Transseptal puncture for left atrial ablation: Risk factors for cardiac tamponade and a proposed causative classification system

Abstract

Aims Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the associations of TSP‐related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our center from 2016 to 2020. Methods and Results Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinized to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. A total of 3239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP‐related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above‐median age [odds ratio (OR): 2.4 (1.19–4.2), p = .006] and those undergoing re‐do procedures [OR: 1.95 (1.29–3.43, p = .042] were at higher risk of TRCT. Of the operator‐dependent variables, choice of transseptal needle (Endrys vs. Brockenbrough, p > .1) or puncture sheath (Swartz vs. Mullins vs. Agilis vs. Vizigo vs. Cryosheath, all p > .1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk [OR: 4.42 (2.45–8.2), p = .001], whilst top quartile operator experience [OR: 0.4 (0.17–0.85), p = .002], transoesophageal echocardiogram [TOE prevalence: 26%, OR: 0.51 (0.11–0.94), p = .023], and use of the SafeSept transseptal guidewire [OR: 0.22 (0.08–0.62), p = .001] reduced TRCT risk. An increase in transseptal guidewire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R2 = 0.72, p < .001) and was associated with a relative risk reduction of 70%. Conclusions During left atrial ablation, the risk of TRCT was reduced by operator experience, TOE‐guidance, and use of a transseptal guidewire, and was increased by patient age, re‐do procedures, and failure to cross the septum first pass.

A zero‐exchange approach for left atrial access in pulmonary vein isolation with pulsed field ablation

“…As already described in the literature, the majority of pericardial tamponades in the setting of LA ablations (almost 70%) are TSP-related. 2 There were no TSP-related pericardial effusions/tamponades in our patient group. Our strategy implies the use of TEE for guiding the TSP, therefore the safety advantage cannot be extrapolated to fluoroscopy-only approaches without periinterventional echocardiographic guidance.…”

“…The main finding of the study is that the TEE‐guided zero‐exchange TSP with a large diameter sheath is safe and effective. One patient suffered a non‐TSP related pericardial tamponade—type D according to the classification system proposed by Maclean et al, 2 which was successfully managed with pericardial puncture.…”

“…However, there are operators preferring a direct approach using a steerable sheath and the transseptal needle for the puncture. Direct TSP with the following steerable sheaths has been previously described 2 : Agilis Nx‐T (Abbott), Vizigo (Johnson & Johnson), FlexCath Advance (Medtronic). Generally, a larger diameter and longer sheath without the use of transoesophageal echocardiography (TEE) or intracardiac echocardiography guidance may increase the risk for complications.…”

Cardiac tamponade with transseptal puncture: Cross with care

“…In this issue of the Journal of Cardiac Electrophysiology , Maclean et al 2 provide a detailed report on a single center's experience with transseptal catheterization. Over 3000 transseptal catheterizations were performed in a 5‐year period.…”

“…Maclean et al 2 also included a cost–benefit analysis based on current United Kingdom pricing and conclude that the use of the needle‐tipped wire is cost‐neutral, even though not every transseptal‐related complication can be prevented with its use. This analysis may provide useful information for operators at other centers who intend to use a needle‐tipped wire but need to justify the expense to hospital administration.…”