Transseptal puncture in the dog utilizing three-dimensional transesophageal echocardiographic guidance

Transseptal puncture is necessary to access the left atrium and mitral valve from a transvenous approach but is poorly described in veterinary medicine. The procedure is generally regarded as difficult and dangerous, particularly given the size of most small animal patients. Precise imaging is paramount to the procedure to ensure that puncture occurs within the desired location and to monitor for potential complications. Transesophageal echocardiography, including biplanar two-dimensional and particularly three-dimensional modalities, has great potential to improve the success and safety of transseptal puncture due to superior visualization of the fossa ovalis and other intracardiac structures. Here, we describe the use of transesophageal echocardiography to guide transseptal puncture based on our experience in 159 dogs, with an emphasis on three-dimensional echocardiography. We also detail how to perform transseptal puncture from a jugular approach, which we consider preferable in most patients. Complications from transseptal puncture are discussed, along with ways to limit those complications.