Added value of transoesophageal echocardiography during transseptal puncture performed by inexperienced operators.

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.

You can't judge a book by its cover: a pseudo 1st degree A-V block in apparent absence of retrograde conduction.

We report 3 tracings from an electrophysiological study in which the appearance of a pseudo 1st degree A-V block helped to unmask the presence of a retrograde conduction, previously unrecognized. Our case highlights the importance in specific cases to have more than 2 intracardiac tracings during an electrophysiological study.

Anatomical extent of pulmonary vein isolation after cryoballoon ablation for atrial fibrillation: comparison between the 23 and 28 mm balloons.

BACKGROUND: Pulmonary vein isolation seems to occur in the distal part of the ostium leaving the atrium largely unablated when using the 23 mm cryoballoon catheter ablation for atrial fibrillation. We hypothesize that ablating with the larger 28 mm cryoballoon would target a wider portion of the left atrial cavity. AIM: To compare the anatomical extent of pulmonary vein isolation using electroanatomical mapping when performing atrial fibrillation ablation with a 23 mm or a 28 mm cryoballoon. METHODS: Eight consecutive patients selected for circumferential pulmonary vein cryoballoon isolation for highly symptomatic paroxysmal atrial fibrillation were randomly assigned to ablation with the 23 or 28 mm balloon. After ablation, electroanatomical mapping was performed to compare the anatomical extent of pulmonary vein isolation between the two balloon dimensions. RESULTS: Extent of pulmonary vein isolation significantly differed when the lesions with either balloon dimensions were compared. Pulmonary vein isolation only occurred in the tubular part of the ostium when performed with the 23 mm balloon. Conversely, the lesion created with the 28 mm balloon included a larger portion of the left atrium. In fact, when using the smaller balloon (23 mm) the mean documented extent of electrical isolation was 20.7 ± 2.8% of the maps' surface, whereas it was 40.2 ± 3.9% when performing ablation with the bigger balloon (28 mm). The difference in calculated area of electrical isolation between group A and B was statistically significant (P < 0.05). CONCLUSION: Pulmonary vein isolation occurs significantly more proximally in the atrium when performing atrial fibrillation ablation with a 28 mm cryoballoon when compared with a 23 mm balloon.

Feasibility, safety, and outcome of a challenging transseptal puncture facilitated by radiofrequency energy delivery: a prospective single-centre study.

AIMS: Although it has been shown that a transseptal (TS) puncture in the electrophysiology laboratory is associated with a high success and a low complication rate, this procedure remains challenging particularly in difficult septum anatomies (aneurismal septum and thick septum) and during repeat TS catheterization. Radiofrequency (RF) electrocautery current delivery through the TS needle has been shown to facilitate the TS puncture. The aim of this study was to verify prospectively the feasibility, safety, and outcome of RF energy delivery associated with the standard TS technique in patients undergoing a challenging TS puncture. METHODS AND RESULTS: Over a 14-month period, 162 consecutive patients underwent left atrial (LA) arrhythmia ablation in our centre. Among them, we enrolled 18 patients who failed LA access after two TS puncture attempts. In these patients, an RF delivery through TS (RF-TS) needle approach was used to reach the LA. All 18 patients had a successful RF-TS at the first attempt. A transoesophageal echocardiography (TEE) guidance and fluoroscopy views were used in all patients. No acute complications were reported. There have been no clinical sequelae after 10 +/- 4 months of follow-up following the RF-TS approach. Challenging TS punctures were more frequent in repeat LA catheterization when compared with the first LA catheterization, respectively, in 35% (13 of 37) and 4% (5 of 125) of the patients. CONCLUSION: Radiofrequency electrocautery delivery associated with the standard TS approach is a safe and reproducible technique to reach the left atrium, using the TEE guidance. This technique is helpful during repeat TS catheterization and in the presence of anatomical atrial septum abnormalities.