Catheterization and Cardiovascular Diagnosis 26:264-265 (1 992)

Feature Topic: Transseptal Technique Update

Editorial Transseptal Catheterization 1992: It Is Here to Stay

David R. Holmes Jr., MD, FACC, FSCAI, and Frank J. Hildner, MD, FACC, FSCAI

Attempts to measure left atrial (LA) pressure date back to the early days of cardiac catheterization when congenital and rheu- matic heart disease attracted the greatest clinical interest. In some instances, investigators found it was possible to pass a catheter through an atrial septal defect or, if no shunt was present, through a foramen ovale that would permit passage of a probing catheter. Techniques involving needle puncture of the right (RV) and left ventricles (LV) had been explored since Reboul and Racine [ I ] used an intercostal anterior parasternal route in dogs in 1933. Reports of direct intercostal, subxiphoid and apical ventricular puncture became frequent beginning with Ponsdomenech and Nunez [2] in 1951. Exploration of entry into the LA by needle puncture paralleled the ventricular experience.

The first systematic clinically useful approach to LA punc- ture, at least from a chronological standpoint, involved poste- rior puncture through a rigid bronchoscope. Once the broncho- scope had reached the canna, a long needle with suitable distal bend was advanced through the device to puncture both the trachea and the LA. Introduced by Facquet et al. [3] in Europe in 1952, use of the method was continued in the United States by Allison and Linden [4] in 1953 and Morrow et al. [5] in 1957. At approximately the same time, in 1954, Radner [6] described an extension of his practice of suprasternal aortic puncture. When the aorta was small, the puncture needle could be passed more deeply and enter the LA selectively. When the aorta was moderate in size or when more physiologic data were desired, measurements from the LA, pulmonary artery and aorta could be obtained in sequence simply by withdrawing the puncture needle. Also at this time, in 1953, Bjork et al. [7] introduced direct posterior paravertebral LA puncture as an alternative to other techniques for measurement of LA pres- sure. Fischer and McCaffrey [8], in 1956, modified the orig- inal method by utilizing a prone position instead of the lateral decubitus, and adding flouroscopic control. Wood et al. [9], in 1956, modified the equipment to allow simultaneous recording of LV and LA pressures. Indeed, most of these techniques were refined, revised, or modified to suit the needs of many investigators [ 101. And while they did allow relatively accurate assessment of pressure, they had the potential for significant complications and were not used as widely as needed.

The clinical need to assess LA pressure in the setting of mitral valve disease or pulmonary hypertension and the need to enter the LV in an antegrade fashion in selected patients with aortic valve disease fostered the development of transseptal catheterization by Ross [ 1 11 and Cope [ 121 in 1959. The orig-

inal method required that a cutdown be made on the saphenous vein so that an 1 1 F catheter could be introduced and passed to the right atrium. Once this was accomplished, a long large- bore (usually 16 gauge) needle was passed through the sheath, positioned against the atrial septum and then pushed through it into the LA. In this position, LA pressures were easily re- corded but LV pressures could be obtained only if a small polyethylene tube passed through the needle into the LV. Sub- sequent passage through the aortic valve was decribed but sel- dom practiced. Because transseptal LA puncture was entirely intraatrial, the potential problems inherent in the external tech- niques such as hemopericardium and wall laceration were sub- stantially reduced. However, the possibilities of right atrial laceration, aortic puncture, and polyethylene tube knotting and shearing were always imminent dangers. Susequently , Brock- enbrough and Braunwald [ 131 introduced a modified transsep- tal method in 1960. This technique used a preformed catheter passed percutaneously into the RA over a standard guide wire. A long needle with a 17-gauge shaft and 20-gauge tip was advanced through the catheter and positioned against the atrial septum. Once puncture was completed and LA pressure doc- umented, the needle was held in place as the catheter was advanced into the LA and usually into the LV. This method has now been superceded by that described by Mullins [I41 in 1977. This percutaneous method allows a soft, thin-walled sheath to enter the LA after puncture and then permits intro- duction of large variety of other devices.

From its inception, transseptal left atrial catheterization has been more demanding, more time-consuming, and associated with the potential for more risks than the other conventional diagnostic right and left heart procedures. It was, nontheless, used widely in a variety of clinical circumstances, both for diagnostic purposes in adults and diagnostic and therapeutic purposes in children. (Creation of atrial septal communications by balloon septostomy was described by Rashkind et al. in 1966 [ 151 and modified to blade septostomy by Park et al. in 1975 [16]). Along with its relatively widespread use, there were several caveats well known to those employing the tech- nique. These included distorted anatomical relationships be- tween the LA, LV, and ascending aorta such as severe LA

From the Mayo Clinic School of Medicine, Rocheseter, Minnesota and, the University of Miami School of Medicine, Miami, Florida.

Received and accepted June 2, 1992.

0 1992 Wiley-Liss, Inc.

Transseptal Catheterization 1992 265

by the operator who has performed 300 to 500 procedures. An operator by that time has learned by experience the nuances that these two articles discuss. Although interesting, the articles then are not necessarily new although they do add excellent and important information. For the person who is just starting the learning curve or is early on the ascending limb, they offer substantial information that can be of help to optimize the procedure and either stay out of trouble or get out of trouble. What, then, is needed for safe, reliable transeptal catheteriza- tion? One needs at least 1) a thorough knowledge of anatomic relationships which these articles undoubtedly enhance, 2) knowledge of the contraindications, and 3) continued perfor- mance of the technique. Operators who perform transeptal procedures only rarely, for example, 1 to 3 times per year, and who do not have experience with hundreds of previous cases, would be better off not doing so, as would their patients.

enlargement, ascending aortic dilatation or aneurysm, dextro- version or dextrocardia and suspected LA thrombus especially during atrial fibrillation. The potential for lethal complications with the early transseptal techniques led to the decline of the procedure. Other new developments also militated against the transseptal approach. These included: I ) the widespread use of pulmonary wedge pressure recording as a surrogate for left atrial pressure; 2) development of extensive clinical skills which allowed for accurate assessment of mitral valve disease and the timing of mitral valve surgery without cardiac cathe- terization every time; 3) recognition that stenotic valves could be safely crossed retrogradely and the aortic valve assessed in that fashion; and finally, 4) the development of increasingly accurate and sophisticated noninvasive evaluation of internal cardiac anatomy and function with echocardiographic tech- niques. The advances and modificatons of the original tech- nique were not enough to keep the technique in widespread general use and a substantial number of cardiologists, perhaps the majority, finished their training during the late 1970’s and the 1980’s without exposure to the technique.

This trend was reversed in the mid and late 1980’s with the development of balloon valvuloplasty. Antegrade aortic valvu- loplasty using a transeptal approach was described and eval- uated, but as the severe limitations of aortic valve dilatation itself were recognized, this approach never played a significant role. On the other hand, mitral valve dilatation has been per- formed with increasing frequency and success in selected pa- tients with mitral stenosis and has become one of the treatments of choice in selected clinical subsets. This, more than anything else, has prompted the resurgence of the transeptal approach.

The two articles by Drs. J-S. Hung and R. Clugston et al. in this issue attest to the interest in the technique and are valuable contributions to the large early clinical series. They expand our knowledge about the approach. Dr. Hung’s approach is to describe accurate scientific methods for ideally positioning the initial puncture to allow subsequent mitral valve dilatation us- ing the Inoue balloon catheter. His experience with over 500 patients forms the basis for his report. Whether the measure- ments used and suggested to optimize the transeptal procedure will be either required, or more importantly, performed rou- tinely, is not at all clear. Such measurements, however, are a useful learning tool and serve well, particularly in patients with very distorted anatomy such as a giant left atrium. Clearly, such an approach has great merit in teaching the technique and understanding it.

Clugston et al. have also added to the literature. Their thrust is to “show that the proper position for locating the area of septal puncture can be selected for the disease process for any given patient and that inadvertent perforations can be avoided.” The details of the procedure are extensively docu- mented. Some of the details about specific equipment such as a “6 inch flexible connecting tube . . .” is not required but reflects the authors’ large experience. Clearly, alternative equipment exists and may be preferred by others. However, the article contains a wealth of information gained from under- standing the dynamic anatomical features in both valvular and congenital heart disease.

What is the role of these two articles? Neither may be needed

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