Electrosurgical energy in combination with a transseptal needle: A novel method for the creation of an atrial communication in hypoplastic left heart syndrome with intact atrial septum

Abstract

Neonates with hypoplastic left heart syndrome (HLHS) and intact atrial septum (IAS) usually present with severe acidosis and hypoxemia that necessitate immediate intervention to create an atrial septal defect (ASD). Transcatheter creation of an ASD in these patients requires transseptal puncture of a thickened atrial septum in the setting of a very small left atrium. We report on a novel method of perforating the atrial septum using radio-frequency energy in combination with a transseptal needle to facilitate transseptal puncture and subsequent stent placement in a very thick atrial septum of a newborn with HLHS/IAS and a small left atrium.

Transseptal puncture using surgical electrocautery in children and adults with and without complex congenital heart disease

“…The high pressure convex atrial septum with hypoplastic LA can cause the sheath/needle unit to slide off the septum and perforate the right atrium and/or glide anteriorly causing aortic injury with the use of forward mechanical force. The cautery technique utilizes RF energy in contrast to mechanical energy, with adequate contact against the septum the needle is more likely to puncture at the desired site as illustrated in our case (Figure ) and Gordon et al . In addition, this approach was particularly valuable in single ventricle patients with extracardiac Fontan conduit (Figure ) in creating fenestration/stent placement in three patients and one patient for an EP procedure (Table ).…”

“…Similarly, in our study 28 of 54 patients (Table ) underwent successful TSP for an EP study and ablation procedure in congenital ( n = 4) and structurally normal heart ( n = 24). Apart from EP procedures there are only a few case reports describing TSP in complex CHD; such as HLHS with the thick atrial septum using RF energy delivered through surgical cautery and Nykanen RF perforating wire .…”

“…However, the indications has grown significantly for cardiac arrhythmias, pulmonary vein interventions, atrial septum decompression for ventricular dysfunction in children and adults with and without congenital heart disease (CHD). Despite familiar techniques used traditionally for TSP, difficulty is experienced in crossing the septum in the setting of repeat septal puncture, aneurysmal septum and complex atrial septum in various CHD patients . In addition, several surgical techniques using pericardium, synthetic material (Dacron, Teflon) for ASD closure, native tissue with scars or synthetic material used for baffle creation in Senning and Mustard procedure (Transposition of great vessels), lateral tunnel creation, or use of conduits/grafts for extracardiac Fontan in single ventricle patients, further creates challenges in structure, configuration, and orientation of the septum.…”

Surgical Electrocautery Facilitated Transseptal Puncture in Children

“…This technique may be even more useful when it is a redo transseptal puncture, since it may be difficult to puncture through a scarred septum 4 or in congenital heart disease such as a hypoplastic left heart syndrome. These patients have a thick atrial septum and a small LA 5 . Crossing patches in patients with congenital heart disease with a similar technique using a dedicated RF wire (Nykanen Radiofrequency Perforation Catheter, Baylis Medical Company, Montreal, Canada) instead of the transseptal needle has also been reported 9 .…”

“…In the last two decades, it became more widely used in pediatric patients with the evolution of ablation for arrhythmias. Transseptal puncture can be challenging 3–5 and lead to complications such as pericardial effusion and tamponade. In adults, methods, such as dedicated radiofrequency (RF) to facilitate transseptal puncture, have become routine 6 .…”