Transseptal puncture using electroanatomical mapping: a safe and cost-effective technique

Abstract

Abstract Background The usual technique of transseptal puncture (TSP) uses fluoroscopy or intracardiac echocardiography. New techniques for oval fossa (OF) identification by electroanatomical mapping (EAM) have been described. However, the technique of direct visualization of the TSP needle added to the OF location by impedance mapping has not been investigated yet. Purpose To evaluate feasibility and safety of the TSP technique guided by the interatrial septum (IAS) impedance mapping and the TSP needle visualization using EAM system. Methods Consecutive patients who underwent ablation using TSP in July and August 2022 in our institute were included. The standard material for the procedure was used in addition to a temporary pacemaker (PM) connection cable. In all cases, the EAM system was CARTO 3 version 7 (Biosense Webster and a bipolar voltage map of right atrium and a impedance map of the IAS were constructed. The OF location was estimated based on the septal region with the lowest impedance and on traditional anatomical landmarks. Using a temporary PM cable connected to the proximal part of the TSP needle stylet, it was possible to visualize its distal portion on the 3D map used to guide the TSP. The entire process was simultaneously monitored under fluoroscopic visualization by an experienced professional. Results A total of 25 patients were included; mean age of 56 +/- 15 years, 16 (64%) were male. The most frequent procedure was atrial fibrillation ablation (86%); left atrium mean size of 40,26 +/- 5,2 mm. 9 patients (36%) were already submetted to a previous procedure using TSP. None of the patients had congenital heart disease. In all cases, the TSP was successfully performed and a correlation between the anatomical references and the lowest impedance region on the map was observed. There were no complications. Conclusion The technique of visualization of the TSP needle using EAM system added to IAS impedance mapping and use of anatomical markers seems to be a safe and cost-effective alternative for performing TSP. This technique could reduce ionizing radiation without need for additional materials.Impedance map and bipolar voltage mapLA (bipolar voltage map) and TSP orifice