. ICE was required for various reasons in some patients (IVP dye allergy, severe vascular disease, severe atrial enlargement, and other anatomical variants). The degree of tenting of FO was also recorded in relationship to aortic margins in LAO 30°.
Results: There is a strong relationship between the TSP site and margins of the NCC in 97/107 (90.1%) patients, TSP were completed successfully by positioning the needle posterior to but within the inferior and superior margins of NCC in RAO. In a few patients, the needle was above (2/107-1.8%) or below NCC (8/107-7.4%). Variable degrees of tenting were visualized (mild 16/107, mod 53/107, severe 38/107). ICE was required in 11/111 (10%) of patients where this method was unsuccessful. Angiographic data was available in 107 patients. No cases of extra cardiac puncture were recorded i.e. no tamponade or dye extravasation.
Conclusions: TSP can be completed safely in the majority of patients using aortic root angiography and relationship to NCC as guidance. This can allow significant cost savings by using ICE in AF ablation only in selected cases.