Key result
Routine use of transoesophageal echocardiography during transseptal puncture led to major repositioning in 16.6% (34/205) of patients, with age, left atrial diameter, and previous PVI as predictors.
Why the study?
Does routine TEE guidance improve correct positioning and prevent complications during fluoroscopy-guided transseptal puncture performed by inexperienced operators in patients undergoing PVI?
Observational (n=205)
Single-blind
Does routine TEE guidance improve correct positioning and prevent complications during fluoroscopy-guided transseptal puncture performed by inexperienced operators in patients undergoing PVI?
Routine use of 2D TEE during transseptal puncture by inexperienced operators frequently identifies the need for major catheter repositioning, particularly in older patients and those with larger left atria or previous PVI.
May support TEE use to guide repositioning; leaves open randomized confirmation of safety benefit.
AIMS: Transseptal puncture (TP) appears to be safe in experienced hands; however, it can be associated with life-threatening complications. The aim of our study was to demonstrate the added value of routine use of transoesophageal echocardiography (TEE) for the correct positioning of the transseptal system in the fossa ovalis, thus potentially preventing complications during fluoroscopy-guided TP performed by inexperienced operators. METHODS AND RESULTS: Two hundred and five patients undergoing pulmonary vein isolation procedure (PVI) for drug-resistant paroxysmal or persistent atrial fibrillation were prospectively included. When the operator (initially blinded to TEE) assumed that the transseptal system was in a correct position according to fluoroscopical landmarks, the latter was then checked with TEE unblinding the physician. If necessary, further refinement of the catheter position was performed. Refinement >10 mm, or in case of catheter pointing directly at the aortic root or posterior wall were considered as major repositioning. Thirty-four patients required major repositioning. Regression analysis revealed age (P: 0.0001, Wald: 12.9, 95% confidence interval: 1.04-1.16), left atrial diameter (P: 0.01, Wald: 6.6, 95% confidence interval: 1.04-1.34), previous PVI (P: 0.01, Wald: 6.3, 95% confidence interval: 1.31-8.76), and atrial septal thickness (P: 0.03, Wald: 4.5, 95% confidence interval: 1.05-3.4) as independent predictors of major revision with TEE. CONCLUSION: Routine 2D TEE in addition to traditional fluoroscopic TP appears to be very useful to guide the TP assembly in a correct puncture position and thus, to avoid TP-related complications. However, further randomized prospective comparative studies are necessary to support these suggestions.
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Bayrak et al. (2011) conducted an observational in Drug-resistant paroxysmal or persistent atrial fibrillation (n=205). Routine use of transoesophageal echocardiography (TEE) vs. Fluoroscopy-guided transseptal puncture alone (initial blinded phase) was evaluated on Major repositioning of the transseptal system (refinement >10 mm or pointing at aortic root/posterior wall). Routine use of transoesophageal echocardiography during transseptal puncture led to major repositioning in 16.6% (34/205) of patients, with age, left atrial diameter, and previous PVI as predictors.
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