Transseptal puncture without fluoroscopy using a radiofrequency needle: A case series

Figures

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  Figure 1. An anatomical map of the right atrium, inferior and superior vena cava and coronary sinus. The bundle of His is marked with a yellow point. The multipolar diagnostic catheter placed in the coronary sinus (blue color). On the left side, the right anterior oblique projection is presented. On the right side, the left anterior oblique projection is presented; A. The ablation catheter is placed in the superior vena cava; B. The SL1 sheath slides over the catheter (which is stabilized in this position) until its tip comes into contact with the proximal poles of the ablation catheter resulting in an impedance change and shifting the part of the catheter shape out of the map; C. Once the sheath slides a bit more distally, the distal poles of the ablation catheter come into contact with the sheath and the whole catheter shape jumps out from the map. This is a sign that the tip of the SL1 sheath is now in the place of the distal part of the catheter (position A).

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  Figure 2. The steps of the “blind phase”; A. At the start position, the dilator is inserted into the sheath until the marker “2”. The radiofrequency (RF) needle is inserted into the dilator until the distance between the end of the pin on the needle and the dilator orifice is equal to the length of the pin itself. Now the needle and dilator are fixed and the sheath slides back over the dilator; B. The connection of the sheath with the dilator (a specific “click”) confirms the connection. Now the dilator and the sheath are sliding back and the needle is still fixed; C. The final position of the sheath dilator and the needle assembly before pulling back. The first two steps (A and B) cannot be traced using the three-dimensional (3D) navigation system. The right side (C) shows the 3D anatomical map of the right atrium, superior vena cava and coronary sinus in the left anterior oblique projection. The green point depicts the unipolar signal of the RF-needle once it appears out from the dilator. In the left upper corner of each picture, the corresponding picture of the distal part of the sheath is shown. Please note the gummy tip of the SL1 sheath, which offers additional safety.

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  Figure 3. Left side three-dimensional anatomical map of the anatomical structures in the right anterior oblique and left anterior oblique projections; right atrium (grey), superior vena cava (SVC) (yellow), inferior vena cava (purple), coronary sinus (red) and right ventricle (green). The blue point depicts the ideal location for transseptal puncture, which was marked with the radiofrequency (RF)-catheter before. On the right side, transesophageal echocardiography (TEE) pictures of the interatrial septal (IAS) in short and bicaval planes; A. The RF-needle (the green point) moves from the SVC towards the IAS. This step cannot be traced using TEE; B. The tip of the RF-needle reached the desired place. The TEE picture showing the “tenting” of the IAS confirms a safe position of the needle; C. The tip of the needle is in the left atrium, out of the right atrium map. TEE pictures show specific spontaneous echo contrasting during energy application. Note, the “tenting” disappears after RF delivery.