Targeting the Future: Three-Dimensional Imaging for Precise Guidance of the Transseptal Puncture

The transseptal puncture (TSP) is a critical step for left-sided structural heart interventions. Precise TSP sets the stage for a successful procedure; however, precision is often limited with current two-dimensional echocardiographic techniques. Additionally, cardiac computed tomography angiography is often utilized for preprocedural TSP planning; however, carrying out a three-dimensional plan with two-dimensional intraprocedural transesophageal echocardiography can be unreliable. In the current imaging vignette, we provide the basis for understanding three-dimensional interatrial septal anatomy, step-by-step guidance for performing TSP, variability in interatrial septal anatomy, and common pitfalls that may lead to suboptimal TSP.