Phased-array intracardiac echocardiography for guiding transseptal catheter placement: utility and learning curve

The utility of a new intracardiac 64-element, phased-array, longitudinal ultrasound imaging system for guiding transseptal catheterization was assessed during 69 crossing attempts in 45 dogs because of the inherent limitations of fluoroscopy and mechanical ultrasound. Multifrequency (7.5-8.5 MHZ) imaging of the membranous fossa ovalis, posterior left atrium, and left atrial appendage was conducted from the right atrium. Contact of the Brockenbrough needle with the interatrial septum as reflected by membranous fossa ovalis "tenting" was uniformly identified. Transseptal crossing and advancement of the dilator and sheath were adequately imaged because of deeper ultrasound tissue penetration. Transseptal catheterization was successfully accomplished in 44 of 45 dogs: on the first attempt in 40 and with additional attempts in 4 and confirmed by direct far-field imaging of nonagitated saline injection via the sheath. Total transseptal catheterization time was 3.0 +/- 1.8 minutes. Unsuccessful first attempts and/or subsequent sheath pullback into the right atrium with catheter manipulation were also readily recognized. Insertion of the transseptal needle beyond the ultrasound imaging plane resulted in perforation of the posterior left atrial wall in three attempts. Accompanying effusions in these animals and three others related to subsequent intracardiac ablation catheter manipulation were readily identified and monitored echocardiographically. In conclusion, phased-array intracardiac imaging provides a highly reliable means of guiding transseptal access to the left atrium. In addition, inadvertent complications such as perforation and pericardial effusion development can be readily recognized.