Transseptal Group Research Articles

Proximally positioned femoral grafts decrease passive anterior tibial subluxation in anterior cruciate ligament reconstruction using a posterior trans-septal portal.

To compare the anterior and posterior trans-septal (TS) portal approaches in anterior cruciate ligament reconstruction (ACLR) by evaluating femoral tunnel positioning and passive anterior tibial subluxation (PATS). A total of 205 patients who underwent primary ACLR using the outside-in technique between March 2018 and December 2021 were retrospectively enrolled. Patients were classified into two groups based on the viewing techniques: the anterior group was treated using anteromedial or anterolateral portals (n = 155), and the TS group was treated using posterior TS portal (n = 55). The relative locations of the femoral tunnel were evaluated using the deep-shallow planes (X-axis) and superior-inferior planes (Y-axis) with the quadrant method in the lateral femoral condyle on a 3-dimensional computed tomography image. Anterior tibial subluxation for the lateral and medial compartments relative to the femoral condyles was evaluated as measured on magnetic resonance imaging. Knee laxity was assessed using the pivot-shift test and stress radiography. In the posterior TS group, the femoral tunnel was usually located deeper on the X-axis and more superior on the Y-axis, which corresponds to a more proximal position, than in the anterior group (deeper on the X-axis and superior on the Y-axis). Moreover, the femoral tunnel locations in this group were more compactly distributed than those in the anterior group. The TS group showed significantly better reduction of postoperative PATS in the lateral compartments than the anterior group (anterior group vs. TS group: lateral compartment, 3.2 ± 3.1 vs. 4.5 ± 3.2mm; p = .016). Significantly better results were found in the TS group for knee stability as assessed by the pivot-shift grade (p = .044); however, there were no significant differences between the two groups with respect to patient-reported outcome measures (p > .05) and other complications (p = .090). Our results suggest that positioning the femoral tunnel using the posterior TS portal approach may lead to better outcomes in terms of PATS and rotational stability compared to the anterior portal approach in ACLR.

Transseptal approach versus retrograde aortic approach in mapping and ablation of ventricular arrhythmias from anterolateral papillary muscles.

The anterior and lateral position of the anterolateral papillary muscle (ALPM) has found to be reached with better catheter stability and less mechanical bumping via the transseptal (TS) compared to the retrograde aortic (RA) approach. The aim of this study is to compare the TS and RA approaches on mapping and ablation of ventricular arrhythmias (VAs) arising from ALPMs. Thirty-two patients with ALPM-VAs undergoing mapping and ablation via the TS approach were included and compared with 31 patients via the RA approach within the same period. Acute success was compared, as well as other outcomes including misinterpreted mapping results due to bumping, radiofrequency (RF) attempts, procedural time and success rate at 12-month follow-up. Acute success was achieved in more cases in the TS group (96.4% vs. 72.0%, p = .020). During activation mapping, bump-provoked premature ventricular complexes (PVCs) misinterpreted as clinical PVCs were more common in the RA group (30.0% vs. 58.3%, p = .036), leading to more RF attempts (3.5 ± 2.7 vs. 7.2 ± 6.8, p = .006). Suppression of VAs were finally achieved in the unsuccessful cases by changing to the alternative approach, but the procedural time was significantly less in the TS group (90.0 ± 33.0 vs. 113.7 ± 41.1 min, p = .027) with less need to change the approach, although follow-up success rates were similar (75.0% vs. 71.0%, p = .718). A TS rather than RA approach as the initial approach appears to facilitate mapping and ablation of ALPM-VAs, specifically by decreasing the possibility of misleading mapping results caused by bump-provoked PVC, and increase the acute success rate thereby.

PO-03-159 TRANSSEPTAL VERSUS RETROGRADE AORTIC ABLATION OF LEFT-SIDED ACCESSORY PATHWAYS IN PEDIATRIC PATIENTS IN THE MODERN ERA

In the modern era of widespread use of three-dimensional electroanatomical mapping and minimal fluoroscopy, a comparison of the advantages and disadvantages of transseptal (TS) and retrograde aortic (RA) approaches to left-sided accessory pathway ablation in pediatrics has not been performed. The purpose of this study is to evaluate procedural safety and outcomes of catheter ablation via TS versus RA catheterization in pediatric patients with structurally normal heart and left-sided accessory pathways. This is a retrospective single-center chart review of pediatric patients from 2012-2021 at a free-standing children's hospital. This study was approved by our Institution Review Board. Inclusion criteria include age 0-21 years with a structurally normal heart. Exclusion criteria include significant structural heart disease and patients in whom ablation was not attempted. Outcomes assessed include procedural success, complications, recurrence, fluoroscopy exposure, and total ablation time. A total of 161 patients across 160 procedures met inclusion criteria. The median age was 13.5 years ([IQR] 9 - 16) and 40.4% (n=65) were female with median weight of 53.1kg (28.5-66.0). TS was performed in 58.1% (n=93) of procedures, while RA catheterization was performed in the other 41.9% (n=67). There were no significant differences in age, gender, weight, body surface area, or indication for ablation between either approach. Ablation success was achieved in 100.0% (n=67) of TS patients compared to 96.8% (n=90) of RA patients. There were no complications in the TS group and 4 (4.3%) complications in the RA group, with no major complications or mortality for either group. Overall, fluoroless ablation was achieved 79 procedures (50.6%), with zero fluoroscopy achieved in significantly more RA cases compared to TS (70.8% vs 23.9% p<0.001). For patients where follow-up clinic visit data was available (n=98), the median follow-up time was 31.2 (7-83) months. Recurrence was observed in 8 (11.9%) TS patients versus 14 (15.1%) RA patients (p=0.55). In the modern era with three-dimensional mapping and low fluoroscopy, both transseptal and retrograde aortic approaches to left-sided AP ablation in pediatric patients remain equivocally safe and efficacious. Although zero fluoroscopy was achieved in significantly more RA cases, nonsignificant increases in complications and recurrence were also observed in the RA approach compared to TS.

Atrial approaches in mitral valve surgery: a propensity analysis of differences in the incidence of clinically relevant adverse effects

BackgroundThe lack of evidence on complications using mitral valve approaches leaves the choice of risk exposure to the surgeon’s preference, based on individual experience, speed, ease, and quality of exposure.MethodsThe present study analysed patients undergoing mitral valve surgery using a superior transseptal approach or a left-atrial approach between 2006 and 2018. We included first-time elective mitral valve procedures, isolated, or combined, without a history of rhythm disturbances. We used propensity score matching based on 26 perioperative variables. The primary endpoint was the association between the superior transeptal approach and clinically significant adverse outcomes, including arrhythmias, need for a permanent pacemaker, cerebrovascular events, and mortality.ResultsA total of 652 patients met the inclusion criteria; 391 received the left atrial approach, and 261 received the superior transseptal approach. After matching, 96 patients were compared with 69 patients, respectively. The distribution of the preoperative and perioperative variables was similar. There was no difference in the incidence of supraventricular tachyarrhythmias or the need for treatment. The incidence of nodal rhythm (p = 0.008) and length of stay in intensive care (p = 0.04) were higher in the superior transseptal group, but the need for permanent pacemaker implantation was the same. Likewise, there was no difference in the need for anticoagulation due to arrhythmia, the incidence of cerebrovascular events or mortality in the postoperative period or in the long-term follow-up.ConclusionWe did not find an association with permanent heart rhythm disorders or any other significant adverse clinical outcome. Therefore, the superior transeptal approach is useful and safe for mitral valve exposure.

Improved nasal recovery and intact olfactory function after a transseptal approach for endoscopic endonasal transsphenoidal adenomectomy: A retrospective analysis.

Endoscopic endonasal transsphenoidal adenomectomy (TSA) is the most frequently performed skull base surgery, and researchers have recently focused on preserving nasal function. The endoscopic transseptal approach is a promising procedure due to its reduced injury to the nasal mucosa; however, there are no studies comparing rhinological and neurosurgical outcomes concurrently with the standard endoscopic transnasal approach. Therefore, we conducted this study to investigate whether the transseptal approach could reduce nasal morbidities with comparable neurosurgical outcomes. We retrospectively reviewed 25 patients who underwent endoscopic endonasal transseptal TSA for pituitary adenoma without encasement of internal carotid artery from January 2019 to December 2020. Another 25 patients who received transnasal approach from January 2017 to December 2018 were selected as controls. Patients with diseases affecting the nasal cavity/olfaction or usage of a nasoseptal flap were excluded for a better comparison of the two procedures. We collected data from radiological studies, endocrine studies, endoscopic evaluations, 22-item sinonasal outcome tests (SNOT-22) and Top International Biotech Smell Identification Test (TIBSIT) for comparison. Lower postoperative SNOT-22 and Lund-Kennedy endoscopic scores were observed in the transseptal group. The effect size of differences were classified as large effect (The absolute value of Cohen's d > 0.8). Nevertheless, the TIBSIT scores were not significantly different. The rates of gross total resection, recovery of hormonal abnormalities, and complications were not significantly different. After controlling possible confounding factors using multivariate analysis, the endoscopic transseptal approach remained an independent factor for lower SNOT-22 scores and Lund-Kennedy endoscopic scores. The endoscopic transseptal approach provides improved recovery of nasal mucosa and intact olfaction without compromising neurosurgical outcomes. 2b.

Rhythm disorders after isolated mitral valve surgery: Consideration of the variations of the sinoatrial nodal artery in choice of atriotomy.

Background This study aims to investigate the effect of atriotomy approaches applied in mitral valve surgery and variations of the sinoatrial nodal artery on postoperative arrhythmias and the need for a temporary or permanent pacemaker. Methods Data of 241 patients (108 males, 133 females, mean age: 53.7±12.3 years; range, 18 to 82 years) who underwent isolated mitral valve surgery with a median sternotomy between January 2009 and December 2019 were retrospectively analyzed. The patients were divided into three groups according to the surgical approach for mitral valve exploration as left atriotomy (n=47), transseptal (n=131), and superior transseptal (n=63). By scanning the hospital records, the origin of the sinoatrial nodal artery was determined in the coronary angiography images obtained before surgery. Postoperative rhythm changes were analyzed based on electrocardiography and telemetry recordings. Results Temporary pacing was required in 31 (49.2%) patients in the superior transseptal group, 40 (30.5%) patients in the transseptal group, and 12 (25.5%) patients in the left atriotomy group, indicating a statistically significantly higher rate in the superior transseptal group (p=0.013). Permanent pacemaker implantation was required in only one patient (superior transseptal), indicating no significant difference among the groups. The first-degree atrioventricular block was seen in 28 (44.4%) patients in the superior transseptal group, 42 (32.1%) patients in the transseptal group, and 13 (27.7%) patients in the left atriotomy group (p=0.130). The PR interval in the postoperative period was longer in the superior transseptal group than in the left atriotomy group in patients with the sinoatrial nodal artery originating from the right coronary artery (p=0.049). No significant difference was observed among the surgical approaches regarding the PR interval in patients with the sinoatrial nodal artery originating from the left circumflex coronary artery after surgery. Conclusion We believe that the choice of atriotomy in isolated mitral valve surgery and sinoatrial nodal artery variations do not affect permanent arrhythmia alone. Still, the superior transseptal approach causes the electrical conduction to slow down temporarily more than the left atriotomy and transseptal method.

Access options for transcatheter mitral valve implantation in patients with prior surgical bioprosthesis.

Transcatheter mitral valve-in-valve (TMVIV) procedure, either transapical (TA) or trans-septal (TS) has become a valuable alternative to conventional redo surgery in case of failing mitral bioprosthesis with good clinical outcomes. Here we present our fourteen-year institutional experience. All consecutive patients treated with TMVIV with either TA or TS access at our centre between July 2007 and July 2020 were included. Periprocedural and 30-day follow-up (FU) results are reported and TA and TS data are compared. Eighty-two patients were included, of those 60 (73.2%) were TA while 22 (26.8%) were TS. Men represented 51.2% of the population with a mean age of 77.3±9.0 years. STS score and EuroSCORE II were 11.4%±6.2% and 11.5%±6.5% respectively. Baseline characteristics of TA and TS groups were comparable. TMVIV was performed at a median time of 9.3 years [interquartile range (IQR), 7.9-12.0 days] from the initial mitral valve surgery. Balloon expandable transcatheter heart valve (THV) prostheses (Edwards LifeSciences Corp., Irvine, CA, USA) were used exclusively. Technical success was 97.6% (96.7% and 100.0% for TA and TS respectively) with two (2.4%) periprocedural death, both in the TA group (P=0.533). We observed four (4.9%) left ventricular outflow tract (LVOT) obstructions with one being hemodynamically significant. Six (7.3%) major bleeding occurred in the TA group, not significantly different from TS group (P=0.279). The median length of stay was 6 days (IQR, 4-12 days, 1.5 vs. 7.0 days for TS and TA groups respectively, P=0.001). The overall 30-day mortality rate was 3.7%. We also observed three (3.7%) structural valve deteriorations and in one (1.2%) case the patient required redo mitral surgery at two months. Eighty-seven-point-eight percent of patients were I-II New York Heart Association (NYHA) class. At 30-day FU mean transmitral valve gradient was 7.3±2.7 mmHg and one patient (1.2%) had mitral regurgitation greater than mild. TA and TS groups were comparable. Our 14-year single-center experience with TMVIV confirms procedural safety and is an effective alternative to redo surgery with comparable results with both TA and TS. With device, technical improvements and increasing operators' experience, TS is the preferred option for TMVIV. However, in some highly selected patient, TA may still play an important role.

Application of transseptal puncture to radiofrequency catheter ablation in children with left accessory pathway induced paroxysmal supraventricular tachycardia

Objective To explore the value of transseptal puncture for left-sided accessory pathway in radiofrequency catheter ablation in children with paroxysmal supraventricular tachycardia(PSVT). Methods Thirty-three patients with PSVT who had underwent radiofrequency catheter ablation in the First Affiliated Hospital, Sun Yat-Sen University from January 2012 to December 2017 were retrospectively analyzed.All the cases were treated by transaortic approach(transaortic group) or transseptal approach(transseptal group). The immediate success rates, total fluoroscopy time and radiation exposure between 2 groups were compared, and the perioperative complications and recurrence rates were observed between 2 groups. Results Thirty-three cases of children were enrolled, 22 cases were male and 11 cases were female.Nineteen cases were treated by transaortic approach(transaortic group), while 18 cases were treated by transseptal approach(transseptal group), including 4 recurrent cases in the transaortic group who were switched to transseptal approach because of previous treatment failure.The age was (10.16±3.06) years and (10.67±2.20) years, and the weight was (37.68±14.28) kg and (37.33±8.64) kg, respectively.There were no significant diffe-rences in age and weight statistics between 2 groups(all P>0.05). The total fluoroscopy time was (20.16±11.41) minutes and (12.56±5.23) minutes, and the median dose of radiation exposure was 67.0 mGy and 33.5 mGy, respectively.The postoperative recurrence rate was 21% (4/19 cases) and 0 (0/18 cases), respectively.There were significant differences in total fluoroscopy time, radiation exposure and recurrence rate statistics between 2 groups(t=2.627, Z=-2.31, χ2=4.249, all P<0.05). No complications were found in both 2 groups. Conclusions It is safe and feasible by transseptal puncture for left-sided accessory pathway in radiofrequency catheter ablation in children with PSVT.Radiofrequency catheter ablation by transseptal approach could significantly reduce the postoperative recu-rrence rate, and should be the first choice for left-side accessory pathway in children. Key words: Child; Paroxysmal supraventricular tachycardia; Transseptal puncture; Left-sided accessory pathway; Catheter ablation

Comparison of Left Atriotomy and Superior Transseptal Approaches in Mitral Valve Surgery.

To compare the operative and post-operative outcomes of mitral valve surgery (MVS) with a superior transseptal (STS) approach and a left atriotomy (LA) approach. In a tertiary academic center, the charts of patients who underwent MVS between 2012 and 2016 were analyzed retrospectively. A total of 135 patients underwent MVS. Forty patients who underwent MVS with the STS approach were enrolled in the study as the STS group. In the same period, we selected 40 patients who underwent MVS with the LA approach to serve as the control group (LA group). Two groups were operated by the same surgeon. To minimize the bias related to the lack of randomization in this observational study, LA group patients were selected using propensity score matching. According to the study design, the preoperative characteristics of gender, age, mitral valve stenosis, and mitral valve insufficiency were matched (P = .368, P = .920, P = .250 and P = .057, respectively). The cardiopulmonary bypass time was 91.2 ± 12.1 minutes in the superior transseptal group and 72.8 ± 6.4 minutes in the left atriotomy group (P < .001). Additionally, duration of clamp time was significantly shorter in the left atriotomy group (P < .001). Estimated blood loss was significantly less in patients with a left atriotomy (535.8 ml versus 658.0 mL, P < .001). Duration of intensive care unit stay and hospitalization time were significantly longer in patients who underwent the superior transseptal approach compared with patients who underwent left atriotomy (P < .001 versus P < .001, respectively). Post-operative dysrhythmia rate and mortality rate were similar between the groups. Our study demonstrated that MVS with LA decreased cardiopulmonary bypass time, duration of clamp time, amount of hemorrhage, duration of intensive care unit stay, and hospitalization time compared with MVS with STS.

Utility and safety of the SafeSept™ transseptal guidewire for electrophysiology studies with catheter ablation in pediatric and congenital heart disease.

The atrial transseptal procedure is used in catheter ablation of left-sided arrhythmias. Studies in adult patients have shown the SafeSept™ transseptal guidewire (SSTG) to be effective in atrial transseptal procedures. We analyzed our 5-year experience with SSTG use in pediatric and congenital heart disease patients undergoing catheter ablation. This is a single-center retrospective analysis of patients undergoing catheter ablation from 2009 to 2014. We identified all procedures where SSTG was used for atrial transseptal or trans-baffle access. Success of transseptal access and complications were recorded and compared to the standard transseptal approach without the SSTG. One hundred twenty-seven patients underwent 132 attempted atrial transseptal or trans-baffle procedures using SSTG. Median age was 14 (1.2-38) years. Arrhythmia substrates included AV reentrant tachycardia (90.2%), atrial tachycardia (4.5%), ventricular tachycardia (2.3%), and AV nodal reentrant tachycardia (2.3%). Transseptal or trans-baffle access was successful in 96.2% of the SSTG cases compared to 98.9% in the standard transseptal group without SSTG (p = NS). The youngest patient with successful atrial transseptal procedure using SSTG was 4years old. SSTG was used to successfully cross a surgically created atrial baffle in a patient who had undergone the Mustard procedure. There was one major complication in both groups, 0.8% in the SSTG group compared to the standard transseptal group without SSTG, 1.1% (p = NS). The major complication in the SSTG group occurred when the SSTG crossed the aorta into the coronary artery system and mimicked placement in the left atrial appendage, with subsequent placement of a transseptal sheath into the aorta, requiring sternotomy and surgical intervention. SSTG is effective for use in atrial transseptal and surgical trans-baffle access in pediatric and congenital heart disease patients. Placement of the SSTG into the pulmonary vein is necessary to avoid major complications, and if not achieved requires additional methods to determine appropriate left atrial placement.

Accuracy and Reproducibility of the Femoral Tunnel With Different Viewing Techniques in the ACL Reconstruction

The purpose of this study was to compare the accuracy and reproducibility of the femoral tunnel location among 3 different viewing techniques used during outside-in anterior cruciate ligament (ACL) reconstruction with 3- dimensional (3-D) computed tomography (CT): (1) an anterolateral (AL) or anteromedial (AM) portal with a 30° arthroscope (A group) vs (2) a posterolateral (PL) portal with a 70° arthroscope (PL group) vs (3) a trans-septal (TS) portal with a 30° arthroscope (TS group). A total of 106 patients undergoing outside-in ACL reconstruction were recruited. Patients were divided into 3 groups according to viewing technique (A group=36 patients; PL group=35 patients; TS group=35 patients). Femoral tunnel locations were evaluated with the quadrant method and the anatomic coordinate axes measurement (ACAM) method in the medial wall of the lateral femoral condyle using 3-D reconstructed CT. The accuracy and reproducibility of the femoral tunnel locations were compared among the 3 techniques. The accuracy of the tunnel location was higher in the TS group by the quadrant method as well as the ACAM method. The reproducibility of the femoral tunnel position in the TS group was the highest, and the femoral tunnel locations of the TS group were more compactly distributed compared with those of the A and PL groups. The accuracy and reproducibility of the femoral tunnel location could be improved with a TS portal viewed using a 30° arthroscope. Anteromedial/anterolateral and PL portals viewed using a 70° arthroscope showed no difference. [Orthopedics. 2016; 39(6):e1085-e1091.].

Abstract 17014: Getting to Zero: Impact of Electroanatomical Mapping on Fluoroscopy Use in Pediatric Catheter Ablation

Introduction: Over the past several years, alternative imaging techniques including electroanatomic mapping systems such as CARTO®3 (C3) have been developed to improve anatomic resolution and potentially limit radiation exposure in electrophysiology (EP) procedures. We retrospectively examined the effect of the introduction of C3 on patient radiation exposure during EP studies and ablation procedures at a children’s hospital. Methods: All patients that underwent EP and ablation procedures between January 2012 and November 2014 were included; demographic information, fluoroscopy time in minutes (FT), total radiation dose in mGy (RAD), and dose-area product in μGy/m2 (DAP) were collected. Patients were stratified by time period (before vs. after C3 introduction), structural group (normal heart, congenital heart disease (CHD), and those with normal cardiac anatomy requiring trans-septal (TS) access), and arrhythmia diagnosis (Accessory Pathway (AP), AV Nodal Reentry Tachycardia (AVNRT), atrial, or ventricular arrhythmia). Mean values were compared using a single sample t-test, as well as analysis of covariance to control for age, weight, and arrhythmia diagnosis. Results: Mean FT decreased after the introduction of C3 in patients with normal hearts (p&lt;0.001), AP (p&lt;0.001), AVNRT (p=0.002), and CHD (p=0.007). After controlling for age, weight, and arrhythmia diagnosis, there was a statistically significant decrease in FT in all three groups (normal heart, CHD and TS), in RAD in the TS group, and in DAP in both the normal heart and TS groups. In all other groups, there was a trend towards decreased RAD and DAP, but they did not reach statistical significance. After the introduction of C3, zero fluoroscopy was achieved in 18/66 (27%) and ≤ 1 minute of FT in 28/66 (42%) of ablation procedures in patients with normal hearts. Conclusions: We have shown a decrease in all metrics that measure radiation exposure when comparing the time periods before and after the introduction of C3, secondary to reducing fluoroscopy time, fluoroscopic pulse rate and radiation dose per pulse. Further refinements are still needed to decrease radiation exposure towards the goal of zero fluoroscopy, but this cannot be achieved without thinking beyond fluoroscopy time.

Comparison of totally occlusive nasal pack, internal nasal splint, and transseptal suture technique after septoplasty in terms of immediate respiratory distress related to anesthesia and surgical complications

Conclusion: The patients who underwent septoplasty with bilateral totally occlusive nasal packing had an increased risk of experiencing respiratory distress (RD). Objective: To compare the immediate RD rates during recovery from anesthesia and surgical complications of totally occlusive nasal pack, internal nasal splint, and transseptal suture technique. Methods: A total of 150 patients were assigned to one of three groups according to the technique utilized following septoplasty: transseptal suturing, internal nasal splint, or Merocel (nasal dressing without airway). To determine RD related to anesthesia in the operating theatre, the criterion was defined as any unanticipated hypoxemia, hypoventilation or upper airway obstruction (stridor or laryngospasm) requiring an active and specific intervention. Postoperative hemorrhage, infection, synechia formation, and septal perforation were evaluated. Results: Patients in the Merocel group were 3.6 times more likely to have RD than patients in the transseptal suture and internal nasal splint groups. Also, patients who smoked had an increased risk of RD during the recovery phase of anesthesia after the septoplasty. In addition, all three techniques resulted in similar complication rates after septoplasty, with the exception of minor hemorrhage, which had a significantly higher rate in the transseptal suture group.

Antegrade Side Branch Access in Branched Aortic Arch Endografts: A Porcine Feasibility Study

To describe the deployment technique for a single side branch arch endograft in a porcine model and prove the concept of transseptal or transapical antegrade access for catheterization and introduction of the mating stent-graft. Six domestic pigs were operated with retrograde delivery of a single side branch arch endograft and antegrade introduction of a mating stent-graft using transseptal access (n=3) and transapical access (n=3). Technical feasibility, operating time, radiation parameters, and hemodynamic changes were studied. Transseptal and transapical access techniques were feasible in all animals. Catheterization and introduction of the mating stent-graft was feasible in 2 of 3 animals in the transseptal group and all animals in the transapical group. Technical feasibility was better in the transapical group, with shorter operating and fluoroscopy times and less hemodynamic impact during endograft deployment. Hemodynamic changes were short and reversible in all animals in both groups. Antegrade transcardiac access to the aortic arch for implantation of mating stent-grafts in branched arch endografting is feasible in a porcine model with reversible impact on hemodynamic measures during deployment. Transapical access was technically easier, with shorter operating and fluoroscopy times.

Nasal packing and transseptal suturing techniques: surgical and anaesthetic perspectives

The objective of this study is to compare the nasal packing and the transseptal suturing techniques regarding the extubation difficulty evaluation scores, follow-up times in post-anaesthesia care unit (PACU), pain scores, and postoperative complications. Two hundred patients who underwent septoplasty from January 2009 to October 2009 were randomly assigned either to have nasal packs (n: 100) or transeptal sutures (n: 100). In the transseptal suture group, extubation was easier and PACU follow-up times were shorter, when compared to the nasal packing group (p < 0.001). Patients with nasal packing had significantly higher pain scores (p < 0.001). Minor bleeding was significantly higher in the transseptal group with seven cases, compared to the nasal packing group without any bleeding cases (p = 0.014). There were two patients who had postoperative major bleeding, and two patients who had septal hematoma in the transseptal suture group. One patient with nasal packing had postoperative infection. Septal perforation was not seen in any of the cases. While patients in both groups experienced postoperative crusting, patients in the transseptal suture group also complained about foreign body sensation. Extubation was more comfortable; post-anaesthesia monitorization duration was shorter, and postoperative pain was less, but minor bleeding was seen more with transseptal sutures. There was no significant difference in terms of major bleeding, hematoma, infection or perforation. Foreign body sensation was the main cause of postoperative discomfort in the transseptal suture group. Transseptal suturing might be a significantly comfortable, cost-effective and reliable alternative to nasal packing.

Impact of Patent Foramen Ovale on Left Atrial Linear Lesions in the Context of Atrial Fibrillation Ablation

We investigated the impact of the mode of left atrial (LA) access via patent foramen ovale (PFO) versus transseptal (TS) puncture on LA linear lesions during atrial fibrillation (AF) ablation. We investigated 139 (PFO: 25) consecutive patients who underwent mitral isthmus (MI) and/or LA roof linear ablation. Technical endpoint was completeness of linear lesions and duration of radiofrequency (RF) application. During the initial procedure, complete MI and LA roof blocks were created in 13 of 19 (68%) and 14 of 17 (82%) patients in the PFO group, and in 57 of 94 (61%) and 54 of 70 (74%) patients in the TS group, respectively (P = NS). There was no significant difference in RF durations at MI (11.1 ± 8.9 and 15.1 ± 7.6 minutes, P = 0.11), and LA roof (10.1 ± 3.5 and 8.3 ± 5.0 minutes, P = 0.21) between the 2 groups. Among 28 patients who underwent repeat linear ablation, complete MI and LA roof blocks were created in 3 of 4 (75%) and 0 of 1 (0%) patients in the PFO group, and in 16 of 21 (76%) and 7 of 10 (70%) patients in the TS group, respectively (P = NS). There was no significant difference in RF durations at MI (15.3 ± 8.3 and 19.5 ± 18.3 minutes, P = 0.71), and LA roof (19.0 and 10.3 ± 5.4 minutes, P = 0.19) between the 2 groups. Clinical outcomes at 12 months were also similar. There were no significant differences in the procedural success rates, durations of RF application, 12-month clinical outcomes, and complication rates of LA linear ablation between the PFO and TS groups. Accessing the LA via a PFO is not an unfavorable approach toward LA linear ablation.

A Randomized Comparison of Transseptal and Transaortic Approaches for Magnetically Guided Ablation of Left-Sided Accessory Pathways

Radiofrequency catheter ablation of left-sided accessory pathways (APs) can be performed either by a transseptal (TS) or transaortic (TA) approach. When performed manually, these techniques are equally effective. The aim of this prospective randomized study was to compare these approaches using a magnetic navigation system (MNS) (Niobe, Stereotaxis, St. Louis, MO, USA). Twenty-two consecutive patients were randomized to undergo ablation of a left-sided AP by either a TS or a TA approach. The MNS was used in all patients for catheter navigation and eventual ablation, after electrophysiology study (EPS) confirmed the presence of left-sided APs. Crossover was allowed after failure of the initial approach. Success rates, procedure, fluoroscopy, and ablation times were compared. Of 11 procedures, 10 (91%) were successful in the TS group. The patient crossed over to the TA approach remained unsuccessful. Successful elimination of the AP was obtained in nine (82%) of 11 of the TA procedures. Of the two patients who crossed over to a TS procedure in the same session, one was successful and one remained unsuccessful. Total procedure time did not differ in both groups (87.1 ± 30.8 vs 90.9 ± 26.5 minutes). When total procedure and patient fluoroscopy times were divided into EPS time, time to first application, to successful application, and time to perform TS puncture or to retrogradely cross the aortic valve, only the last measurement differed significantly for both groups (P < 0.01). Ablation times were comparable in both groups. No major complications occurred. Our data show that TS and TA approaches are equal in success rate and total procedure, patient fluoroscopy, and ablation time when using the MNS for left-sided AP ablation. However, crossing the aortic valve with the MNS is faster than completing a TS puncture.

Transseptal versus transaortic approach for radiofrequency ablation in patients with cardioverter–defibrillator and electrical storm

Radiofrequency current ablation (RFCA) of ventricular tachycardia (VT) is usually performed using a retrograde transaortic approach. We compared the mapping accuracy, procedural course, safety, and results of VT ablation using transseptal and transaortic route. Twenty-one consecutive patients with ischemic cardiomyopathy and history of electrical storm underwent RFCA with electro-anatomic mapping system. In six patients, ablation was performed with transseptal approach (transseptal group); in 15, retrograde approach to the left ventricle was used (retrograde group). The endocardial surface of the left ventricle was similarly accessible in both methods. Less detailed maps of interventricular septum were constructed with the use of transseptal approach. The RFCA success rate was similar in the transseptal and retrograde groups (83 vs. 80%, p = NS). The median procedural time was 112 min in transseptal vs. 145 min in the retrograde group; radiation exposure was 200 vs. 67 mGy, respectively (both p < 0.05), and fluoroscopy time was 22 vs.16 min (p = NS). During the 3-month follow-up, VT recurrence occurred in one patient in the transseptal group and in three patients in the retrograde group (p = NS). Transseptal approach is an accurate, safe, feasible, and effective method of RF ablation in patients with malignant, recurrent ventricular arrhythmias. However, limited access to the septal regions with the use of this method has to be remembered. Transseptal approach may be considered as an alternative to the transaortic route in patients with contraindication to the latter.

Transseptal technique of percutaneous PFO closure results in persistent interatrial shunting

Our goal was to review the effectiveness of the transseptal and tunnel techniques of patent foramen ovale (PFO) closure. Percutaneous PFO closure is an increasingly common treatment for prevention of paradoxical embolism and is typically performed by passing the device through the defect tunnel itself. The transseptal technique, in which the septum primum is punctured to create a hole through which the device is passed, has been proposed for patients with long-tunnel PFO. From May 2001 to December 2003, 120 patients underwent PFO closure at our institution and were included in this analysis. Defect closure was assessed by transesophageal echocardiography (TEE) with bubble study. Clinical follow-up data were obtained by clinic visits or standardized telephone interviews. Device closure was successfully completed in all patients, with 12 (10%) undergoing transseptal closure and 108 (90%) undergoing tunnel closure. Immediately following the procedure, complete closure occurred in 6 of 12 (50%) of the transseptal group and 88 of 108 (81.5%) of the tunnel group (P = 0.0120). Of the 89 patients (74.2%) who returned for 6-month TEE, complete closure was demonstrated in 4 out of 10 (40%) of the transseptal group and 58 out of 79 (73.4%) of the tunnel group (P = 0.0303). There have been four transient ischemic attacks during a mean follow-up of 11 months. The transseptal technique of PFO closure results in a higher proportion of patients with persistent interatrial shunting when compared with the tunnel technique. Whether this is due to a difference in technique, device, or patient anatomy is unclear.

Combined superior-transseptal approach versus conventional approach for mitral valve surgery.

This study was designed to evaluate the safety and effectiveness of the combined superior-transseptal approach for mitral valve surgery. We compared the preoperative status, operative factors, and postoperative outcomes among patients having mitral valve operations with three atrial incisions. The incisions were transseptal (n = 40), combined superior-transseptal (n = 33), and left atrial (n = 22). The cardiopulmonary bypass time and cross-clamp time were significantly higher in the superior-transseptal group compared with the transseptal group. No significant difference in blood loss was found among the three groups. The incidence of sinus node dysfunction in the early postoperative period was more common in the superior-transseptal group. The maintenance of sinus rhythm at the mid-term follow-up in patients with preoperative sinus rhythm was not significantly different among the three groups. On the other hand, a few patients in the superior-transseptal and transseptal groups with the preoperative sinus rhythm developed sick sinus syndrome requiring permanent pacemaker implantation. The use of the combined superior-transseptal approach was safe and effective, and was not associated with a higher incidence of rhythm disturbance. Because this approach provided an optimal exposure of the mitral valve and subvalvular apparatus, it has been positively adopted for use in patients undergoing complex and difficult mitral valve operation. To use this approach for patients undergoing mitral valve surgery through this approach, however, further follow-up study of the sinus node function is necessary.