title: Impact of transesophageal echocardiography during transseptal puncture on atrial fibrillation ablation.
abstract: BACKGROUND
  The 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.
  
  
  METHODS
  Ninety-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.
  
  
  RESULTS
  Fluoroscopy 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.
  
  
  CONCLUSIONS
  TEE-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.
authors.affiliation: Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey.
authors.forename: İsmail
authors.initials: İ
authors.lastname: Erden
authors.affiliation: Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey.
authors.forename: Emine Çakcak
authors.initials: EÇ
authors.lastname: Erden
authors.affiliation: Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey.
authors.forename: Ebru
authors.initials: E
authors.lastname: Golcuk
authors.affiliation: Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey.
authors.forename: Tolga
authors.initials: T
authors.lastname: Aksu
authors.affiliation: Bursa State Hospital, Cardiology, Clinic, Hasta Yurdu Cd., No. 31, PK 16040 Tophane, Bursa, Turkey.
authors.forename: Kıvanç
authors.initials: K
authors.lastname: Yalin
authors.affiliation: Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey.
authors.forename: Tümer Erdem
authors.initials: TE
authors.lastname: Güler
authors.affiliation: Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey.
authors.forename: Kazım Serhan
authors.initials: KS
authors.lastname: Özcan
authors.affiliation: Kocaeli Derince Training and Research Hospital, Department of Cardiology, Ibni Sina Mah., Sopalı Mevki, Lojman Sok., Derince Merkez, PK 41900 Derince, Kocaeli, Turkey.
authors.forename: Burak
authors.initials: B
authors.lastname: Turan
keywords: Ablation; Atrial fibrillation; Echocardiography; Transseptal puncture