Transseptal Puncture for Left Atrial Appendage Closure: A Consensus Document From the Second European Left Atrial Appendage Club

Figures

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  Figure 1. Transseptal sheath and needle. (A) Superior left transseptal sheath, SL0, SL1, and SL2 present with different curvatures. (B) Mullins sheath with dilator. (C) BRK and BRK-1 Transseptal Needle (XS, extra sharp).

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  Figure 2. The optimal TSP position (dashed arrow). (A) A posterior TSP location is favorable in case of anterior bend of the proximal neck of the LAA; (B) a more central to anterior TSP location is favorable when there is a reverse or posterior orientation of the proximal LAA. The left circumflex artery is located anteriorly of the LAA, as seen on MSCT images. LAA, left atrial appendage; LCx, left circumflex artery; TSP, transseptal puncture.

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  Figure 3. 3D MSCT-based preplanning for optimal TSP position. An angiographic view of the left atrium and appendage is reconstructed to define the optimal TSP position along the anterior-posterior and inferior-superior axes. The TSP position should be chosen where it aligns best with the proximal axis of the appendage. (A) First, in an RAO or lateral view, the optimal TSP position along the anterior-posterior axis can be identified. (B) Second, in an LAO apical view, the optimal TSP position along the superior-inferior axis can be identified. LAO, left anterior oblique; MSCT, multislice computed tomography; RAO, right anterior oblique; TSP, transseptal puncture.

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  Figure 4. Stepwise MSCT-based assessment of TSP location with multiplanar reconstruction. Step 1, Scroll anterior to posterior through axial, sagittal, and coronal planes to determine LAA orientation. Step 2, place the crosshair at the LAA ostium—1 plane through the coumadin ridge and another through the circumflex artery (red∗), align the crosshair to the virtual center line, the short-axis view of the LAA ostium becomes visible. Step 3, connect the center of the ostium to the center of the landing zone to view the proximal LAA axis and assess anterior versus posterior bend and assess if this angle is predominantly anterior (<90°) or posterior (≥90°). LAA colored in light blue.

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  Figure 5. 3D TEE-based preplanning for optimal TSP position. A 3D view of the fossa (dashed red line) and the LAA ostium (white arrow) within the left atrium is reconstructed to define the optimal TSP position along the anterior-posterior axis. (A, B) First, the LAA position within the left atrium and their spatial relation is visualized. The LAA can vary from a more posterior (A) to a more anterior (B) location in the left atrium. (C) Second, the proximal orientation of the LAA is revealed by “cutting” through the roof of the appendage. In case (A), a mid-TSP position could be preferred, whereas in cases (B) and (C), a more posterior puncture is favorable, as indicated by the red arrow. LAO, left anterior oblique; MSCT, multislice computed tomography; RAO, right anterior oblique; TSP, transseptal puncture.

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  Figure 6. TEE procedural guidance for TSP. (A) First, the superior-inferior axis is assessed at a bicaval view (90°-110°). (B) Second, the anterior-posterior axis is visualized in the short-axis view (30°-60°). AV, aortic valve; IVC, inferior vena cava; LA, left atrium; RA, right atrium; RV, right ventricle; SVC, superior vena cava; TSP, transseptal puncture; TV, tricuspid valve.

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  Figure 7. ICE procedural guidance for TSP. The ICE catheter is positioned in the right atrium at the “home view” where the TV and right ventricle are shown from the right atrium (A). A retroflex motion from the right atrial home view reveals the IAS, indicating the superior-inferior axis for the TSP. A manual rotation of the ICE catheter shows the anterior (counter-clock) to posterior (clockwise) parts of the fossa ovalis with the nearby structures seen in the far field of the ultrasound beam indicating the orientation of the ICE catheter. The aortic valve or aorta can be identified in the anterior aspect of the fossa (B) while moving toward posterior (ie, a clockwise rotation), the LAA (C), and pulmonary vein bifurcation (D) become visible. Ao; aorta; AV, aortic valve; CS, coronary sinus; ICE, intracardiac echocardiography; IVC, inferior vena cava; LA, left atrium; LAA, left atrial appendage; LLPV, left lower pulmonary vein; LUPV, left upper pulmonary vein; LV, left ventricle; MV, mitral valve; RA, right atrium; RV, right ventricle; SVC, superior vena cava; TSP, transseptal puncture; TV, tricuspid valve.

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  Central Illustration. A stepwise algorithm to prepare and perform TSP in LAAC. LAA, left atrial appendage; MSCT, multislice computed tomography; RF, radiofrequency; TEE, transesophageal echocardiography; TSP, transseptal puncture.