1. Trans-septal Catheterization December 6, 2012 Jonathan Tobis, MD Professor of Medicine Director of Interventional Cardiology, UCLA Trans-septal Catheterization December 6, 2012 Jonathan Tobis, MD Professor of Medicine Director of Interventional Cardiology, UCLA

2. Transseptal Procedure Steps 1.Prepare equipment. Sheath, dilator, BRK needle. 2.Introduce sheath/dilator into SVC over 0.032” wire. 3.Position BRK needle inside assembly. 4.Drag assembly into RA in PA view, it will move medially to the left and engage the Fossa Ovalis. 5.Confirm correct position in RAO (ant-post: needle should be post to pigtail in aorta, parallel with spine.

3. 6. Confirm in LAO: needle should be directed posterior. 7. Confirm by TEE or ICE: tenting of atrial septum. 8. Advance needle into LA. Confirm by pressure, LA injection of saline on echo or contrast by fluoro. 9. Advance sheath/dilator into LA. Careful about tenting septum, and not pushing needle too far into LA. 10.Remove dilator and needle.

4. BRK-1 may be easier for flat septum, normal size LA BRK may be better for curved LA septum eg mitral stenosis You can bend the needle to alter the curve

5. TEE guidance: tenting atrial septum

6. Sheath enters LA and tents or pulls the septum, then “pops” through. You have to be well inside the LA with the sheath, or the sheath may spring back into the RA when you remove the dilator or guidewire.

7. Steps for TS Puncture 1.Advance sheath + dilator over 0.032” wire to SVC 2.Advance BRK needle to 1cm of end of dilator

8. Steps for TS Puncture 3. Withdraw the TS catheter in PA view until it moves medially. The catheter is rotated posteriorly at 4-6 o’clock.

9. Steps for TS Puncture 3. Withdraw the TS catheter in PA view until it moves medially PA or mild LAO RAO

10. Staining the inter-atrial septum in LAO

11. Proper position: RAO and LAO

12. Advancing the needle across the foramen ovale

13. Useful Hints for Transseptal Puncture 1.TEE or ICE has made TSP much easier, but you still need to understand the anatomy. 2.Different Fluoro views are very helpful: PA when bringing the catheter into the RA RAO to see antero-posterior with pigtail in Ao. LAO to see the needle is directed posteriorly 3.Do not let the needle extend beyond dilator until you are ready to puncture. 4.When inserting up IVC, let the needle rotate freely, or you can perforate the sheath.

14. Useful Hints for Transseptal Puncture 5. Crossing a thick septum (MS or post surgery) can be difficult. May need RF energy or bovi. 6. Large left atrium (MS) the septum bulges toward RA so imagine the needle sliding over the surface of a grapefruit. The angle of the needle may have to be in the 9 o’clock position, but the needle tip will be parallel to the spine in the RAO view. 7. If the needle enters the pericardium or aorta, do not advance the sheath. Confirm with pressure and contrast. Withdraw assembly, reverse heparin if it was given, comeback to fight another day.

15. Be Careful Out There !