title: Transseptal access for left atrial ablation: the catheter-probing techniques are not without risk.
abstract: BACKGROUND
  Transseptal puncture (TP) is a prerequisite for LA ablations. LA access can be gained by catheter probing in case of PFO (trans-PFO method) or puncture of the interatrial septum (IAS) using a transseptal needle. A 2nd access can again be gained via PFO, a 2nd TP or catheter probing of the previous puncture site (probe-TS method). This study investigates the risk factors and complications related to the mode of transseptal access.
  
  
  RESULTS
  From August 2010 to August 2012, a total of 544 LA ablations, were performed. The mode of LA access was either a double TP or a single TP followed by the probe-TS or the trans-PFO method, respectively. TP was always guided by TEE and was successfully performed without complications in all cases. In contrast, 6/410 patients (1.5%) in whom catheter probing was performed (probe-TS, n = 4, trans-PFO, n = 2) had a dissection of the superior IAS originating from inside the oval fossa (n = 5) or perforation above the oval fossa (n = 1). Perforation into the pericardial space occurred in 4/6 patients, leading to one cardiac tamponade. In 5/6 patients, LA ablation was successfully completed, after repeated TP, despite effective anticoagulation. Patients with complications had the following characteristics: LA size 46 ± 4 mm, persistent AF (5/6), a repeat transseptal procedure (3/6) and a right-sided pouch (RSP, 5/6).
  
  
  CONCLUSIONS
  Interatrial septum dissection/perforation, occasionally with perforation into the pericardial space, is an unreported complication of TP, especially with the catheter-probing techniques. An RSP is an unrecognized risk factor in this context and can be visualized by TEE.
authors.affiliation: Arrhythmia Department.
authors.forename: Heiko
authors.initials: H
authors.lastname: Lehrmann
authors.affiliation: Echocardiography Department, University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Schneider
authors.affiliation: Arrhythmia Department.
authors.forename: Amir S
authors.initials: AS
authors.lastname: Jadidi
authors.affiliation: Arrhythmia Department.
authors.forename: Chan-Il
authors.initials: CI
authors.lastname: Park
authors.affiliation: Arrhythmia Department.
authors.forename: Jochen
authors.initials: J
authors.lastname: Schiebeling-Römer
authors.affiliation: Arrhythmia Department.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Allgeier
authors.affiliation: Arrhythmia Department.
authors.forename: Thomas
authors.initials: T
authors.lastname: Arentz
authors.affiliation: Arrhythmia Department.
authors.forename: Reinhold
authors.initials: R
authors.lastname: Weber
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001282:Atrial Flutter / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D054087:Atrial Septum / Q000000981:diagnostic imaging / Q000293:injuries; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D062906:Cardiac Catheters; D002305:Cardiac Tamponade / Q000209:etiology; D017115:Catheter Ablation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D005260:Female; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006335:Heart Injuries / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011677:Punctures; D015641:Radiography, Interventional; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome
keywords: atrial fibrillation; cardiac perforation; catheter ablation; pericardial tamponade; right-sided pouch; transseptal puncture