Impact of transesophageal echocardiography during transseptal puncture on atrial fibrillation ablation

Abstract

BackgroundThe aim of our study was to demonstrate the added value of routine transesophageal echocardiography (TEE) for correctly positioning the transseptal system in the fossa ovalis (FO), thus potentially preventing complications during fluoroscopy-guided transseptal puncture (TP), and for assessing the optimal puncture site within the FO according to the expected procedure type.MethodsNinety-one patients undergoing pulmonary vein isolation (PVI) procedures by cryoballoon technique for drug-resistant paroxysmal or persistent atrial fibrillation (AF) were prospectively included. In 57 patients, the TP procedure was performed under fluoroscopic guidance and septal localization was confirmed by contrast injection through the needle and demonstration of septal tenting in both the anteroposterior and left lateral fluoroscopic projections. In 34 patients, TP was performed under TEE guidance and positioning was targeted to perform the TP procedure in the more anterior and inferior locations of the FO. Two patient groups were compared according to the incidence of complications directly attributable to transseptal catheterization, thromboembolic complications, recurrence rates after the ablation procedure, total procedural time, and fluoroscopy time.ResultsFluoroscopy time (p<0.001), total cryoablation time (p=0.002), and total procedural time (p<0.001) were shorter in the TEE-guided group. Left inferior pulmonary vein (LIPV) cryoablation time (p=0.007) and right inferior pulmonary vein (RIPV) cryoablation time (p=0.004) were significantly shorter and the number of applications to the LIPV (p=0.007) and RIPV (p=0.005) were significantly fewer in the TEE-guided group. Although there was a trend toward higher complication rates (20.6% vs. 31.6%, p=0.37) and recurrence rates (11.8% vs. 20.1%, p=0.26) in the fluoroscopy-guided group, the differences between the groups were not statistically significant.ConclusionsTEE-guided TP for AF ablation is associated with shorter fluoroscopy time, shorter total cryoablation time, and shorter total procedural time. Importantly, TEE-guided TP facilitates cryoablation of the inferior pulmonary veins.

Anatomic predictors of late right inferior pulmonary vein reconnection in the setting of second‐generation cryoballoon ablation

“…Previous reports are in support of a TS puncture at a low and anterior location on the FO near the inferior limbus, providing a mechanical advantage when ablating the inferior PVs . Our observations are in favor of a low TS puncture, considering that a lower TS location improves the RIPV‐TS frontal angle and allows for better alignment between the CB and RIPV ostium with contact improvement at the bottom region as a result, as shown in Figure .…”

“…balloon technologies are comparable in concept, similar anatomic variables might have an impact on the hot balloon. However, as the laser balloon has more compliance and the application can be delivered under visual control through an integrated endoscope, it is unclear at this moment if the same finding of this study can be applied to the laser balloon.4.2 | TS puncture and ablation strategiesPrevious reports are in support of a TS puncture at a low and anterior location on the FO near the inferior limbus, providing a mechanical advantage when ablating the inferior PVs 17,18. Our observations are in favor of a low TS puncture, considering that a lower TS location improves the RIPV-TS frontal angle and allows forF I G U R E 2 ROC curve for RIPV frontal angle, illustrating the predictive value for late RIPV reconnection.…”

Completely nonfluoroscopic catheter ablation of left atrial arrhythmias and ventricular tachycardia

“…Although our preferred imaging modality during NFA of complex arrhythmias is ICE imaging, there are certain disadvantages, which include catheter cost and operator experience. The use of a transesophageal echocardiograph (TEE) to guide transseptal puncture is well described, has been shown to be useful, and is the imaging modality of choice at many centers …”

Transseptal Access to the Left Atrium: Tips and Tricks to Keep it Safe Derived from Single Operator Experience and Review of the Literature

“…Although there are no systematic reviews and meta-analyses of patient series undergoing TSP, several patient series have documented that fluoroscopy-guided TSP with various modifications of the technique that was employed in this series has been effective in 95-100% of the cases with a complication rate ranging from 0.0% to 6.7%, albeit with a mortality rate of 0.018%-0.2% [ 4 , 12 - 24 ]. Echo imaging techniques were employed in cases with difficult TSP [ 10 , 19 ]. These issues will be analyzed and discussed further in the Discussion section.…”

“…According to an observational study comparing 91 patients undergoing TSP for AF ablation guided by either fluoroscopy (n=57) or TEE (n=34), TEE-guided TSP was associated with shorter procedures and only a trend toward lower complication rates (20.6% vs . 31.6%) with no statistically significant difference (p=0.37) [ 10 ] (N.B. : these rates refer to the total procedure complication rates and not just to TSP complications).…”