Safety of fluoroscopy-guided transseptal approach for ablation of left-sided arrhythmias.
OBJECTIVE
The transseptal approach is used for left atrial access during the ablation of atrial fibrillation (AF) and other left-sided arrhythmia substrates. Transseptal puncture (TP) is commonly performed with fluoroscopic guidance, contrast injection, and pressure monitoring. In many centres, additional techniques [intracardiac echocardiography (ICE), transoesophageal echocardiography (TEE), radiofrequency needle] are used to facilitate TP but its use adds costs. In this retrospective study, we studied the safety and complication rate when TP was routinely done with fluoroscopic guidance, contrast injection, and pressure monitoring using ICE or TEE only in selected cases.


RESULTS
This study analysed 4690 consecutive TP performed between 2000 and 2015: 3408 (72.6%) were ablation of AF, left-sided atrial flutter, or left-sided atrial tachycardia (non-AP group); 1153 (24.6%) were ablation of left-sided accessory pathway, AP group; and 129 (2.8%) were ablation of ventricular tachycardia. Transseptal puncture was done under fluoroscopy, pressure monitoring, and commonly using contrast media injection. In 27 procedures, ICE or TEE was used to guide the TP. We found 34 tamponades (Tx) that required pericardial drainage of which 28 (0.59%) could possibly be TP related and six could not. The total complication rate for all Tx was 0.72%. A higher rate of tamponades was observed in the AF (non-AP) group than in the AP group (0.88 vs. 0.17%, P < 0.02). The highest rate of tamponades was registered during the operators 51-100 cases, 1.3%, and decreased to 0.4% in cases 101-200, P = 0.04.


CONCLUSIONS
TP can safely be done under fluoroscopy and pressure monitoring without routine use of additional techniques. With experience, operators should be able to further decrease complication rate.
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Zviad
Z
Matoshvili
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Hamid
H
Bastani
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Tara
T
Bourke
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Frieder
F
Braunschweig
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Nikola
N
Drca
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Kristjan
K
Gudmundsson
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Per
P
Insulander
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Anette
A
Jemtrén
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Göran
G
Kennebäck
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Ott
O
Saluveer
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Jonas
J
Schwieler
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Jari
J
Tapanainen
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Christer
C
Wredlert
Department of Cardiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Mats
M
Jensen-Urstad
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001282:Atrial Flutter / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016279:Atrial Function, Left; D006328:Cardiac Catheterization; D002305:Cardiac Tamponade / Q000209:etiology / Q000628:therapy; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D003287:Contrast Media / Q000008:administration & dosage; D017548:Echocardiography, Transesophageal; D005260:Female; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006346:Heart Septum / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D061214:Patient Safety; D011677:Punctures; D015641:Radiography, Interventional / Q000009:adverse effects; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013617:Tachycardia, Supraventricular / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
D003287:Contrast Media
Ablation; Atrial fibrillation; Cardiac tamponade; Intracardiac echocardiography; Transseptal puncture