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Published on: February 8, 2022
Transesophageal Echocardiography Improves Precision in Transseptal Puncture Compared to Fluoroscopy in Left Atrial
Lyuboslav Katov1, Yannick Teumer1, Katrin Lederbogen1
1Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
Insights
Transesophageal echocardiography (TEE) guidance significantly improves transseptal puncture (TSP) accuracy and safety in electrophysiology (EP) procedures compared to fluoroscopy alone. TEE allows for real-time adjustments, enhancing catheter positioning for complex cardiac ablations.
Area of Science:
- Cardiovascular Electrophysiology
- Medical Imaging
- Interventional Cardiology
Background:
- Complex arrhythmias often originate in the left atrium, requiring electrophysiological (EP) procedures like radiofrequency ablation and pulmonary vein isolation.
- Transseptal puncture (TSP) is crucial for accessing the left atrium during EP procedures, demanding precise catheter positioning.
- Current TSP guidance relies on fluoroscopy and interventional echocardiography, with limited comparative data on their efficacy and safety.
Purpose of the Study:
- To systematically evaluate the feasibility, safety, and accuracy of transesophageal echocardiography (TEE)-guided TSP versus fluoroscopy-guided TSP.
- To compare catheter positioning outcomes between TEE-guided and fluoroscopy-guided transseptal punctures in patients undergoing left atrial EP procedures.
Main Methods:
- A prospective study involving 150 consecutive patients undergoing left atrial EP procedures.
- Fluoroscopy was used for initial transseptal needle positioning, followed by verification and adjustment with transesophageal echocardiography (TEE).
- Septal positions were categorized as optimal, suboptimal, poor, or dangerous based on TEE imaging.
Main Results:
- Fluoroscopy alone resulted in optimal, suboptimal, and poor/dangerous positions in 32.7%, 43.3%, and 24.0% of patients, respectively.
- After TEE-guided adjustments, optimal and suboptimal positions were achieved in 59.3% and 40.7% of patients, with no poor or dangerous positions noted.
- TEE guidance demonstrated a significant improvement in achieving optimal and safe transseptal needle placement.
Conclusions:
- Transesophageal echocardiography (TEE)-guided transseptal puncture (TSP) is a feasible and more accurate imaging method for EP procedures.
- TEE guidance enhances the safety of TSP by eliminating poor or dangerous needle positions.
- TEE-guided TSP represents a superior approach for catheter positioning in left atrial electrophysiological interventions.
Abstract:
Background: Complex arrhythmias often arise from the left side of the heart, necessitating established electrophysiological (EP) procedures like 3D-mapping-assisted radiofrequency (RF) ablations or pulmonary vein isolation (PVI). These procedures typically require transseptal access, emphasizing the critical role of achieving an optimal catheter position through a precise transseptal puncture (TSP). Commonly employed imaging methods for TSP guidance include fluoroscopy and interventional echocardiography. Despite their routine use, there is limited evidence on which imaging modality offers superior catheter positioning for EP procedures, and safety concerns regarding transseptal punctures with imaging remain underexplored. This study aims to systematically evaluate the feasibility, safety, and accuracy of echo-guided TSP compared to fluoroscopy-guided TSP. Methods: In this prospective study, 150 consecutive patients undergoing left atrial EP procedures were enrolled between October 2023 and February 2024 at the Ulm University Heart Center. Following optimal fluoroscopy-guided transseptal needle positioning at the interatrial septum, the catheter placement was further verified using transesophageal echocardiography (TEE). Adjustments were made in cases of suboptimal needle positioning observed in TEE. The fluoroscopically achieved septal positions were categorized based on TEE images as optimal, suboptimal, poor, or dangerous. Results: Among the 150 patients included (58.0% male), fluoroscopy achieved optimal, suboptimal, and poor/dangerous positions in 32.7%, 43.3%, and 24.0%, respectively. After TEE-guided adjustments, optimal and suboptimal positions were achieved in 59.3% and 40.7% of patients, respectively. No instances of poor or dangerous transseptal needle positions were observed under TEE guidance. Conclusions: TEE-guided TSP emerges as a feasible, more accurate, and safer imaging method for transseptal punctures in EP procedures.
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