title: Right atrial angiography facilitates transseptal puncture for complex ablation in patients with unusual anatomy.
abstract: OBJECTIVE
  The number of transseptal punctures performed worldwide has increased exponentially with the development of ablation therapies for atrial arrhythmias. Safe access into the left atrium in these procedures is often complicated by abnormal anatomy. We assessed the potential of right atrial angiography to facilitate transseptal puncture for atrial ablation.
  
  
  RESULTS
  We examined all transseptal punctures performed for complex left atrial ablation in our centre over a 29-month period. In cases where conventional transseptal techniques failed, we performed orthogonal right atrial angiography to define cardiac anatomy and orientation. During the study period, 255 transseptal procedures were performed. Of these, 16 cases were complicated by distorted atrial anatomy, extreme cardiac rotation or unexpected location of the atria in relation to the diaphragm, preventing left atrial access using conventional fluoroscopy. The application of right atrial angiography facilitated successful transseptal puncture in all patients when use of conventional mapping catheters and fluoroscopy proved unhelpful. There were no complications relating to right atrial angiography.
  
  
  CONCLUSIONS
  These cases highlight a number of difficulties encountered when performing transseptal punctures. Previously reported adjunctive techniques require specialised equipment, general anaesthesia or multiple catheters that may be unavailable or impede the procedure. Right atrial angiography is a simple and safe adjunct to conventional techniques to facilitate complex transseptal procedures.
authors.affiliation: Department of Cardiac Electrophysiology, The Heart Hospital, UCLH Foundation Trust, 16-18 Westmoreland Street, London, W1G 8PH, UK.
authors.forename: Dominic P S
authors.initials: DP
authors.lastname: Rogers
authors.forename: Pier D
authors.initials: PD
authors.lastname: Lambiase
authors.forename: Mehul
authors.initials: M
authors.lastname: Dhinoja
authors.forename: Martin D
authors.initials: MD
authors.lastname: Lowe
authors.forename: Anthony W C
authors.initials: AW
authors.lastname: Chow
mesh_terms: D000368:Aged; D000792:Angiography / Q000379:methods; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging* / Q000601:surgery*; D005260:Female; D006325:Heart Atria / Q000000981:diagnostic imaging* / Q000601:surgery*; D006329:Heart Conduction System / Q000000981:diagnostic imaging / Q000601:surgery; D006346:Heart Septum / Q000000981:diagnostic imaging* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011677:Punctures / Q000379:methods*; D025321:Surgery, Computer-Assisted / Q000379:methods*; D016896:Treatment Outcome