Modified Transseptal Puncture Technique in Challenging Septa: A Randomized Comparison to Conventional Technique

Abstract

Background. Transseptal puncture (TSP) can be challenging. We compared safety and efficacy of a modified TSP technique (“mosquito” technique, MOSQ-TSP) to conventional TSP (CONV-TSP). Method. Patients undergoing AF ablation in whom first attempt of TSP did not result in left atrial (LA) pressure (failure to cross, FTC) were randomized to MOSQ-TSP (i.e., puncture of the fossa via a wafer-thin inner stylet) or CONV-TSP (i.e., additional punctures at different positions). Primary endpoint was LA access. Secondary endpoints were safety, time, fluoroscopic dose (dose-area product, DAP), and number of additional punctures from FTC to final LA access. Result. Of 384 patients, 68 had FTC (MOSQ-TSP, n = 34 versus CONV-TSP, n = 34). No complications were reported. In MOSQ-TSP, primary endpoint was 100% (versus 73.5%, p < 0.002), median time to LA access was 72 s [from 37 to 384 s] (versus 326 s [from 75 s to 1936 s], p < 0.002), mean DAP to LA access was 1778 ± 2315 mGy/cm2 (versus 9347 ± 10690 mGy/cm2, p < 0.002), and median number of additional punctures was 2 [1 to 3] (versus 0, p < 0.002). Conclusion. In AF patients in whom the first attempt of TSP fails, the “mosquito” technique allows effective, safe, and time sparing LA access. This approach might facilitate TSP in elastic, aneurysmatic, or fibrosed septa.

Robotic navigation shows superior improvement in efficiency for atrial fibrillation ablation

“…The study by Kataria et al evaluated long-term outcome data of 336 patients undergoing PVI with MAN and RMN guided RF [22] . (P=0.008).…”

Complication prevention in ablation procedures: How to perform transseptal puncture safely in case of atrial septum aneurysm

“…As a result, IAS tenting is directly visible using fluoroscopy and the needle passing through the IAS can immediately be recognized. A further option for penetrating the tenting septum in challenging cases without additional resources is the use of the inner stylet of the Brockenbrough needle as a “mosquito,” which has been evaluated in a small study (34 patients in the intervention group) with promising results 17 . Moreover, Aksu and colleagues 18 presented a deep inspiration maneuver to facilitate difficult TSP in a very small series of patients (11 patients in the intervention group).

Figure 5Marking the atrial septum with contrast agent.

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Transvenous Treatment of Carotid Aneurysms Through Transseptal Access

“…12 In contrast, the risk of transseptal puncture (TP)/TSA is low, in the range of 0.5%e2%. 16 It is a conventional technique that dates back to 1959 17 and is currently used by cardiologists widely for ablation of atrial fibrillation. A recently published series of 504 consecutive TPs reports no access-related complications using contemporary access methods.…”

“…18 Likewise, a randomized study comparing 2 different TP methods found that the complication rate with both methods was zero percent. 16 For the endovascular treatment of valvular disease, it is not unusual to perform an angioplasty of the TP site with large balloons (up to 15 mm in diameter) without complications secondary to the TSA.…”