Transseptal Catheterization with TEE or ICE Guidance

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  • Hemodynamic assessment
    • Across mitral valve, using simultaneous left ventricular (LV) pressure recording, when percutaneous catheter wedge pressure is not sufficient
    • Measurement of LV pressure when a prosthetic aortic valve is present
  • Therapeutic possibilities
    • Electrophysiologic procedures – atrial fibrillation ablation, ablation of left-sided bypass tracts
    • Percutaneous treatment of mitral valve disease
      • Balloon valvuloplasty for mitral stenosis
      • Mitra-Clip procedure for mitral regurgitation
      • Percutaneous closure of prosthetic mitral paravalvular leaks
    • Percutaneous closure of atrial appendage for patients with atrial fibrillation
    • May be used in percutaneous closure of post-infarct ventricular septal defect
    • May be used as a means to close a patent foramen ovale (PFO), in the face of a long- tunnel PFO
    • May be a therapeutic procedure to cause a right-to-left shunt in infants with absence of flow to the left heart or in adults with end-stage pulmonary hypertension and right heart failure
  • Most consider the presence of a thrombus in the left atrial appendage to be a contraindication, typically seen in the left atrial appendage
  • Coagulopathic state
  • Interrupted inferior vena cava
  • Distorted septal anatomy caused by congenital heart disease or repair
  • Pregnancy
  • Syringe and small (eg, 25-gauge) needle for local anesthetic infiltration
  • 1% lidocaine or other appropriate local anesthetic solution
  • Appropriate sedative medications, such as midazolam, if IV sedation is anticipated
  • Sterile prep solution
  • Sterile mask, gown, drapes, gloves
  • Eye protection
  • Standard patient monitors: blood pressure (BP) cuff, pulse oximeter, ECG
  • Oxygen source and delivery system (eg, nasal cannula, mask)
  • Resuscitation cart, including resuscitation drugs, defibrillator, and intubation equipment
  • 8F sheath, puncture needle and wire, for right femoral venous access
  • Optional sheath for arterial puncture (no particular French size required)
  • Optional 8F or 9F sheath for left femoral venous access
  • Intracardiac echocardiography (ICE) is to be used to guide transseptal puncture. ICE probe, console, and sonographer to run the console if cardiac echocardiography (echo) will be used to guide transseptal puncture
  • Optional transesophageal echo (TEE) probe, with console, echocardiographer to perform the TEE, and sonographer to run the console
  • Optional pigtail catheter, suitable to French size of arterial access catheter
  • Transseptal catheter with dilator. In some circumstances the dilator may be used without the catheter, if other transseptal equipment is going to be used (eg, for mitral valve procedures)
  • Brockenbrough (transseptal) needle
  • Hemodynamic setup, including tubing, stopcock, and sensor. Frequently, a second system is set up for simultaneous LV or arterial pressure recording and/or monitoring
  • 0.032" wire – standard-length J-wire
  • Optional 0.032" Inoue (coil) wire
  • Optional contrast for right atrial angiography
  • Heparin for parenteral administration
  • Equipment needed for pericardiocentesis, including a long-puncture needle, a wire, and a catheter for drainage
  • Gauze and pressure dressing for femoral puncture site

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Patients should remain on bed rest for 2 to 6 hours to prevent bleeding at femoral access sites and refrain from significant physical activity for 5 to 14 days afterward.
  • Patients should be cautioned to watch for swelling or bleeding at the femoral puncture site and to report these immediately to the nursing staff.
  • Patients who take metformin should be advised not to resume taking it for at least 48 hours after the procedure.

(specific to transseptal puncture)

  • Pericardial tamponade caused by puncture of the right atrial free wall, left atrial free wall, or appendage after crossing septum or entering inferiorly located transverse sinus, despite a successful puncture.
  • Puncture into aorta (which may lead to tamponade or hematoma).
  • Creation of a clinically important atrial septal defect. If the patient has right heart failure, this can cause hypoxemia if there is too much right-to-left shunting.
  • Complications relative to the procedure being performed that required the transseptal puncture.
  • Thromboembolic complications, including neurologic or cardiac complications from air or clot entering those arterial systems.
  • Vascular complications from access and manipulation through the vascular systems.
  • Arrhythmias.
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