Complications of transseptal catheterization for different cardiac procedures

Abstract

Background

Cardiac tamponade is the main complication of transseptal catheterization that is necessary for a variety of cardiac interventions and electrophysiology procedures.

Methods

A retrospective assessment of all consecutive procedures that required transseptal puncture by the same experienced operator (with already > 100 previous trans-septal procedures) during the period 2000–2012 was performed. We recorded any puncture-related complications of pericardial effusion and cardiac tamponade (acute or delayed).

Results

A total of 393 procedures were retrieved: Group 1 [ablation of left-sided accessory pathways (n = 77), atrioventricular nodal reentry tachycardia-left septal access (AVNRT) (n = 12), and Inoue balloon mitral valvuloplasty (n = 27)], and Group 2 [atrial fibrillation (AF) ablation procedures: ostial pulmonary vein isolation (PVI) (including RF (n = 76) and cryo-balloon (n = 30)), circumferential PVI (n = 51), and combined procedures (n = 120)]. In total, 5 cases of tamponade were recorded, four of them were acute and one delayed (occurring 1 h after the procedure). All tamponade cases occurred only during or after AF ablation procedures (cryo-balloon ablation = 1, circumferential PVI = 2, and combined procedures = 2). In one case emergency atrial repair following median sternotomy was necessary, and in another a surgical drainage through a limited thoracotomy was performed. The other three cases were treated with pericardiocentesis and drainage for 12 h. No patient was on uninterrupted oral anticoagulation during the procedure.

Conclusions

AF ablation is associated with a higher incidence of tamponade compared to other procedures that require transseptal access. Such procedures should only be performed in hospitals with access to emergency surgical support.

Introduction

Transseptal catheterization is necessary for a variety of cardiac intervention and electrophysiology procedures [1], [2], [3]. Initially utilized mainly for mitral valvuloplasty and ablation of left-sided accessory pathways (AP), is now widely used for percutaneous mitral valve repair and, especially, ablation of atrial fibrillation (AF). Cardiac tamponade, potentially related to the transseptal access, is the main cause of serious complications in AF ablation, and its incidence is higher than with other procedures that employ transseptal catheterization [4]. It also appears to consistently increase with time over the last decade in several [5], [6], [7], although not all [8], [9], studies. In an analysis of Medicare patients for the fiscal years 2001–2006, the incidence of tamponade due to AF ablation increased from 1.3% to 3.6% [5], while Worldwide Survey on AF ablation reported an incidence of tamponade 1.22% in 2005, and 1.31% in 2010 [6], [7]. The reasons for this trend are not exactly known. Tamponade appears to be related to specific ablation techniques with a higher risk of 6% reported for linear lesions [10]. Patients subjected to catheter ablation for AF are usually older than those undergoing mitral valvuloplasty or AP ablation, but, again, results on the impact of ageing on complications rate have been controversial [9], [11], [12]. Another important modifier of the rate of complications is the experience of the ablating center and operators. Most surveys have used data from various centers with operators at varying stages of their learning curves, and this makes results non-indicative of actual trends [9]. Thus, the contribution of particular procedures and patient characteristics may be difficult to assess in published series.

We have, therefore, conducted a retrospective assessment of all cardiac procedures that required transseptal puncture, and have recorded all puncture-related complications, such as pericardial effusion and cardiac tamponade. Both mitral valvuloplasty and catheter ablation procedures such as left-sided AP, atrioventricular nodal reentry tachycardia (AVNRT)-left septal access, and AF, were considered.