2D and 3D Echocardiography Safe and Efﬁcient Transseptal ... · ECH WEEK Comprehensive Review &...

ECH WEEKComprehensive Review & Update of Perioperative Echo

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2D and 3D EchocardiographySafe and Efficient Transseptal Puncture

Feroze Mahmood, MD FASEProfessor

Harvard Medical SchoolDirector Cardiac Anesthesia

Beth Israel Deaconess Medical Center



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Outline

History of Transseptal Puncture

Embryological/Anatomical/Echo Perspective

Nomenclature/Common Language

Echocardiographic Technique



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Transeptal Puncture

Integral Component

Electrophysiological & Structural Heart

Interventions



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Left Heart Catheterization by the Transseptal RouteA Description of the Technic and Its Applications

By JOHN Ross, JR., M.D., EUGENE BRAUNWALD, M.D.,AND ANDREW G. MORROW, M.D.

LEFT ATRIAL pressure was first recordedin man by Cournand et al. during car-

diae catheterization in a patient with anatrial septal defect. Their report in 19471proved the feasibility of passing a catheterfrom the right atrium to the left when aninteratrial communication was present. Whenoperations for the correction of rheumaticmitral and aortic stenosis were undertaken,the value of preoperative measurements ofpressure in the left atrium and left ventriclesoon became apparent. In these patients,without intracardiac communications, it wasnecessary to devise other means of access tothe left-sided chambers of the heart. Themethods of transbronchial and posterior per-cutaneous left atrial puneture2-1 were founldto be practical technics for the measurementof left atrial pressure and each was extendedto permnit left ventricular and aortic cathe-terization as well. It was found that leftventricular pressure could also be measuredby direct transthoracie puncture of thischamber7 or bv means of a catheter passedinto it, in a retrograde fashion, from a pe-ripheral artery.8 The relative advantages anddisadvantages of these various methods ofleft heart catheterizationi have recently beenpresented in detail9 and experience with themhas indicated that none is ideal in all re-spects.

A cardiac catheter, when introduced fromthe saphenous vein, can invariably be passedthrough an interatrial septal defect o' patentforamen ovale, if such a communLieation ispresent. This course of the catheter suggested

From the Clinic of Surgery, National HeartInstitute, Bethesda, MId.

Dr. Ross' present address: Department of Surgery,Columbia-Presbyterian Medical Center, New York,N. Y.

the possibility to Dr. Emilio Del Campo, dur-ing a visit to the National Heart Institute,that the intact interatrial septum could becrossed in the region of the fossa ovalis andprovide another means of access to the leftatrium. It appeared to us that this could beaccomplished by a suitably curved needlepassed through a catheter positioned againstthe septum. In an experimental study indogs'0'11 left atrial puncture by this technicwas found to be simple and without hazard.Transseptal left heart catheterization wasthen applied in clinical studies and prelim-im-ary experienees with it were eneourag-ingZ12 15 The method has now been employedin 130 patients with various formns of heartdisease. The present report describes in detailthe inistruments employed in transseptal leftheart catheterization, the techiiies of the pro-cedure, and somne of its applications in car-diovascu'ar diagnosis and clinical investiga-tion.

Material and MethodEquipmentShortened Right Heart Catheter

The catheter through which the no. 17-gagetransseptal needles are passed is a no. S Aorto-catheter (61 cm. in length) having an extrudedNylon core."" A removable adapter (Tuohy-Borst)is attached to the proximal end of the catheter.The transseptal needles may vary slightly in lengthand the catheter should be compared with thetransseptal needle with which it is to be used;the proximal end of the catheter is cut so that itis 2 eIm. shorter than the needle. The length of thecatheter then corresponds to the length of theneedle froni its tip to a point 2 cm. from the indi-cator arrow (fig. 1).

A no. 7 Aorto-catheter, 53 cm. in length, maybe used in identical fashion with the no. 19-gagetransseptal needle used in infants.

*iManufactured by U. S. Catheter and InstrumentCompany, Glens Falls, New York.

Circulation, Volume XXII, November 1960 927

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Fig. 7.—Anatomie rela¬tions of the fossa ovalisand interatrial septum.The position of the cath¬eter tip before^, and aft¬er B, puncture is shown.Reproduced with permis¬sion from Ross, J., Jr. :Ann. Surg. 149:395, 1959;Philadelphia, J. B. Lip¬pincott Company.

medication, an 18-gauge thin-walled needleis inserted into the right posterior chest wallapproximately 5 cm. lateral to the spinousprocesses at a level corresponding to theposition of the left atrium determinedfluoroscopically. The needle is directed ob¬liquely toward the midline and then pene¬trates the left atrium. The course of theneedle and the anatomic relations of it tonearby structures are illustrated in Figure 9.The left ventricle and aorta may be enteredby a catheter passed through the needle.

The popularity of the posterior percuta¬neous approach has probably been due in

large measure to its technical simplicity andthe ease with which successful left atrialpuncture can ordinarily be accomplished.The needle may be withdrawn over the cath¬eter and studies with the patient basal andduring exercise are possible.16 Right heartcatheterization may be carried out simulta¬neously either in the usual manner orthrough a second needle passed percutane-ously into the right atrium.17

The earlier enthusiasm for this methodhas been tempered by the increasing numberof serious complications attendant upon it.Since the needle must traverse the free

TRANSSEPTAL LT HT. CATH.

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Fig. 8.—

Simultaneousrecords of left ventricu¬lar (LV) and brachialarterial (BA) pressuresrecorded by the trans-septal method in a patientwith congenital aorticstenosis. The magnitudeof the aortic systolicgradient is indicated bythe hatched areas.

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RECORDING OF BLOOD PRESSURE FROM THE LEFT AURICLE AND THE PULMONARY VEINS IN HUMAN SUBJECTS

WITH INTERAURICULAR SEPTAL DEFECT’

A. COURNAND, H. L. MOTLEY, A. HIMMELSTEIN, D. DRESDALE AND J. BALDWIN

From the Cardio-Pulmonary Laboratory, Chest Service, Bellevue Hospital and the Department of Medicine, College of Physicians and Surgeons, Columbia University, afnd the Department

of Pediatrics, New York University College of Medicine, New York City

Received for publication April 29, 1947

Pressure tracings from the left auricle and the pulmonary veins have been obtained, using the cardiac catheterization technique (1, 2, 3, 4) in three young human subjects, 5 months, 2 years and 5 years of age, with an interauricular septal defect; and compared with pressure tracings in the right auricle. As far as can be ascertained such tracings have not been previously reported in man. The auricular septal defect was not associated in any of the cases with a demonstrable anomaly of the mitral or tricuspid valve. There was no evidence of cardiac decompensation at the time of study, and on the basis of the fluoroscopic findings there was no apparent dilation of the right or left auricle. The systolic blood pressure in the right ventricle was elevated in the 3 cases, pre- sumably as a result of an increase in pulmonary flow; however, in one case a moderate degree of pulmonary stenosis could be demonstrated, the pulmonary artery systolic pressure (33 mm. Hg) being lower than the right ventricular systolic pressure (59 mm. Hg).

TECHNIQUE. A no. 6 French ureteral radio-opaque catheter was introduced into the venous system by way of the internal saphenous vein exposed in the femoral region. Under fluoroscopic control the tip of the catheter was placed successively in the right auricle, the left auricle and one of the pulmonary veins (fig. 1). Tracings were obtained, within a short time interval, from the various locations, using a Hamilton manometer and/or an electrical apparatus (5) for the pressure recordings. Electrocardiograms were taken simultaneously using the standard lead II. The time lag between electrical events recorded with the electrocardiograph, and mechanical events simultaneously induced and recorded, was found to be 0.01 second, for both types of manometers. During the entire procedure, a steady state of the respiration and circulation was maintained, the subjects being under avertin anesthesia.

RESULTS. In the top row of figure 2 appear pressure tracings taken with the Hamilton manometer a few minutes apart from the right auricle and from the left auricle of the child 5 months old, In the bottom row is illustrated a tracing recorded from the left auricle of a child, age 2 years, using the electrical recorder. The similarity of both tracings of left auricular blood pressure is

1 Under grants from the Commonwealth Fund and the Life Insurance Medical Rcseareh Fund Gift for Study of Action of Certain Cardiovascular Drugs.

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The Bronchoscopic Measurement of LeftAuricular Pressure

By P. R. ALLISON, F.R.C.S., AND 1H. J. LINDEN, M.B., CH.B.

A specially adapted needle on the end of a Jackson's suction tube has been used to pierce the leftauricle of the heart through the upper end of one of the main bronchi. Pressure measurements andwave forms have been recorded in patients suffering from lung disease with normal hearts, in thosewith mitral stenosis and mitral regurgitation. This preliminaryl communication describes themethod and shows some typical results.

T HE ONLY CHAMBER of the heartnot so far accessible to direct pressuremeasurement has been the left auricle.

The surgery of mitral stenosis has increasedthe need for information about the hemody-namics of the left auricle, and the presentinvestigation was planned as a contribution tothis end. Although much has been learnedfrom the measurement of pulmonary capillarypressure, there has been no proof that thisreflects all the changes that may occur in theleft auricle. There has certainly been a needto investigate this, and the direct approachhas therefore been undertaken.

The left auricle is so closely related to theesophagus behind, the bifurcation of thetrachea above and the two bronchi on eachside that these channels presented an obviousmethod of approach. Experience in the meas-urement of pressures in esophageal varicesthrough the esophagoscope, aiid in the aspira-tion of congenital bronchial cysts through thebronchoscope had already been obtained, andit seemed an easy thing to apply this experi-ence to direct puncture of the left auricle. Trialson the cadaver showed that it was equallyeasy to pass a needle into the auricle throughthe esophagoscope at a point about 30 cm.from the alveolar margin, or through thebronchoscope at the level of the carina orupper end of one of the main bronchi. The lat-ter path seemed to be the cleaner one as swabstaken from this region when there is no obviousrespiratory infection are always sterile. It wasthis approach, therefore, that was finallyadopted for the living patient.

From the Department of Thoracic Surgery, TheGeneral Infirmary, Leeds, England.

ANATOMY

The bifurcation of the pulmonary arterylies anterior to the lower end of the tracheaand the carina. Immediately below the bifurca-tion of the pulmonary artery lies the leftauricle and as this bulges backwards into theconcavity of the thoracic spine it lies betweenthe two main bronchi. The superior pulmonaryveins lie in front of the bronchi, and the in-ferior veins pass behind the bronchi. The lineof the anterior wall of the trachea, if prolongeddownward, would pass through the pericardiumbehind the pulmonary artery into the leftauricle.

APPARATUS

The apparatus consists of a stanclar(l membranemanometer filled with fluid to which a "catheter-like" tube and a needle are attached. The needle isfused to a metal bronchus-aspirating tube 50 cm.long and with 2 mm. bore, which is attached to themanometer by a length of rigid polythene tubingof 3 mm. bore. The length of the tubing is kept ata minimum, but a convenient length for ease ofinsertion is found to be 40 cm. (fig. 1).

The system was found to have an undampednatural frequency of 50 cycles a second, and althoughit is realized that components of the fundamentalpulse wave oscillating at more than 25 cycles asecond will not be recorded faithfully, it is con-sidlered that this factor will produce negligible dis-tortion of the fundamental pulse wave itself, whenthe system is critically damped. Damping has beenachieved by using the puncturing needle as thedamping needle, this having the advantage of pre-venting free dampe(l vibrations in the fluid system.The minimum length for insertion into the leftauricle is 4 cm. so that the needle must be at least5 cm. in length.

Critical damping was found by the method ofWarburg,l and in the present work a figure between

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LEFT AURICULAR PRESSURE MEASUREMENTS IN MAN*VIKING OLoV BJORK, M.D., GUNNAR MALMSTR6M, M.D. AND LARS GUSTAV UGGLA, M.D.

STOCKOLM, SWEDENFROM THE SURGICAL CLINIC OF CLARENCE CRAFOORD, M D. OF SABBATSBERG HOSPITAL, STOCKHOLM, SWEDEN

THE SURGICAL TREATMENT of mitral ste-nosis has necessitated the search for im-proved diagnostical methods.

The direct pressure measurements in theleft auricle then seems to be a logical nextstep in the preoperative investigation.

The estimation of the amount of regurgi-tation through the stenosed mitral valve isof great importance, and may not be accu-rately made by known clinical methods. Incases with a certain degree of insufficiencycomplicating the stenosis, the regurgitationmay increase after a valvulotomy.

Indirect methods to evaluate the degreeof insufficiency by electrokymography andheart catheterization include so far toomany unknown factors to be conclusive.The pulmonary capillary pressure curve hasbeen ascribed the most significant value.

In cases with a high pressure in thepulmonary artery, however, this pressuremay influence the capillary pressure to acertain degree. Therefore, it is not possibleto decide with certainty from the form ofthe capillary pressure curve if a systolicpressure peak in a case of mitral stenosiswith sinus rhythm is due to mitral regurgi-tation or a transmission of the pulmonaryarterial pressure wave, or to a summationof both factors.

The left auricular pressure curve maythen be more significant in the determina-tion of the degree of mitral insufficiencycomplicating the stenosis. A method forthe direct pressure measurements in the leftauricle is presented.

* Submitted for publication April, 1953.

INDIRECT METHODS

A. Puncture of the left auricle throughthe left main bronchus during bronchoscopyhas been reported in ten cases.7 Thismethod seems to be practicable only incases with a considerable dilatation of theleft auricle.

B. Pressure measurements in the leftauricle through the esophagus via anesophaguscope was tried by our team to-gether with H. Engstrom, in 1952. It wasfound difficult to localize the needle byscreening, once the aorta was entered.

Both these methods are tiresome and un-comfortable for the patient. The absolutepressure values obtained are difficult toevaluate, as the patients are straining andproducing a variable degree of increasedintrathoracic pressure.

DIRECr METHODS

A. Anterior approach. The needle maybe introduced through the anterior chestwall through the left ventricle into the leftauricle. This may easily be performed indogs. Objections to this method are:

1. The danger of injuring a coronaryartery or the mitral valves, as the needle hasto pass the valvular area.

2. The danger of producing ventricularfibrillation.

B. Posterior approach. The posterior ap-proach has been explored by one of us(V. 0. B.) during intrathoracic surgery.

1. From the left side. When a needle isintroduced from the back, to the left side of

718

BJORK, MALMSTROM AND UGGLA

(only performed in one case together withKjellberg).

Errors of th7e method. It is easy to intro-duce the needle into a dilated left auriclein cases of mitral disease, and somewhatmore difficult into a normal auricle. Tenminutes after the blood sample is taken, itsoxygen tension is known. The pressuremeasurement will immediately disclose thatthe needle has been introduced into the

was treated by streptokinas, streptodornasand several aspirations, after which therewas no severe sequel to the patient. Thebleeding is considered to be due to the in-jury of an intercostal artery. Roentgeno-gram showed no enlargement of the peri-cardium. The needle was introduced withthe patient in position for cardioangiog-raphy, but in a very uncomfortable posi-tion for the surgeon. It is suggested that the

FIG. 2 FIG. 35FIG. 2. Diagram showing the puncture point 5 cm. to the right of the midline above the

ninth rib.FIG. 3. The needle is introduced along the vertebral body.

aorta or left ventricle. The needle may,however, be located in one of the right pul-monary veins near the inflow into theauricle. The pulse pattern is, however,mainly the same in the vein as in theauricle. In the left auricle the needle canbe introduced several centimeters with thesame pressure curve.

If the needle enters the azygos vein, venacava, the pulmonary artery or the rightheart, this is easily detected by oxygen ten-sion measurement.

Complications. The complications so farencountered have been a small pneumo-thorax, too small to warrant exsufflation.This happened in Case 1, which had normalmitral valves and no enlargement of theleft auricle. In a case of mitral stenosis(Case 9) in which cardioangiography wasperformed through the needle in the leftauricle, a hemothorax was encountered. This

puncture be done with the patient in thebest position for the surgeon. Once theneedle is introduced, the patient is givenanesthesia and turned in position for car-dioangiography.

CASE REPORTS

Case 1. Nornal mitral valves. A 22-year-oldman had a malignant tumor of the thymus removedthrough a sternum splitting incisicon. Three and one-half months after operation he developed fluid inthe left pleura and enlargement of axillary lymphnodes. The fluid was aspirated, but a pronouncedthickening of the left pleura was found. Physicalexamination and roentgenogram revealed a heartof normal size with normal sounds. Ecg was normal.

Case 2. Mitral stenosis with a very pronouncedinsufficiency. A 50-year-old man had his valvularlesion diagnosed in 1918. In 1951, he had anhemoptysis, and in 1953 he was an invalid.

Physical examination: There was no voussure.A presystolic -and a systolic murmur were heardover the apex.

Roentgenoggram: The heart volume was 550ml./m2 with enlargement of both left auricle and

720

Annals of SurgeryNovember, 1 9 5 3

Acta Medica Scandinavica. Vol. CXLVIII, fasc. I, 1954.

From the Department of Medicine, University Hospital, Lund, Sweden.

Suprasternal Puncture of the Left Atrium for Flow Studies. BY

STIG RADNER.

(Submitted for pnblication Anguvt 18, 1953.)

Suprasternal puncture of the thoracic aorta is being used as a routine method in our laboratory for studying the outflow hemodynamics of the left heart. The technique was described by the present author in 1953.

While performing aortic punctures, the needle was occasionally passed through the space between the aorta and the trachea. At the bottom of this space the resistance of the left atrium might be felt and its cavity punctured.

Post mortem studies were performed on more than fifty corpses, with thoracic organs left in situ, and the left atrium was found to be accessible for direct puncture from the suprasternal fossa in all of the cases. After the anatomical studies had been completed, the present technique of left atrial puncture was applied in living subjects for investigating the inflow hemodynamics of the left heart.

Anatomical Notes. The left atrium is situated in the midline, crucified by its venous extremities

in the pulmonary hili, and surrounded by two sets of tubular structures and cavi- ties (Fig. l). The main bronchi straddle over its posterior part, and between the bronchi it is curtained by the descending aorta, the oesophagus and the right pleural cavity - the posterior relations. The anterior part of the left atrium is embraced by the ascendent aorta, the bifurcating pulmonary artery, the superior vena cava and the right atrium - the anterior relations. Between the two groups of structures there is a space which permits the extrapleural and extratubular approach to the left atrium from the suprasternal notch. The transverse sinus of the pericardial sac covers the upper part of the atrium behind the pulmonary artery, and puncture is made through the sinus in most cases.

Suprasternal Needle. A special double needle is used (Fig. 2). It consists of an outer needle attached

to a three-way tube, and an inner needle which is inserted into the outer through

Acta Medica Scandinavica. Vol. CXLVIII, fasc. I, 1954.

From the Department of Medicine, University Hospital, Lund, Sweden.

Suprasternal Puncture of the Left Atrium for Flow Studies. BY

STIG RADNER.

(Submitted for pnblication Anguvt 18, 1953.)

Suprasternal puncture of the thoracic aorta is being used as a routine method in our laboratory for studying the outflow hemodynamics of the left heart. The technique was described by the present author in 1953.

While performing aortic punctures, the needle was occasionally passed through the space between the aorta and the trachea. At the bottom of this space the resistance of the left atrium might be felt and its cavity punctured.

Post mortem studies were performed on more than fifty corpses, with thoracic organs left in situ, and the left atrium was found to be accessible for direct puncture from the suprasternal fossa in all of the cases. After the anatomical studies had been completed, the present technique of left atrial puncture was applied in living subjects for investigating the inflow hemodynamics of the left heart.

Anatomical Notes. The left atrium is situated in the midline, crucified by its venous extremities

in the pulmonary hili, and surrounded by two sets of tubular structures and cavi- ties (Fig. l). The main bronchi straddle over its posterior part, and between the bronchi it is curtained by the descending aorta, the oesophagus and the right pleural cavity - the posterior relations. The anterior part of the left atrium is embraced by the ascendent aorta, the bifurcating pulmonary artery, the superior vena cava and the right atrium - the anterior relations. Between the two groups of structures there is a space which permits the extrapleural and extratubular approach to the left atrium from the suprasternal notch. The transverse sinus of the pericardial sac covers the upper part of the atrium behind the pulmonary artery, and puncture is made through the sinus in most cases.

Suprasternal Needle. A special double needle is used (Fig. 2). It consists of an outer needle attached

to a three-way tube, and an inner needle which is inserted into the outer through

5s PTLG RADNEl i .

this tube. The internal diameter of the inner needle is 0 .25 mm, and same diameter of the outer is 0.6:; the external diameter of the outer needle is 0.83 mm. The sharp tip of the inner needle projects for about 2 mm outside the outer, which is obliquely cut and streamlined. The free length of the outer needle is 165 mm.

S U P M ~ N A L PUNCTURES I

Fig. 1. Drawing to show the anatomical relationships of the left atrium. Arrows indicate the direction of suprasternal punctures of the aorta and the left atrium. T. = Trachea. I;. b. = Left main bronchus.

P. a. = Pulmonary artery, cut to show first part of its right branch.

The three-way tube has one stop-cock on each limb to permit infusion, aspiration and pressure measurement through the outer needle. For recording pressures, its proximal straight limb is connected with a Tybjaerg Hansen manometer by means of a short piece of a Cournand catheter No. 7, and a canalized bayonet knob. Before puncturing, a one cc syringe is attached to the inner needle for flushing and aspiration.

Tecbnique. Premedication is not necessary. The patient is placed in a supine position, with

the head bent slightly backwards and turned to the left. Local anaesthetic without adrenalin is injected from the point of entrance through the skin in front of the trachea, and towards the aortic arch, but not below this level. The double needle is inserted in the midline 3-4 cm above the upper border of the sternum; if it is inserted into the bottom of the suprasternal notch the skin forms a pursing fun- nel around it.

The needle is directed along the anterior border of the trachea, and posteriorly

BRONCHOSCOPIC MEASUREMENT OF LEFT AURICULAR PRESSURE

INTERNAL DIAVMETER 2MM.

5.5 -60c.m.INTERNALDIAMETER0.30IM. APPROX.

FIG. 1. Drawing of the needle welded to a bronchoscopic aspirating tube used for puncture of theleft auricle of the heart.

m

FIG. 2. Drawing of the view clown the broncho-scope showing the carina, and the needle piercingthe anteromedial wall of the right main bronchus.

0.7 and 0.8 has been accepted. The needles whichcomplied with these requirements were approxi-mately of 0.3 mm. bore and 5.5 to 6.0 em. in length,and were most easily made from British wire gage,number 24 needles. Trial and error, with variousneedles, was thought to be a better way of findingoptimum damping, than calculation, which wouldin itself require experimental proof.

Great care should be used in filling the fluid sys-tem, for a small air bubble will cause overdampedtracings. To show up such an error it is useful to

apply a square wave impact immediately aftersetting up the apparatus and before each set ofrecordings. Vibration of the system must be pre-vented, and to this end efforts are now being madeto eliminate the polythene tubing and use the needlemanometer system as a single rigid instrument.

TECHNICThe patient is given 10.0 mg. morphia and

0.6 mg. atropine for premedication. The throatand larynx are painted with 2 per cent Ametho-caine hydrochloride and a few drops of this areinstilled into the trachea. The adult Negusbronchoscope is passed down to the carina andthis too is sprayed with the local anesthetic. Aswab has been taken from the medial wall ofthe right main bronchus for bacteriologicexamination, and this, so far, has always beensterile. The needle on the cannula, connectedto the manometer and filled with saline-heparinsolution, is introduced into the bronchoseope,and, with the solution dripping, it is passedthrough the anteromedial wall of the rightmain bronchus at the carina (fig. 2). The needlepasses about 4 cm. before entering the auriclebut this depends a little on the size of thechamber.

RESULTSThe present communication is mainly to

describe a simple technic for measuring leftauricular pressures rather than to draw con-clusions from the small number of results sofar obtained. The following preliminary ob-servations have been made: (1) Bronchoscopicmeasurement of left auricular pressure incontrol patients suffering from some diseaseother than mitral stenosis for which a thoracot-

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Fig. 3.—Diagram ofthe double-walled needleemployed in transbron¬chial left atrial puncture.Reproduced with permis¬sion from Morrow, A.G. ; Braunwald, E. ; Hal¬ler, J. ., Jr., and Sharp, . H. : Circulation 16:1033, 1957; New York,Grunc & Stratton, Inc.

portion of the pericardium and does not or¬dinarily traverse the free pericardial space;this anatomic fact is believed to account forthe absence of complications due to intra-pericardial bleeding.

The transbronchial method of left heartcatheterization is not particularly suited tothe study of children, since general anesthe¬sia is required and the problems of main¬taining adequate ventilation as well assufficient relaxation are significant. Even inadults bronchoscopy itself may be associatedwith significant discomfort in some patients.The participation of an experienced andinterested endoscopist is necessary, andsuch a person is often not routinely avail¬able in the laboratory.

2. Transseptal Left Heart Catheteriza¬tion.—The ease wiih which a cardiac cath-

éter, introduced from the saphenous vein,can be directed across an atrial septal defectsuggested this most recently developed tech¬nique of left heart catheterization.9"12 Afterisolation of the saphenous vein a standardcatheter may be introduced and completeright heart catheterization carried out. Ashortened No. 9 Lehman catheter is thenpassed into the right atrium, and a speciallyconstructed, curved 17-gauge needle * is in¬serted into it. The tip of the catheter, stillenclosing the needle point, is positionedfluoroscopically to lie against the interatrialseptum near the fossa ovalis. Often thecatheter tip can be engaged beneath thesuperior rim of the fossa. The needle(Fig. 6) is then pushed from the catheter,

* Manufactured by the Becton-Dickinson Co.,Rutherford, N.J.

Fig. 4.—View of bron-choscope and needle inplace during transbron¬chial puncture of theleft atrium.

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Perioperative transoesophageal echocardiography:current status and future directionsFeroze Mahmood,1 Stanton Keith Shernan2

▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/heartjnl-2015-307962).1Department of Anesthesia,Critical Care and PainMedicine, Beth IsraelDeaconess Medical Center,Harvard Medical School,Boston, Massachusetts, USA2Department ofAnesthesiology, Perioperativeand Pain Medicine, Brighamand Women’s Hospital,Harvard Medical School,Boston, Massachusetts, USA

Correspondence toDr Feroze Mahmood,Department of Anesthesia,Critical Care and PainMedicine, Beth IsraelDeaconess Medical Center,Harvard Medical School,Deaconess Road, CC470,Boston, MA 02215, USA;[email protected]

Received 10 December 2015Revised 7 March 2016Accepted 15 March 2016

To cite: Mahmood F,Shernan SK. Heart PublishedOnline First: [please includeDay Month Year]doi:10.1136/heartjnl-2015-307962

ABSTRACTTransoesophageal echocardiography (TOE) is usedin the perioperative arena to monitor patients duringlife-threatening emergencies, cardiac and high-risk non-cardiac surgeries. It provides qualitative and quantitativeinformation on valvular and ventricular functions, anddynamic cardiac anatomy can be displayed with aphysiological perspective. This technology has evolvedfrom two-dimensional (2D) to the ready availability ofreal-time three-dimensional (RT-3D) imaging in theoperating rooms. Enhanced spatial and temporalresolutions with 3D imaging have most significantlyimpacted the quality of intraoperative surgical valverepair and replacement decisions. Additionally, 3Dimaging has facilitated the advent of minimally invasiveand percutaneous interventions for structural heartdisease. Information derived from TEE is routinely usedto evaluate a patient’s suitability for an intervention,provide guidance during the intervention and eventuallycomment on the quality and success of the procedure.Expertise in perioperative TEE is an integral componentof a cardiac anaesthesiologist’s skill sets. With structuralheart disease interventions becoming more minimallyinvasive, the intraoperative guidance provided by TEEwill continue to be a critical component of theseprocedures. With improving computational andprocessing power, the expectations from TEE willcontinue to be incremental in the perioperative arena.

INTRODUCTIONThe term ‘perioperative transoesophageal echocar-diography’ is defined as the use of transoesophagealechocardiography (TEE) for clinical care of patientsbefore, during and immediately after surgery,including the critical care setting.1 Its role is estab-lished as the modality of choice for management oflife-threatening emergencies.2 3 Other applicationsinclude its use as a qualitative and quantitativecardiac structural and functional monitor beforeand after interventions.4 5 Real-time three-dimensional (RT-3D) imaging has expanded its roleas a procedural adjunct during minimally invasiveand percutaneous cardiac interventions (figure 1).5 6

It is routinely used as a perioperative monitor forpatients at risk of haemodynamic instability, forexample, liver transplantation. Non-cardiac surgicaluses of TEE include perioperative assessment ofmyocardial function, volume status and for follow-ing response to therapy.7

Use of TEE is not specialty-specific, and practi-tioners from various disciplines use TEE in theperioperative arena. Whereas training in periopera-tive TEE is a milestone of accredited cardiac anaes-thesia and cardiology fellowship programmes,certification is not specialty-specific.8 National

Board of Echocardiography (NBE) has introducedguidelines for basic to advanced certification levelsfor the perioperative use of TEE. The expectationsof basic level certification include use of TEE formonitoring purposes only. It is recommended thatbasic level echocardiographers consult advancedpractitioners prior to establishing diagnoses thatcan impact surgical decision-making. Advancedlevel certification covers the entire scope of the useof TEE in the perioperative arena.9

HISTORY OF PERIOPERATIVE TEEOesophageal echocardiography was developed in themid-1970s to acquire cardiac structural informationfrom patients with suboptimal transthoracic echo(TTE) images. The first generation oesophageal probewas large and the procedure was associated with dis-comfort for patients who were awake (figure 2).10

During the same time frame, a much smaller epicar-dial echocardiography was developed to analysebiventricular function during cardiac surgery. Besidesother logistical challenges, it required interruption ofthe surgical procedure and posed an infection risk. Toovercome these limitations, the epicardial echo probewas attached to an oesophageal stethoscope to allowacquisition of TEE images without interruption of thesurgical procedure. Next, a phased array TEE probewas used for monitoring of wall motion abnormalities(WMAs) during non-cardiac surgery and diagnosis ofintracardiac air bubbles during neurosurgical proce-dures.11 This was followed by commercial develop-ment of TEE probes equipped with Dopplercapabilities and biplane-phased and multiplane-phased array transducers.11–14 In 1994, first dynamic3D images of mitral valve (MV) were obtained usingrotational scan plane technology.15 A TEE probecapable of intraoperative RT-3D TEE imaging wasdeveloped in 2007.16 These technological develop-ments were driven by clinical needs and indicationsand have therefore resulted in improved patient careand outcomes (figure 2).11–22 With improvements incomputation and processing, complex quantitativeanalyses of cardiac structure and function can also befeasibly performed in the operating room.23

CONDUCT OF A PERIOPERATIVETRANSOESOPHAGEAL ECHO EXAMINATIONA perioperative TEE examination during cardiacsurgery differs in various aspects from an out-patient diagnostic examination. It is performed onpatients under general anaesthesia (GA) who areparalysed and in supine position. The scope of anelective examination is more comprehensive in itsdomain in regard to cardiac structure and functionthan a focused diagnostic examination. It is time-limited in that there are precardiopulmonary and

Mahmood F, Shernan SK. Heart 2016;0:1–9. doi:10.1136/heartjnl-2015-307962 1

Review Heart Online First, published on April 5, 2016 as 10.1136/heartjnl-2015-307962

Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& BCS) under licence.

group.bmj.com on April 6, 2016 - Published by http://heart.bmj.com/Downloaded from



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Transseptal Puncture

Imaging Guidance

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Goal

To SAFELY Traverse the Inter-Atrial Septum through the Fossa Ovalis from RA to LA without going

through the extra-cardiac space In majority of the cases it can be achieved by fluoroscopy alone

Complexity of intervention requires precision in puncture

Procedure Specific Transseptal Puncture



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Embryology & Anatomy



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Embryonic IAS

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62 W. Klimek-Piotrowska et al. / Annals of Anatomy 205 (2016) 60–64

Table 1Results of obtained anatomical measurements and calculations.

Name N Minimum Maximum Median Mean SD

Heart weight (g) 135 150.0 780.0 448.0 451.5 113.7Distance between ICV and SVC ostia (mm) 135 17.0 62.0 34.0 35.0 7.3Interatrial septum width (mm) 135 12.8 62.0 28.6 29.3 8.1FO CD (mm) 135 3.8 26.9 12.0 12.1 3.6FO AP (mm) 135 4.9 24.3 14.0 14.1 3.6FO area (mm2) 135 9.2 424.3 136.9 142.7 65.0Fossa ovalis/Interatrial septum-Ratio (%) 135 2.9 51.5 17.6 18.3 9.0LR (mm) 135 7.0 30.4 21.1 20.7 5.2LO (mm) 135 2.9 28.0 8.9 10.1 4.4LS (mm) 135 4.0 28.0 12.0 12.6 5.2RIM (mm) 135 1.1 11.2 3.8 4.4 2.4PFO channel length (mm) 33 4.2 15.6 10.4 10.5 3.2RSP depth (mm) 16 3.0 17.1 5.0 6.3 3.8

N – number of hearts; FO – fossa ovalis; FO AP – anteroposterior fossa ovalis diameter; FO CD – craniocaudal fossa ovalis diameter; IVC – inferior vena cava; LO – the distancefrom the limbus of the fossa ovalis to the inferior vena cava ostium; LR – the distance from the limbus of the fossa ovalis to the right atrioventricular ring; LS – the distancefrom the limbus of the fossa ovalis to the right atrium roof; PFO – patent foramen ovale; RIM – distance from the limbus fossae ovalis to the edge of the infero-anterior rim;RSP – right-sided septal pouch; SD – standard deviations; SVC – superior vena cava.

Fig. 1. The right atrium scheme. The view of interatrial septum from the rightatrial side (mean values). Stippled area represents the true interatrial septum. IVC– inferior vena cava; SVC – superior vena cava.

interatrial septum (Krishnan and Salazar, 2010). In this study, aseptal pouch opening to the right atrium was observed in 11.9%of specimens (Fig. 2c). The apex of the RSP was observed in asuperiorly directed orientation in all specimens. The most commonlocation of the RSP orifice was as follows: superior-anterior (62.5%),superior-central (25%), superior-posterior (6.25%), and anterior(6.25%) circumference of the fossa ovalis. The septal pouch openedto the left atrium was observed in 51.2% of specimens.

No observations of structures traversing the atrium from atrialwall to interatrial septum were collected during this study (musclebridges and networks), however in 7.4% of cases, the fossa ovaliswas associated with a net-like structure within the limbus of thefossae ovalis (Fig. 2d). Fig. 2 shows four variations of observed fossaovalis anatomy: “smooth” fossa ovalis, PFO, RSP and net-like for-mation within the fossa ovalis. The interatrial septum wall wasalways the thinnest in the fossa ovalis area (especially in its supe-rior part). The translumination of the fossa ovalis floor did not revealany difference in its thickness and translucency among four namedgroups. No interatrial septal aneurysms and atrial septal defectswere observed.

Fig. 2. Photographs of cadaveric heart specimens showing four different types offossa ovalis anatomy. A – “smooth” fossa ovalis; B – patent foramen ovale; C – right-sided septal pouch (blindly ending pocket within interatrial septum which is openedinto right atrium); D – net-like formation within the fossa ovalis.

4. Discussion

Speaking about the interatrial septum we need to realize theexistence of two different, often mistaken, concepts: atrial sep-tum and the true (clinically significant) interatrial septum. Thedifference between these two concepts is huge. Traditionally com-prehended, the interatrial septum represents an extensive areaof musculature interposed between the two atria and is boundedas follows: inferiorly by the IVC ostium, antero-inferiorly by thecoronary sinus orifice, anteriorly by the right atrioventricular ring(septal leaflet), antero-superiorly by the non-coronary sinus of Val-salva, superiorly by the SVC ostium, and finally posteriorly by foldsof the atrial wall (Sweeney and Rosenquist, 1979). This area appearsextensive at first sight and could be called a “false” interatrial sep-tum, since transections and dissections reveal that very little part ofthe aforementioned area can be removed without opening the rightatrial wall and arriving outside the heart (Anderson and Brown,1996).

Annals of Anatomy 205 (2016) 60–64

Contents lists available at ScienceDirect

Annals of Anatomy

jou rn al hom epage: www.elsev ier .com/ locate /aanat

Research article

Anatomy of the true interatrial septum for transseptal access to theleft atrium

Wiesława Klimek-Piotrowska1, Mateusz K. Hołda ∗,1, Mateusz Koziej, Katarzyna Piątek,Jakub HołdaDepartment of Anatomy, Jagiellonian University Medical College, Cracow, Poland

a r t i c l e i n f o

Article history:Received 6 January 2016Received in revised form 23 January 2016Accepted 25 January 2016

Keywords:Transseptal punctureSeptal pouchPatent foramen ovaleFossa ovalis

a b s t r a c t

Clinical anatomy of the interatrial septum is treacherous, difficult and its unfamiliarity can cause manyserious complications. This work aims to create an anatomical map of the true interatrial septum. Anappreciation of the anatomical situation is essential for safe and efficacious transseptal access from theright atrium to the left heart chambers. Examination of 135 autopsied human hearts (Caucasian) ofboth sexes (28% females) aged from 19 to 94 years old (47.0 ± 18.2) with BMI = 27.1 ± 6.0 kg/m2 wasconducted. Focus was specifically targeted on the assessment of the fossa ovalis, patent foramen ovale(PFO), and right-sided septal pouch (RSP) morphology. Mean values of cranio-caudal and antero-posteriorfossa ovalis diameters were 12.1 ± 3.6 and 14.1 ± 3.6 mm, respectively. The fossa ovalis was situated anaverage of 10.1 ± 4.4 mm above the inferior vena cava ostium, 20.7 ± 5.2 mm from the right atrioventric-ular ring, and 12.6 ± 5.2 mm under the right atrium roof. Four types of fossa ovalis anatomy have beenobserved (smooth-56.3%, PFO-24.4%, RSP-11.9%, net-like formation-7.4%). The PFO mean channel lengthwas 10.5 ± 5.2 mm. The tunnel-like PFO (channel length ≥12 mm) was observed in 8.9% of specimens.The RSP was observed in 11.9% of specimens (with mean depth = 6.3 ± 3.8 mm) and was directed apexupward in all observed specimens (may imitate the PFO channel). The fossa ovalis/interatrial septumsurface area ratio was 18.3 ± 9.0%. In conclusion: (1) An anatomical map of the interatrial septum fromthe right atrial side was presented. (2) The RSP may imitate the PFO channel. (3) The “true” interatrialseptum represents only about 20% of the whole interatrial septum area. (4) There is wide variation in thelocation and geometry of the fossa ovalis. (5) We could distinguish four different types of the fossa ovalisarea.

© 2016 Elsevier GmbH. All rights reserved.

1. Introduction

It has been over half a century since Ross, Braunwald, and Mor-row provided the first description of the transseptal left atrialpuncture technique, which permits a direct route to the left atriumvia the systemic venous system, right atrium and interatrial septum(Ross et al., 1960). Prior to this development, obtaining percu-taneous access to the left atrium was one of the most difficultcardiac procedures. The left atrium was commonly reached by ret-rograde arterial cannulation via the left ventricle and mitral valve,although the manipulation of catheters proved problematic due

∗ Corresponding author at: Department of Anatomy Jagiellonian University Med-ical College Kopernika 12, 31-034 Kraków, Poland. Tel.: +48 124229511;fax: +48 124229511.

E-mail address: [email protected] (M.K. Hołda).1 These authors contributed equally.

to multiple required 90◦ turns (Zimmerman et al., 1950). Alter-native techniques, such as: transbronchial (Facquet et al., 1952),transthoracic (Bjork et al., 1953), suprasternal (Radner, 1954) anddirect ventricular (Brock et al., 1956) puncture have been pro-posed, but each has certain disadvantages. Another method of leftatrial access utilized natural connections between the right and leftatria, such as a patent foramen ovale (PFO) or other atrial septaldefects. This access was new, still developed, and limited to a smallnumber of patients with favorable anatomical conditions. Brock-enbrough (Brockenbrough et al., 1962), and later Mullins (Mullins,1983) refined the transseptal puncture procedure with several crit-ical modifications. Today, both transseptal puncture and accessthrough PFO are widely used cardiac techniques. Transseptal accessis commonly employed during the following procedures: catheterablation, pulmonary vein isolation, left atrial appendage closure,PFO and atrial septal defect repair, percutaneous mitral valvulo-plasty, MitraClip catheter-based mitral valve repair, hemodynamicassessment of the mitral valve, paravalvular leak closure, and as

http://dx.doi.org/10.1016/j.aanat.2016.01.0090940-9602/© 2016 Elsevier GmbH. All rights reserved.



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REVIEW

The Importance of Attitudinally AppropriateDescription of Cardiac Anatomy

ROBERT H. ANDERSON1 AND MARIOS LOUKAS2*1Cardiac Unit, Institute of Child Health, University College, London, United Kingdom

2Department of Anatomical Sciences, School of Medicine, St. George’s University, Grenada, West Indies

The essence of anatomic description is to account for structures as they liewithin the body as viewed in the so-called anatomic position. This importantbasic principle of gross anatomy has been ignored for years by those describ-ing the relationships of structures within the heart, these cardiac componentsusually being described in the setting of the heart removed from the body, andpositioned on its apex. With the increasing use in clinical practice of tomo-graphic techniques for diagnosis, in which the heart is viewed as it lies withinthe body, this conventional approach to description of cardiac structuresbecomes increasingly confusing. Thus, when the heart is viewed in attitudinallyappropriate fashion, with the apex pointing to the left, and with the so-calledright heart chambers positioned anteriorly relative to the so-called left coun-terparts, the current adjectives used for description are found to be wanting.For example, with the heart in the position it occupies during life, the so-calledposterior descending coronary artery is seen to be positioned inferiorly relativeto the ventricular mass. It is more correct to describe this artery as being infe-rior and interventricular. Such a change has major clinical significance, sinceblockage of the artery produces inferior myocardial infarction, the leads usedfor electrocardiographic recording being placed so as to respect the anatomicposition. Another example of the deficiencies of the ‘‘Valentine’’ approach tocardiac description is seen when the mitral valve is viewed in attitudinallyappropriate fashion. The papillary muscles supporting the tendinous cords areseen to be located inferiorly and adjacent to the ventricular septum, and supe-riorly and located on the posterior left ventricular wall when viewed in thisfashion. Currently, however, the inferoseptal muscle is described as beingposteromedial. Those performing electrophysiological studies of the heart havealready appreciated the problems created by assessing the heart in ‘‘Valen-tine’’ fashion, since when described in this way, a catheter passing upwardsthrough the inferior caval vein is said to progress in an anterior fashion. Acommittee has recommended use of attitudinally appropriate terminology toavoid these problems. We suggest that those teaching cardiac anatomy inmedical schools should also insist on the use of attitudinally appropriate no-menclature when describing the heart, as is currently the case for all otherstructures in the body. Clin. Anat. 22:47–51, 2009. VVC 2008 Wiley-Liss, Inc.

Key words: cardiac position; anatomic position; cardiac apex; mitral valve

*Correspondence to: Marios Loukas, Associate Professor, Depart-ment of Anatomical Sciences, St George’s University, School ofMedicine, Grenada, West Indies.E-mail: [email protected] [email protected]

Received 13 October 2008; Accepted 22 October 2008

Published online 16 December 2008 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/ca.20741

VVC 2008 Wiley-Liss, Inc.

Clinical Anatomy 22:47–51 (2009)

Fig. 2. The heart has been removed from the body,positioned in attitudinally appropriate position, and thenviewed from the apex of the left ventricle. As can beseen, the ventricular mass takes the form of a squashedcone, with anterior, inferior, and posterior borders. Thelabels show the location of these borders relative to thethoracic structures, and illustrate the acute and obtuseangles between the borders.

Fig. 1. A cast of the so-called right and left cham-bers of the heart, cast in blue and red, respectively, hasbeen superimposed on a chest radiograph from a nor-mal individual. As can be seen, the long axis of theheart extends from the right shoulder toward the lefthypochondrium. The vertical arrow indicates the midlineof the body. The heart is usually positioned within themediastinum such that one third is to the right of themidline, and two thirds to the left.

Fig. 3. The cast of the heartshown in Figure 1 is enlarged toshow the chambers forming thevarious borders of the frontal car-diac silhouette.

Fig. 2. The heart has been removed from the body,positioned in attitudinally appropriate position, and thenviewed from the apex of the left ventricle. As can beseen, the ventricular mass takes the form of a squashedcone, with anterior, inferior, and posterior borders. Thelabels show the location of these borders relative to thethoracic structures, and illustrate the acute and obtuseangles between the borders.

Fig. 1. A cast of the so-called right and left cham-bers of the heart, cast in blue and red, respectively, hasbeen superimposed on a chest radiograph from a nor-mal individual. As can be seen, the long axis of theheart extends from the right shoulder toward the lefthypochondrium. The vertical arrow indicates the midlineof the body. The heart is usually positioned within themediastinum such that one third is to the right of themidline, and two thirds to the left.

Fig. 3. The cast of the heartshown in Figure 1 is enlarged toshow the chambers forming thevarious borders of the frontal car-diac silhouette.

tion concerning the location of the chambers relativeto the bodily coordinates. Such conventions, how-ever, do not solve the problems currently existingwith naming structures such as the coronary arteriesand the papillary muscles of the mitral valve.

It is well recognized that the major branches ofthe coronary arteries occupy either the atrioventricu-lar or the interventricular grooves. We have alreadydescribed how the anterior interventricular arterydescends along the left border of the cardiac silhou-ette, marking the leftward extent of the morphologi-cally right ventricle. The other artery demarcatingthe opposite end of the ventricular septum, however,runs along the midpoint of the diaphragmatic surfaceof the ventricular mass. When viewed relative to thebodily coordinates, the artery as it enters the inter-ventricular groove is often positioned towards thefront of the chest relative to its anterior counterpart(Fig. 5). When traced towards the cardiac apex, itruns horizontally along the diaphragmatic surface ofthe ventricular mass, and in some instances mayeven ascent as it courses towards the ventricularapex. Under no circumstances can the artery sensi-bly be said to be posterior and descending. Yet, invirtually all anatomic textbooks, along with textsdevoted to clinical cardiology, the structure isdescribed as the posterior descending coronary ar-tery. This unfortunate circumstance arises from theunfortunate penchant of generations of anatomistsof taking the heart from the body and positioning iton its apex prior to embarking on anatomic descrip-tions. For current medical students, and thoseembarking on a career in clinical cardiology, it is farmore sensible to describe the artery appropriately asbeing inferior and interventricular. This carries addedweight, since it is well established that blockage of

Fig. 4. The position of the cardiac valves has beensuperimposed on the frontal silhouette as viewed in atti-tudinally appropriate fashion.

Figure 5.

50 Anderson and Loukas



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Inter-Atrial Septum



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LAO RAO

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clockwise rotation of the catheter bring theIAS and FO into view (septal view) (Figure 7). Withthe sheath and dilator apparatus engaged againstthe FO in the septal view, the height of the TSP canbe readily assessed. The anterior-posterior locationof the TSP can then be determined with an anterior(counterclockwise rotation) and posterior (clockwiserotation) of the transducer, allowing needle adjust-ment before puncturing the FO (33). This surveyalso allows screening for PFO and characteri-zation of the IAS properties (thick septum, septalaneurysm, prior patch repair, and so on). After

successful TSP, ICE allows direct visualization ofthe needle tip and its relationship to the sur-rounding cardiac structures (39).

Fusion of different imaging modalities has gainedincreasing popularity in structural heart disease (SHD)interventions over the past decade. Currently, thecombination of TEE and fluoroscopy (e.g., EchoNavi-gator, Philips, Amsterdam, theNetherlands) is the onlymodality that allows real-time image fusion of highquality during SHD interventions. The utility of theEchoNavigator system to facilitate a targeted TSP hasbeen demonstrated in several studies (37,40). Newer

FIGURE 4 Fluoroscopic Projections for Transseptal Puncture Guidance

Ao¼ aorta; AR ¼ aortic root; AV¼ aortic valve; CS¼ coronary sinus; LAA ¼ left atrial appendage; LAO ¼ left anterior oblique; PA ¼ pulmonaryartery; RAO ¼ right anterior oblique; TV ¼ tricuspid valve; other abbreviations as in Figure 2.

Alkhouli et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 2 4 , 2 0 1 6

Transseptal Puncture Techniques D E C E M B E R 2 6 , 2 0 1 6 : 2 4 6 5 – 8 02470

clockwise rotation of the catheter bring theIAS and FO into view (septal view) (Figure 7). Withthe sheath and dilator apparatus engaged againstthe FO in the septal view, the height of the TSP canbe readily assessed. The anterior-posterior locationof the TSP can then be determined with an anterior(counterclockwise rotation) and posterior (clockwiserotation) of the transducer, allowing needle adjust-ment before puncturing the FO (33). This surveyalso allows screening for PFO and characteri-zation of the IAS properties (thick septum, septalaneurysm, prior patch repair, and so on). After

successful TSP, ICE allows direct visualization ofthe needle tip and its relationship to the sur-rounding cardiac structures (39).

Fusion of different imaging modalities has gainedincreasing popularity in structural heart disease (SHD)interventions over the past decade. Currently, thecombination of TEE and fluoroscopy (e.g., EchoNavi-gator, Philips, Amsterdam, theNetherlands) is the onlymodality that allows real-time image fusion of highquality during SHD interventions. The utility of theEchoNavigator system to facilitate a targeted TSP hasbeen demonstrated in several studies (37,40). Newer

FIGURE 4 Fluoroscopic Projections for Transseptal Puncture Guidance

Ao¼ aorta; AR ¼ aortic root; AV¼ aortic valve; CS¼ coronary sinus; LAA ¼ left atrial appendage; LAO ¼ left anterior oblique; PA ¼ pulmonaryartery; RAO ¼ right anterior oblique; TV ¼ tricuspid valve; other abbreviations as in Figure 2.

Alkhouli et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 2 4 , 2 0 1 6

Transseptal Puncture Techniques D E C E M B E R 2 6 , 2 0 1 6 : 2 4 6 5 – 8 02470

Angiographic vs Echocardiography

Projection Tomograms



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Echocardiographic Guidance

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Communication



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Echocardiographic Guidance

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“Live” Narrow Sector Mode “Live” Wide Angle Mode



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Steps of the ProcedureDescription of the Inter-Atrial Septum

Procedure specific site selection

Tracking the wire

Confirmation of site

Tenting

Puncture



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Simultaneous Orthogonal Imaging



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Cases

Structural Heart



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More Anterior than Posterior Infero-Superior - OK

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Four centimeter circle

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Final Thoughts

3D Echocardiographic Guidance is Integral to a Safe Transseptal Puncture

Common Nomenclature

Simultaneous Orthogonal Plane Imaging MORE useful than rendered 3D imaging

2D and 3D Echocardiography Safe and Efﬁcient Transseptal ... · ECH WEEK Comprehensive Review &...

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Transcript of 2D and 3D Echocardiography Safe and Efﬁcient Transseptal ... · ECH WEEK Comprehensive Review &...