A useful reassuring sign for performing a safe second transseptal puncture

Excerpt

Radiofrequency ablation for atrial fibrillation generally requires two transseptal sheaths to deliver a multipolar mapping catheter and an ablation catheter into the left atrium. Transseptal access using the SafeSept transseptal guidewire (Pressure Products, San Pedro, CA) is safe and has become common in current practice in many electrophysiology laboratories. In order to safely utilize the SafeSept wire, it should be placed in a left pulmonary vein (PV); however, it is not always easy to navigate the wire into the left PVs. Here, we describe a reassuring sign for a safe second transseptal puncture utilizing the SafeSept guidewire. We place the first transseptal sheath (EZ Cross, Boston Scientific, Marlborough, MA) guided by fluoroscopy, pressure monitoring, and advancement of the SafeSept guidewire through a BRK-1 needle into the left PV beyond the cardiac silhouette. We then advance the multipolar mapping catheter (PentaRay, Biosense Webester, Inc., Diamond Bar, CA) into the left upper pulmonary vein and proceed with the second transseptal puncture using an Agilis sheath (Abbott Laboratories, St. Paul, MN) and the SafeSept guidewire. When the SafeSept guidewire physically interacts with the poles of the mapping catheter (Fig. 1a), it creates noise on the mapping catheter (Fig. 1b), which is reproducible. Once this sign is present, a second transseptal puncture can be safely performed since it assures that the SafeSept resides in the left atrium. We have utilized this sign for over 200 transseptal punctures from Jan, 2015, to March, 2018, with no complications of cardiac tamponade or failed transseptal access.

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