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Balloon Septoplasty for Left Atrial Transseptal Access
Study Questions:
What is the role of atrial balloon septoplasty (ABS) in patients with difficult transseptal catheterization?
Methods:
ABS was performed in patients (n = 15 [0.17% of all cases], 2 centers, over 6 years) to facilitate transseptal catheterization and catheter ablation of atrial fibrillation (AF). Nine patients had previously undergone surgical (n = 7) or percutaneous (n = 2) closure of an atrial septal defect (ASD). Prior transseptal catheterization had been performed in 13 patients. Intracardiac echocardiography was used to guide the transseptal puncture. When the sheath could not be advanced into the left atrium (LA) over the transseptal needle, the operators first attempted to track the assembly over a stiff guidewire. When this and other approaches failed, they proceeded with ABS.
Results:
A noncompliant dilatation catheter (0.035 inch; diameter, 4-10 mm; length, 2-15 mm) was advanced over the wire and positioned across the interatrial septum. Dilatation of the septum required 1-6 inflations at 4-14 atmospheres. The sheath was then advanced (after balloon deflation) into the LA. The ABS portion required about 21 minutes (total procedure time, 241 minutes). There were no acute complications related to septoplasty. An echocardiogram was performed in 14 patients (93%) at some point during follow-up and revealed a residual ASD in one patient.
Conclusions:
The authors concluded that ABS is safe and effective in facilitating LA access in patients with thickened/scarred interatrial septum and those who have previously undergone closure of an ASD.
Perspective:
Transseptal catheterization using intracardiac echocardiography can be performed in the vast majority of patients within a few minutes. However, it may be challenging to gain LA access in some owing to a thickened interatrial septum (related to prior LA procedures), surgical or percutaneous closure of an ASD, and aneurysmal configuration of the septum. Even in these cases, LA access can be achieved with stiffened wires, serial dilatation, and perseverance. The authors highlight the role of balloon septoplasty in situations where conventional tools and tricks are ineffective.
Keywords: Angioplasty, Balloon, Arrhythmias, Cardiac, Atrial Fibrillation, Atrial Septum, Cardiac Surgical Procedures, Cardiology Interventions, Catheter Ablation, Catheterization, Dilatation, Echocardiography, Heart Septal Defects, Atrial
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