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        "titulo" => "A arte da pun&#231;&#227;o transseptal &#8211; perdida na tradu&#231;&#227;o&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Transseptal puncture emerged 60 years ago and its indications have changed progressively over the decades&#46; Currently&#44; it is a technique performed by multiple disciplines with different objectives and training protocols&#46; Greater accuracy and technological sophistication have replaced the fine art of the classical technique&#44; which was guided solely by fluoroscopy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the 1950s&#44; there was growing interest in left heart catheterization&#46; The initial approaches included puncture of the left atrium &#40;suprasternal&#44; posterior transthoracic or transbronchial&#41; and apical or subxiphoid puncture of the left ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> John Ross&#44; Andrew Morrow and Eugene Braunwald then developed transseptal puncture&#44; which emerged as the standard technique to access the left heart&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a> In the next decade&#44; transseptal puncture was pivotal for the study of left ventricular function and the diagnosis of obstructive hypertrophic cardiomyopathy and left heart valvular disease&#46; In the 1970s&#44; retrograde left heart catheterization progressively replaced the transseptal puncture technique&#44; only for it to recover in the 1980s with the emergence of balloon mitral valvuloplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Henceforth&#44; the art of transseptal puncture was limited to specialized centers and dispersed among subspecialties&#46; Interventional cardiology teams gradually lost their skills&#44; due to the diminishing prevalence of rheumatic valve disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Subsequently&#44; transseptal puncture was resurrected for atrial fibrillation ablation<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> and electrophysiologists became the experts in the field&#46; It became an everyday procedure for pulmonary vein isolation and atypical left atrial flutter or ventricular tachycardia ablation&#46; More recently&#44; interventional cardiologists refined the technique for new and demanding transseptal structural interventions&#44; such as left atrial appendage closure&#44; mitral valve repair&#44; mitral valve-in-valve&#44; valve-in-ring and valve-in-MAC &#40;mitral annular calcification&#41;&#44; and mitral paravalvular leak closure&#46; Increasing demand for safety and efficacy&#44; as well as for enhanced precision&#44; increased the complexity and sophistication of transseptal puncture&#46; Multimodality imaging&#44; mainly with transesophageal or intracardiac echocardiography associated with fluoroscopy&#44; became the default for many centers&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> What had been contraindications in the early days of transseptal puncture were overcome by the common use of multimodality imaging in conditions such as giant right atrium&#44; severe rotational abnormalities of the heart and great vessels&#44; kyphoscoliosis and marked dilation of the ascending aorta&#46; Currently&#44; the practice of transseptal puncture is varied&#44; with different training requirements&#44; performed by multiple subspecialties and tailored according to the demands of each intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Additionally&#44; many aspects of the fine art of the classical technique were lost over the years&#44; due to the introduction of different protocols and technologies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The current issue of the <span class="elsevierStyleItalic">Journal</span> sees the publication of a small series by Martinez-Sande et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> of 22 patients with atrial fibrillation and contraindication for iodinated contrast administration&#44; who were scheduled for pulmonary vein isolation&#46; As an alternative to contrast administration&#44; transseptal puncture was followed by the introduction of a 0&#46;014-inch floppy guidewire&#44; to confirm correct positioning and to facilitate sheath advancement into the left atrium&#46; Success was achieved in all patients&#44; without complications&#46; The authors considered this variation of the technique to be a reasonable solution for patients with severe contrast allergy and renal insufficiency in centers that rely mainly on fluoroscopy&#44; with limited access to transesophageal or intracardiac echocardiography&#46; The studied technique variation is not original&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> In our opinion&#44; a judicious classical technique with careful and accurate intracardiac pressure assessment avoids the use of a guidewire to confirm correct positioning&#46; Nonetheless&#44; we recognize the potential usefulness of this variation in difficult anatomies&#44; in which crossing the septum is particularly challenging&#44; requiring unusual sheath torqueing and forceful pushing&#46; In these cases&#44; the wire appears to provide extra safety by minimizing the risk of contact between the tip of the needle&#47;dilator and the atrial free wall&#46; We acknowledge the speculative nature of this debate given the fact that few or no trials have been performed in this field&#46; However&#44; it appears that wire-guided transseptal puncture does not mitigate the risk of crossing the muscular septum and is not a genuine alternative to multimodality imaging when a precise puncture is required&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In summary&#44; transseptal puncture has been adapted and reinvented since its creation&#46; It is still a demanding technique with a steep learning curve and considerable risk of severe complications&#46; Technological advances have increased its accuracy and safety&#44; but have undoubtedly also increased its complexity and affected the fine art of its beginnings&#46; As the technique has been passed down through the generations&#44; improvements have been sought and added&#44; but some of its basic principles have been lost in translation&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">E&#46; Infante de Oliveira declares research grants&#44; educational grants and&#47;or speaker &#47; proctor &#47; advisory board honoraries from the following companies&#58; Medtronic&#44; Boston Scientific&#44; Abbott&#44; Terumo&#44; Volcano-Philips&#44; Bayer&#44; Boehringer Ingelheim&#44; Astrazeneca&#44; Daiichi-Sankyo&#44; Bristol-Myers Squibb-Pfizer&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">J&#46; de Sousa has no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
The art of transseptal puncture – lost in translation?
A arte da punção transseptal – perdida na tradução?
E. Infante de Oliveira
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e.infante.de.oliveira@gmail.com

Corresponding author.
, J. de Sousa
Cardiology Department, Santa Maria University Hospital (CHLN), Lisbon Academic Medical Centre, Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Transseptal puncture emerged 60 years ago and its indications have changed progressively over the decades&#46; Currently&#44; it is a technique performed by multiple disciplines with different objectives and training protocols&#46; Greater accuracy and technological sophistication have replaced the fine art of the classical technique&#44; which was guided solely by fluoroscopy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the 1950s&#44; there was growing interest in left heart catheterization&#46; The initial approaches included puncture of the left atrium &#40;suprasternal&#44; posterior transthoracic or transbronchial&#41; and apical or subxiphoid puncture of the left ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> John Ross&#44; Andrew Morrow and Eugene Braunwald then developed transseptal puncture&#44; which emerged as the standard technique to access the left heart&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a> In the next decade&#44; transseptal puncture was pivotal for the study of left ventricular function and the diagnosis of obstructive hypertrophic cardiomyopathy and left heart valvular disease&#46; In the 1970s&#44; retrograde left heart catheterization progressively replaced the transseptal puncture technique&#44; only for it to recover in the 1980s with the emergence of balloon mitral valvuloplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Henceforth&#44; the art of transseptal puncture was limited to specialized centers and dispersed among subspecialties&#46; Interventional cardiology teams gradually lost their skills&#44; due to the diminishing prevalence of rheumatic valve disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Subsequently&#44; transseptal puncture was resurrected for atrial fibrillation ablation<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> and electrophysiologists became the experts in the field&#46; It became an everyday procedure for pulmonary vein isolation and atypical left atrial flutter or ventricular tachycardia ablation&#46; More recently&#44; interventional cardiologists refined the technique for new and demanding transseptal structural interventions&#44; such as left atrial appendage closure&#44; mitral valve repair&#44; mitral valve-in-valve&#44; valve-in-ring and valve-in-MAC &#40;mitral annular calcification&#41;&#44; and mitral paravalvular leak closure&#46; Increasing demand for safety and efficacy&#44; as well as for enhanced precision&#44; increased the complexity and sophistication of transseptal puncture&#46; Multimodality imaging&#44; mainly with transesophageal or intracardiac echocardiography associated with fluoroscopy&#44; became the default for many centers&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> What had been contraindications in the early days of transseptal puncture were overcome by the common use of multimodality imaging in conditions such as giant right atrium&#44; severe rotational abnormalities of the heart and great vessels&#44; kyphoscoliosis and marked dilation of the ascending aorta&#46; Currently&#44; the practice of transseptal puncture is varied&#44; with different training requirements&#44; performed by multiple subspecialties and tailored according to the demands of each intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Additionally&#44; many aspects of the fine art of the classical technique were lost over the years&#44; due to the introduction of different protocols and technologies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The current issue of the <span class="elsevierStyleItalic">Journal</span> sees the publication of a small series by Martinez-Sande et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> of 22 patients with atrial fibrillation and contraindication for iodinated contrast administration&#44; who were scheduled for pulmonary vein isolation&#46; As an alternative to contrast administration&#44; transseptal puncture was followed by the introduction of a 0&#46;014-inch floppy guidewire&#44; to confirm correct positioning and to facilitate sheath advancement into the left atrium&#46; Success was achieved in all patients&#44; without complications&#46; The authors considered this variation of the technique to be a reasonable solution for patients with severe contrast allergy and renal insufficiency in centers that rely mainly on fluoroscopy&#44; with limited access to transesophageal or intracardiac echocardiography&#46; The studied technique variation is not original&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> In our opinion&#44; a judicious classical technique with careful and accurate intracardiac pressure assessment avoids the use of a guidewire to confirm correct positioning&#46; Nonetheless&#44; we recognize the potential usefulness of this variation in difficult anatomies&#44; in which crossing the septum is particularly challenging&#44; requiring unusual sheath torqueing and forceful pushing&#46; In these cases&#44; the wire appears to provide extra safety by minimizing the risk of contact between the tip of the needle&#47;dilator and the atrial free wall&#46; We acknowledge the speculative nature of this debate given the fact that few or no trials have been performed in this field&#46; However&#44; it appears that wire-guided transseptal puncture does not mitigate the risk of crossing the muscular septum and is not a genuine alternative to multimodality imaging when a precise puncture is required&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In summary&#44; transseptal puncture has been adapted and reinvented since its creation&#46; It is still a demanding technique with a steep learning curve and considerable risk of severe complications&#46; Technological advances have increased its accuracy and safety&#44; but have undoubtedly also increased its complexity and affected the fine art of its beginnings&#46; As the technique has been passed down through the generations&#44; improvements have been sought and added&#44; but some of its basic principles have been lost in translation&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">E&#46; Infante de Oliveira declares research grants&#44; educational grants and&#47;or speaker &#47; proctor &#47; advisory board honoraries from the following companies&#58; Medtronic&#44; Boston Scientific&#44; Abbott&#44; Terumo&#44; Volcano-Philips&#44; Bayer&#44; Boehringer Ingelheim&#44; Astrazeneca&#44; Daiichi-Sankyo&#44; Bristol-Myers Squibb-Pfizer&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">J&#46; de Sousa has no conflicts of interest to declare&#46;</p></span></span>"
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