Complications of transseptal catheterization for different cardiac procedures☆,☆☆
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.
Section snippets
Patients
Data from consecutive procedures performed by the same operator during the period 2000–2012 were analysed. Patients' records and all required data were available in a uniform computerized database. The operator (DGK) has already got considerable experience on transseptal catheterization having had more than 100 successful procedures for various purposes. Studied procedures were performed at Athens Euroclinic, Greece, the General Hospital of Nicosia, Cyprus, and the Hippokration Hospital,
Patients' characteristics
A total of 393 procedures [116 cases in Group 1 (left-side AP ablation (n = 77), AVNRT ablation (n = 12), mitral valvuloplasty (n = 27)) and 277 AF-ablation related cases in Group 2 (ostial PVI (radiofrequency (n = 76) and cryo-balloon (n = 30) ablation, circumferential PVI (n = 51), and combined procedures (n = 120)] that required transseptal puncture were retrospectively retrieved. Patients included in Group 1 were relative younger (40 ± 14 versus 54 ± 11 for Group 1 versus 2 respectively, p-value < 0.001); and
Discussion
To the best of our knowledge, this is the first series on most procedures in which transseptal access is indicated and performed by the same operator. Our results indicate that AF ablation represents an independent risk factor for tamponade during procedures that utilize transseptal catheterization.
In the initial report of Roelke and colleagues on 1279 transseptal cases mainly performed for diagnostic purposes or mitral balloon valvuloplasty, the incidence of tamponade was 1.2% [1]. De Poniti
References (19)
- et al.
Comparison of the transseptal approach to the transaortic approach for ablation of left-sided accessory pathways in patients with Wolff-Parkinson-White syndrome
Am J Cardiol
(2003) - et al.
Trends in utilization and complications of catheter ablation for atrial fibrillation in Medicare beneficiaries
Heart Rhythm
(2009) - et al.
Trans-septal catheterization in the electrophysiology laboratory: data from a multicenter survey spanning 12 years
J Am Coll Cardiol
(2006) - et al.
Complications arising from catheter ablation of atrial fibrillation: temporal trends and predictors
Heart Rhythm
(2011) Transseptal puncture through atrial septal closure devices
Heart Rhythm
(2011)- et al.
The technique and safety of transseptal left heart catheterization: the Massachusetts General Hospital experience with 1,279 procedures
Cathet Cardiovasc Diagn
(1994) - et al.
Low-energy DC catheter ablation of left atrial ectopic tachycardia that had resulted in reversible cardiomyopathy
Pacing Clin Electrophysiol
(1993) - et al.
Heart Rhythm Society Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation
Heart Rhythm
(2012) - et al.
Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation
Circulation
(2005)
Cited by (32)
Direct cardiac reprogramming: A new technology for cardiac repair
2023, Journal of Molecular and Cellular CardiologyTransseptal puncture: Review of anatomy, techniques, complications and challenges, a critical view
2022, International Journal of CardiologyAn Unusual Complication of Transseptal Puncture
2021, JACC: Case ReportsCitation Excerpt :In the current era, transseptal puncture is widely used during many common cardiac procedures and is performed without the aid of transesophageal echocardiography or intracardiac echocardiography in many countries. Transseptal access, despite being increasingly performed and having an excellent safety profile, can be associated with complications regardless of indication (4). Understanding the embryological development and anatomy of the interatrial septum is critical for operators performing this procedure.
Three-dimensional electroanatomical mapping to guide transseptal catheterization
2018, HeartRhythm Case ReportsCitation Excerpt :Although during most day-to-day cases a transseptal puncture can be performed safely through the use of fluoroscopy with or without the use of intracardiac echocardiography, this case illustrates that extreme variations in patient anatomy can rarely result in marked displacement of the fossa ovalis, rendering this generally simple and routine procedure at times challenging. Though transseptal catheterization is often the least discussed part of the ablation procedure, it continues to remain the very step most commonly prone to complications.3–5 This case demonstrates the importance of utilizing multiple imaging modalities to enhance the safety of transseptal catheterization.
Combined MitraClip implantation and left atrial appendage occlusion using the Watchman device: A case series from a referral center
2017, Revista Portuguesa de CardiologiaCitation Excerpt :Exposing these patients to two separate procedures would present several disadvantages. It is well recognized that transseptal puncture carries a small but important risk of significant complications.19 Furthermore, the use of large sheaths in two different locations may increase the risk of significant residual septal shunting.
Transseptal puncture — Review of anatomy, techniques, complications and challenges
2017, International Journal of CardiologyCitation Excerpt :Less commonly, catheter exit occurs through-and-through at the left atrial posterolateral wall, left atrial roof or left atrial appendage. Atrial fibrillation ablation procedures are higher risk, because of the need for multiple punctures, extensive catheter manipulation and systemic anticoagulation [62]. When compared to pulmonary vein isolation (PVI) techniques, RF procedures carry the additional possibility of perforating the left atrial wall from high energy or popping [63].