Feasibility, efficacy, and safety of intracardiac echocardiography guided transseptal puncture: a single-center retrospective study
Authors: Prolic Kalinsek T , Rauber M , Podlogar V , Antolic B , Topalovic M , Klemen L , Stublar J , Vrbanjscak M , Pernat A , Lakic N , Kuhelj D , Jan M 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Transseptal puncture (TSP) is routinely performed to gain access into the left atrium for left-sided arrhythmias. Although fluoroscopy is mainly used for visualization of TSP, intracardiac echocardiography has been increasingly used to visualize the TSP. However, the available data to support routine use of ICE for visualization is scarce, particularly for pediatric patients and patients with cardiac implantable electronic devices (CIED).

Purpose
The purpose of this single-center retrospective study was to evaluate feasibility, efficacy, and safety of ICE guided TSP, also including pediatric patients and patients with CIED.

Methods
In this retrospective study, we analyzed consecutive patients who underwent ICE guided TSP from July 2014 to December 2021. When TSP was performed in patients with CIED, the device´s parameters were tested before and after the procedure. Adverse events (AE) were classified as those that were directly associated with the TSP and those who might be associated with the TSP. All AE either required an intervention, prolonged hospital stay, or had a negative impact on patient´s health.

Results
The study included 1360 consecutive patients (44.6% (607/1360) male; mean age 59.1 ± 15.6 years; mean BMI 28.1 ± 5.0 kg/m2), 4.3% (59/1360) of patients were pediatric (the youngest was 4 years old and weighed 17 kg) and 8.9% had a CIED (121/1360 – 56.2% (68/121) single chamber; 33.1% (40/121) dual chamber; 10.7% (13/121) resynchronization device). In majority, atrial fibrillation or atypical atrial flutter were the main indication for TSP (75.4%; 1062/1360), followed by ventricular tachycardia (9.4%; 128/1360), ventricular preexcitation (8.8%; 120/1360), and atrial tachycardia (3.5%; 47/1360). A total of 1839 punctures were performed (64.3% (875/1360) single TSP; 35.7% (485/1360) double TSP). Only in two patients (0.14%; 2/1360) the TSP was initially not possible. In one, it was later performed with radiofrequency needle. In total, there were 0.7% (13/1839) of AE. Two events (0.11%; 2/1839) were directly associated with the TSP. In one patient, a tamponade occurred immediately after a double TSP. In another patient with a dual chamber CIED, the ventricular lead was dislocated during the maneuvering of the TSP assembly. The other 11 events (0.6%; 11/1839 - 2 late tamponades and 9 pericardial effusions) could be associated with the TSP, however, they could also be associated with ablations or maneuvering of the catheters. In patients with CIED, there were 3 AE (2.1%; 3/144) – 1 AE was directly associated with the TSP (ventricular lead dislocation described above) and 2 AE which might be associated with the TSP (1 late tamponade and 1 pericardial effusion). There were no AE (0.0%; 0/60) in pediatric patients.

Conclusion
ICE guided TSP is an effective and safe method for obtaining left atrial access in adult and pediatric patients. Special care should be given to patients with CIED as lead dislocation is possible.