Recognizing and reacting to complications of trans-septal puncture

ABSTRACT

Introduction: The transseptal puncture (TSP) enables access to the left heart, through the fossa ovalis (FO), both in electrophysiology and in cardiac interventional procedures. TSP is usually safe in experienced hands. Sometimes TSP can be technically demanding and carries the risk of severe complications in approximately 1%. While performing a TSP, every effort should be taken in order to avoid complications. In the event of complications, prompt recognition and reaction are essential and a combined ‘heart-team’ management may be the most effective approach.

Areas covered: Main TSP-related complications are cardiac tamponade, aortic root puncture, embolic stroke, transient ST elevation of inferior leads and iatrogenic atrial septal defect. A challenging TSP may be expected in presence of difficult IAS-FO anatomies, previous TSP, IAS occluder device and previous IAS surgical repair. Use of echo imaging and special needles (ie., radiofrequency needle and J-shaped guidewire) may avoid TSP-related complications in difficult settings.

Expert commentary: Some tools are available to help minimize the risks of TSP. However, their availability might be limited. To increase safety of TSP, an adequate training of physicians, identification of patients in whom it might be difficult and a prompt recognition of complications seem to be the most important background.

KEYWORDS:

• Difficult anatomy
• inter atrial septum
• interventional cardiology
• transcatheter ablation
• transseptal puncture related complications
• transesophageal echocardiography

Declaration of interest

C de Asmundis has received compensation for teaching purpose and proctoring from AF Solution, Medtronic, St Jude Medical, Biotronik, Boston Scientific, has received consulting fees and speaker honoraria from Medtronic; is a member steering committee ETNA-AF-Europe Daiichi Sankyo Europe. GB Chierchia has received compensation for teaching purpose and proctoring from AF Solution, Medtronic and Biotroink. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

This paper was not funded.