Abstract
Interatrial septal puncture has become more and more important in the era of percutaneous intervention for structural heart diseases. Some arrhythmia ablation procedures may also require septal puncture. However, septal puncture is probably one of the most risky percutaneous intervention techniques. It may inadvertently perforate the atrial wall or the ascending aorta, leading to cardiac tamponade or even death. Online guidance with TEE can dramatically reduce the risk. Selection of optimal bicaval plane is of paramount importance. The Brockenbrough puncture needle within the Mullin sheath should be managed so that the typical tenting sign can appear on this plane before protruding the puncture needle. Online TEE is also very convenient for guiding balloon commissurotomy in patients with mitral stenosis. It can provide immediate post-dilatation hemodynamic information through Doppler measurements, and reveal flail mitral valve if the chordae have ruptured. It can reduce the risk of cerebral embolism in patients with isolated immobile appendageal thrombus, if they decide to undergo balloon commissurotomy after anticoagulation for more than three months. Importantly it can detect life-threatening complications such as pericardial tamponade promptly and reliably. Indeed, mastering the technique of online TEE guidance is truly rewarding for balloon mitral commissurotomy.
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