General description of procedure, equipment, technique
Atrial septal interventions include the following:
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Transseptal Puncture
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Septoplasty /Atrial Septal Defect Creation
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Transseptal Puncture
Currently, many of the percutaneous catheter-based treatments for adult “structural” heart diseases require access to the left heart via transseptal puncture. However, septal anatomy can often in this patient population be complex due to previous surgical or transcatheter interventions for the atrial septum.
Septoplasty/Atrial Septal Defect Creation
Although uncommon, some patient clinical conditions can be improved by creating a communication between the atria. This is performed in a similar manner as transseptal puncture with subsequent enlargement of the created defect in the atrial septum.
Indications and patient selection
Transseptal Puncture
Transseptal puncture is used to access the left atrium for transcatheter interventions or diagnostic data. The interatrial septum is made by two overlapping tissues. Septum primum is the valve-like flap forming the floor of the fossa ovalis and septum secundum is the muscular rim surrounding the fossa.
Septoplasty/Atrial Septal Defect Creation
1. Pulmonary hypertension with low cardiac output
2. Single ventricle physiology with low cardiac output or hypoxemia
3. Protein-losing enteropathy (failing Fontan physiology)
Contraindications
Transseptal Puncture
No specific contraindications. Patients that require caution include those with the following profile:
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Lipomatous or thickened atrial septum
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Previous atrial septal occluder device
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Anatomic distortion due to enlargement of the aortic root
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Hypoplastic left atrial cavity
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Currently taking blood thinners
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Bleeding disorder
Septoplasty/Atrial Septal Defect Creation
Similar to transseptal puncture contraindications other than avoiding the creation of a defect that would result in symptomatic systemic hypoxemia.
Details of how the procedure is performed
Transseptal Puncture
Mullins sheath: transseptal needle attached to pressure transducer via a three-way stopcock and a 5-mm syringe with diluted contrast. Position can be guided using intracardiac echocardiography and left atrial position confirmed by agitated saline in the left atrium or contrast that moves toward the mitral valve.
Septoplasty/Atrial Septal Defect Creation
Transseptal puncture followed by a 0.014 wire in the left upper pulmonary vein. Advance the 6-mm, 7-mm, or 8-mm cutting balloon over the wire and angioplasty to no more than 8 atms 2 to 3 times slightly rotating the balloon between inflations.
The cutting balloon inflation and deflation are slow to allow the folding mechanism to work appropriately and the inflated balloon should be maintained for 30 to 60 seconds. This should make an adequate defect but if not you can repeat the entire process, including the transseptal puncture to make a second defect or inflate a low pressure balloon, such as a Tyshak II that is 12 mm to 16 mm, to further extend your existing defect if needed based on saturation and pressure.
Interpretation of results
Transseptal Puncture
Intracardiac echocardiography (ICE) and fluoroscopy.
Septoplasty/Atrial Septal Defect Creation
Clinical findings of saturation and atrial pressure.
Outcomes (applies only to therapeutic procedures)
Septoplasty/Atrial Septal Defect Creation
This is often a palliation for a more significant comorbidity, but it does work to relieve symptoms of low cardiac output in the setting of a failing Fontan, protein-losing enteropathy, and pulmonary hypertension.
Alternative and/or additional procedures to consider
Septoplasty/Atrial Septal Defect Creation
Surgical septoplasty.
Complications and their management
Serious adverse events and management
Transseptal Puncture
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Perforation of the left atrial wall often due to a posterior position on the atrial septum
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Malposition and perforation of the right atrial appendage
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Malposition and perforation of the right ventricular outflow track
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Perforation of the aorta often due to an anterior position on the atrial septum
Septoplasty/Atrial Septal Defect Creation
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Perforation of the left atrial wall often due to a posterior position on the atrial septum
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Malposition and perforation of the right atrial appendage
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Malposition and perforation of the right ventricular outflow track
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Perforation of the aorta often due to an anterior position on the atrial septum
What’s the evidence?
Transseptal Puncture
These are the key studies for transseptal puncture:
Faletra, FF, Nucifora, G, Ho, SY. “Imaging the atrial septum using real-time three-dimensional transesophageal echocardiography: Technical tips, normal anatomy, and its role in transseptal puncture”. J Am Soc Echocardiogr.. vol. 24. 2011. pp. 593-9. (This is a review for 3D TEE during transseptal puncture.)
McGinty, PM, Smith, TW, Rogers, JH. “Transseptal left heart catheterization and the incidence of persistent iatrogenic atrial septal defects”. J Interv Cardiol.. vol. 24. 2011. pp. 254-63. (This article discusses the incidence of ASD after transseptal.)
Septoplasty/Atrial Septal Defect Creation
These are the key studies for atrial septoplasty:
Reichenberger, F, Pepke-Zaba, J, McNeil, K. “Atrial septoplasty in the treatment of severe pulmonary arterial hypertension”. Thorax. vol. 58. 2003. pp. 797-800. (This article reviews overall results for septoplasty to palliate patients with severe pulmonary hypertension.)
Baglini, R, Scardulla, C. “Reduction of a previous atrial septostomy in a patient with end-stage pulmonary hypertension by a manually fenestrated device”. Cardiovasc Revasc Med. vol. 11. 2012. pp. 264(This article reviews septoplasty palliation using a fenestrated device technique for patients with pulmonary hypertension.)
Kurzyna, M, Dabroski, M, Bielecki, D. “Atrial septostomy in treatment of end-stage right heart failure in patients with pulmonary hypertension”. Chest. vol. 131. 2007. pp. 977-83. (This article reviews overall results for septoplasty to palliate patients with severe pulmonary hypertension.)
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