Transseptal catheterization for ablation in the left heart: what to do when the door is locked up tight?

Abstract

This editorial refers to ‘Feasibility, safety, and outcome of a challenging transseptal puncture facilitated by radiofrequency energy delivery: a prospective single-centre study' by L. Capulzini et al ., on page 662. In January 1992, I was in my second year out of training and one day I was involved in the ablation procedure in a patient with a manifest left-sided accessory pathway. After having positioned the catheter and performed the baseline electrophysiological study, it was time to move on to ablation, definitely not routine practice at that time. Accidentally, the steerable catheter entered the left atrium through a patent foramen ovale and to everybody's surprise it was easy to deflect the catheter, reach the target site with a suitable signal and interrupt accessory pathway conduction with the first radiofrequency energy application. This came after months of struggling beneath the mitral valve to reach the site suitable for ablation of left-sided accessory pathways using a transaortic approach. It also demonstrated how access to the left atrium through the atrial septum was immensely useful in some cases. That unexpectedly quick and successful procedure, together with other considerations, stimulated our group to become familiar with the transseptal catheterization (TSP-C), since we could not count on a patent foramen ovale which is present in ∼15–20% patients, usually when not needed. At that time, only a few interventional cardiologists were adequately trained in TSP-C, there was no compulsive need to access the left atrium for ablation purpose with the exception of some cases of left atrial tachycardia, and there was an aura of diffidence around this procedure, known as a possible source of life-threatening intra-procedure complications. Since then, many things have changed and, in recent years, TSP-C has become part of the technical armamentarium of the interventional electrophysiologist. During the pulmonary vein ablation procedure, it represents … *Corresponding author. Tel: +39 0332 278934; fax: +39 0332 393644, Email: rdeponti{at}alice.it