1. Transseptal Access and Mitral Valve Disease
Boston Scientific Fellows Masters Course
February 18-19, 2017
Transseptal Access and Mitral Valve Disease
Sameer Gafoor1,2 .
1Swedish Heart and Vascular: Paul Huang, Darryl Wells, Adam Zivin, Eric Williams,, Ming Zhang,
John Petersen II, Madalena Petrescu, Nimish Muni, Eric Lehr,
Robert Bersin, Glenn Barnhart, Irina Penev,Amanda Ray,
Michelle Batjargal, Thearry Deap, Zachary Newhart, David Mazza
2CVC Frankfurt: Jennifer Franke, Simon Lam, Stefan Bertog, Laura Vaskelyte,
Ilona Hofmann, Markus Reinartz, Horst Sievert
Swedish Heart and Vascular: Swedish Medical Center, Seattle, WA, USA
CVC: CardioVascular Center Frankfurt, Frankfurt, Germany

2. Disclosure Statement of Financial Interest
Research and speaker fees from Boston Scientific, Medtronic, Abbott Vascular

3. Agenda Why learn transseptal access
LAAC
Mitral intervention
Basics of transseptal access procedure
Importance of imaging
Understand anatomy in 3D
Basic steps
Overview of mitral valve disease

4. Why learn transseptal Great highway to Mitral valve Paravalvular leak
LAA closure
Large bore sheath

5. When do you need transseptal
Diagnosis – hemodynamics
Interventions
Mitral – valvuloplasty, mitraclip, paravalvular leak,
Left atrial appendage closure
Pulmonary vein interventions

6. How it looks on fluoro

7. First steps Flush all equipment 0.032 wire into SVC
Remove wire, add sheath + dilator
Advance needle in but not fully
Connect to pressure

8. Next on TEE Turn transseptal to 4-6 o clock
Two jumps: Aortic knob and then Fossa
Rotate the knob of the needle until arrow is more toward 7 o’clock – aim for more posterior rather than anterior

9. Basic technique
Femoral venous access
5 PM

10. Inferior and Posterior for most interventions, e.g. LAA
IVC
SVC
pericardium
aorta
inferior
superior
posterior
anterior
Long axis:
Short axis:

11. Tenting… IVC SVC pericardium aorta inferior superior posterior
anterior
Long axis:
Short axis:

12. Other interventions e.g., Mitraclip
At or near 90° Vertical Plane
At or near 30° Vertical Plane
At or near 0° Vertical Plane
Need to switch rapidly to 0 degree view and measure distance to mitral valve annulus

13. How does this look?

15. Once you have tenting in correct position
Hold sheath and dilator together
Advance needle outside the dilator
Should feel pop and check confirmatory signs
Confirmatory signs
Pressure recording change
Needle in Left atrium on echo

16. Pressure monitoring during puncture
Needle against the IAS
Left atrial pressure tracing
Pressure tracing from the needle tip

17. Intracardiac Echo
8Fr or 10Fr catheter with a 64 element phased-array transducer
Longitudinal plane scan, depth penetration of 12 cm
Four-way tip steerability (Left, Right, anterior, posterior)
Lockable tip

18. Rotational vs. Phased Array ICE

19. Intracardiac Echo

20. Intracardiac Echo

21. Intracardiac Echo
Courtesy Ramon Quesada

22. Intracardiac Echo
Courtesy Ramon Quesada

23. Intracardiac Echo: Tenting
Courtesy Ramon Quesada

24. After transseptal puncture
Hold needle
Then advance sheath and dilator over needle
Hold dilator and needle
Advance sheath over dilator and needle
Remove dilator and needle
De-air the sheath
Give 10,000 units Heparin
If Mullins sheath, insert 6Fr sheath to

25. Troubleshooting: I don’t see the needle anymore: Cause: Larger atrium
Remove the needle
Use 0.032” wire to put Dilator and sheath into SVC
Bend the needle more to give more “reach”
Try again

26. Troubleshooting I can’t tell if I am across the septum or not
Confirmatory test 1: Pressure tracing
Confirmatory test 2: Oxygen saturation
Confirmatory test 3: Give some contrast dye and watch on TEE/ICE

27. Troubleshooting: I can’t get across the septum
Push “slightly” harder, hold tension
Use back end of coronary wire and push through, then switch to front end of coronary wire
Use radiofrequency
Often an issue for crossing septum outside the foramen ovale

28. Troubleshooting Pericardial effusion
Due to puncture of right or left atrial wall
Emergent pericardiocentesis
Stroke/TIA or transient ST elevation
Probably air embolus
Important to keep good technique to de-air

29. Troubleshooting What happened?
Courtesy Ramon Quesada

30. Aortic puncture If just needle – can consider removing
If needle and sheath – then have to call surgery or consider a closure device. However this is not a beginner move!

31. Troubleshooting What if there is a thrombus on the device?
Give heparin
Consider aborting the procedure
Prevention is key – have all materials ready for next steps; give heparin immediately

32. Risk factors for tough transseptal puncture
Kyphoscoliosis
Giant left atrium
Eustachian valve
Courtesy Ramon Quesada

33. Transseptal Needle First design Dr. E Brockenbrough, 1960 NIH
Today’s needles
BRK™– St Jude
Brockenbrough® – Medtronic
Transseptal Needle – Cook
HeartSpan® – Boston Scientific & Biosense Webster
Slide Courtesy of Minneapolis Heart Institute

34. Transseptal Needles 50° 86° Standard curve (50°) Large curve (86°)
Less reach
Easier to adjust target puncture site
Large curve (86°)
More reach
Large right atrium + lower puncture site
86°
Slide Courtesy of Minneapolis Heart Institute

35. Transseptal Needles Curve Options
Available in three: Two adult curves (BRK and BRK-1) and two pediatric (BRK and BRK-2)
Variety of Length
Three adult (71cm, 89cm, 98cm) and one pediatric (56cm)
The 98cm needle designed for use with St. Jude Medical Agilis NxT™ steerable introducer
Slide Courtesy of UC Davis
Image used courtesy of St. Jude Medical, Inc.

36. NRG® RF Transseptal Needle
Baylis Medical Company
Blunt, radiopaque tip with side holes
Fine-tune and visualize precise position
Inject contrast, monitor pressure
Arrow at distal end aligns with distal curve
Handles similar to mechanical needle
Images courtesy of Baylis Medical Company.

37. NRG® RF Transseptal Needle
Baylis Medical Company
RF Puncture
Facilitates the inferior-posterior position required for TSP in LAA closure1
Reduces need for mechanical force
Fine-tune position
Puncture in desired position
Tissue healing comparable to mechanical puncture2
1Rinaldi, Cardiac Interventions Today, 2014
2Veldtman et al, CCI, 2005
Image & video courtesy of Baylis Medical Company.

38. NRG® RF Transseptal Needle
Baylis Medical Company
Reduces tenting by up to 51% compared to mechanical needle1
Mechanical Needle
NRG® RF Needle
Prevents tissue coring observed with Bovie technique2
Reduces incidence of pericardial tamponade3
0 incidences in 575 TSP with NRG
9 incidences in 975 TSP with mechanical needle
Increases TSP crossing success rate compared to mechanical needle
100% successful crossing with RF needle4
27.8% failed crossing with mechanical punctures4
-crossing – tenting, safety (coring & tamponade), success rate
1Rogers et al, (2015) Manuscript in review.
2Knight et al, Circ Arrhythm Electrophysiol, 2012
3Winkle et al, Heart Rhythm, 2011
4Hsu et al, Circulation, 2014
Images courtesy of Baylis Medical Company.

39. NRG® RF Transseptal Needle
Baylis Medical Company
Access in position that aligns with trajectory
Critical to delivery of therapy on target1, 2
ProTrack™ Pigtail Wire or Toray Wire can be advanced to safely secure access
Facilitates exchange for larger sheaths, maintains access and eliminates need to probe LSPV
Can reduce procedural time3
Can reduce risk of perforation3
Standard Guidewire
ProTrack™ Pigtail Wire
1Rich, J Vis Exp. doi: /52811
2Rinaldi, Cardiac Interventions Today, 2014
3Buchner et al, Journal of Interv Cardiol, 2015
Images courtesy of Baylis Medical Company.

40. Usually non-braided sheath
Transseptal Sheath
Non-braided (less torque)
Mullins™ – Medtronic
Performer™– Cook Medical
Fast-Cath™– St. Jude
Braided (more torque)
Swartz™ Braided – St. Jude
TorFlex™– Baylis Medical
Preface® – Biosense Webster
Usually non-braided sheath
Slide Courtesy of Minneapolis Heart Institute

41. Higher number = more acute bend
Transseptal Sheath
SL0
SL1
St. Jude Medical
Baylis Torflex TM
Higher number = more acute bend
Usually 7 to 8.5 Fr
Slide Courtesy of Minneapolis Heart Institute

42. Complications Know pericardiocentesis technique Pericardial effusion
Aortic root puncture
R or L atrial wall puncture
Pleuritic chest pain
Stroke/TIA
Air embolus
Know pericardiocentesis technique
Avoid when possible

43. Sites for Targeted Transseptal
SVC
Superior-Posterior
MitraClip Transcatheter Mitral ViV/ViR
Inferior-Posterior
LAA occluder/ligation
Superior
Transseptal PFO Closure
Anterior
Posterior RA
For other procedures (PVL closure, etc.), transseptal site will vary based on location of pathology. RV
IVC

44. Mitral Valve Disease

45. What are the possibilities for mitral valve disease?
Stone, TCT 2016

46. Coaxial to the mitral valve
Kapadia, TCT 2016

47. Transcatheter mitral valve in valve
Spies, TCT 2016

48. Summary Many different materials available
Goes back to basic techniques
Slow is steady, steady is fast
Know your imaging – fluoro and TEE and ICE
Know your position
Understand potential complications
Know your bailout strategy
Practice and practice and practice – this is an interventional procedure!

49. If you are convinced you want to be a structural cardiologist
Take an advanced year for structural fellowship training… apply for a great program such as this one at Swedish in Seattle

50. Thank You Sameer Gafoor Work: 206-320-8100 Cell: 734-274-1038
Medical Director, Structural Heart Program
Work:
Cell: