Transseptal approach for left atrial arrhythmia ablation in patients with valve prostheses

Atrial transseptal puncture is nowadays routinely performed in the electrophysiology laboratory in order to map and ablate the left atrium. Some concerns, however, exist as to whether to perform atrial transseptal puncture in patients with heart valve prostheses, because of the risk of damaging the valve and of prosthetic valve-related thromboembolic complications. Only a few data are available on transseptal puncture for catheter ablation in patients with heart valve prostheses. We report our experience with atrial transseptal puncture carried out during an electrophysiological procedure in patients with prosthetic valves.

Between January 2003 and January 2006, we performed 227 transseptal punctures in order to map and ablate the left atrium. Among these, nine patients (3.9%) had a heart valve prosthesis. The safety and feasibility of the procedure are reported as well as results at 6-month follow-up.

Atrial transseptal puncture was successful in all patients. In four patients the procedure was performed under transoesophageal guidance after failure of the first attempt. The clinical arrhythmia was successfully ablated in eight patients (88.8%) and one procedure was interrupted because of atrial fibrillation. In seven cases the arrhythmia was successfully ablated in the left atrium; in one patient the arrhythmia was ablated on the right side of the septum after exclusion of a left atrial origin of the arrhythmia following completion of the mapping procedure. One patient had transient vision loss after the procedure, but no other complications were documented during or after atrial transseptal puncture.

Patients with valve prostheses and severely symptomatic drug-refractory arrhythmias can be considered candidates for atrial transseptal puncture and left atrial mapping and ablation. Atrial transseptal puncture is feasible, even though it requires experienced operators.