Transseptal Left Heart Catheterization

Abstract

Left heart catheterization by puncture of the atrial septum was introduced by Manfredi (1956) and elaborated by Ross (1959). We have investigated 65 patients by this method and present our results with particular reference to its safety and effectiveness.SUBJECTS AND METHODThe majority of the patients had rheumatic heart disease ( Table I). The age range was 9 to 67 years and the distribution is shown in Table II. There were three patients under 17 years of age. The size of the left atrium was graded on X-ray (penetrated postero-anterior, right lateral, and right anterior oblique views with barium in the cesophagus) and was found to be normal in 11, slightly enlarged in 23, moderately enlarged in 29, and aneurysmal in 2 patients.The basic technique of transseptal left atrial puncture used was that described by Ross, Braunwald, and Morrow (1960). Briefly, this consists of introducing a 595 cm. long catheter into the right atrium from the right saphenous vein, threading the 61 cm. transseptal needle (Fig. 1) through the catheter and puncturing the septum in the region of the fossa ovalis with the needle. It has not always been found possible to make contact with the atrial septum in the lower half of the right atrial shadow as advised by Ross since a small left atrium frequently lies higher. When this is the case it is considered especially important to maintain the 450 posterior slant of the needle at puncture since the aorta is at the same level but anterior to the left atrium.The entire procedure is done under fluoroscopic control, and blood samples and pressure pulses are taken through the needle immediately before and after the puncture to confirm the position of its tip.When, in ten of the earlier cases of the series, information was required from the left ventricle as well as the atrium, an attempt was made to obtain it by passing a thin polythene tube through the needle once its tip was lying in the left atrium . This procedure was unsatisfactory in our laboratory and was abandoned in favour of advancing the large catheter over the needle after the tip of the needle has been introduced into the atrium. The procedure evolved in our laboratory whereby the needle is held stationary while the catheter is advanced differs slightly from that described by Brockenbrough and Braunwald (1960) and Gorlin et al. (1961) in which the needle and catheter are advanced together for a short distance with the needle point protruding before the catheter is further advanced over the needle. Once the catheter is in the left atrium the needle is withdrawn to the point of puncture and the catheter advanced into the ventricle. The needle is then removed and all the pressure measurements under rest and exercise conditions and the blood samples required in the individual case are obtained, and contrast injection is performed if indicated.When right heart catheterization was indicated it was performed through the same vein either after the left heart catheterization (40 patients) or simultaneous with it (6 patients). The bleeding tha...

Improved design for a transseptal needle.

“…The advantages of this system were that the catheter and needle could be introduced by the percutaneous route via the femoral vein, the larger catheter allowed more accurate recordings of pressures, and selective angiocardiography could be carried out through it. Since this needle was employed the technique has come into widespread use as a method of major importance (Braunwald et al, 1962;Miller and Medd, 1964).However, transseptal catheterization has been associated with complications caused generally by inadvertent puncture either of the free wall of the atrium or of the aorta which is closely related to the anterior part of the interatrial septum. These complications have, in most cases, occurred in the hands of occasional or inexperienced operators but have also been more frequent since the Brockenbrough needle and catheter replaced the original…”

“…The advantages of this system were that the catheter and needle could be introduced by the percutaneous route via the femoral vein, the larger catheter allowed more accurate recordings of pressures, and selective angiocardiography could be carried out through it. Since this needle was employed the technique has come into widespread use as a method of major importance (Braunwald et al, 1962;Miller and Medd, 1964).…”