Development of a transseptal puncture procedure in horses to access the
left heart: a jugular vein and transhepatic zero fluoroscopy approach
Abstract
Background: Radiofrequency ablation has been successfully
applied to treat right atrial arrhythmias in horses. Ablation of
left-sided arrhythmias requires a retrograde transarterial approach
which is complicated. In human medicine, the left atrium is accessed
through transseptal puncture (TSP) of the fossa ovalis (FO) using a
caudal approach via the femoral vein. Objectives: To develop a
zero fluoroscopy TSP technique for horses using a jugular vein (cranial)
and transhepatic (caudal) approach. Study design: In
vivo experimental study. Methods: Transseptal puncture was
performed in 18 horses admitted for euthanasia and donated for
scientific research under general anaesthesia: using a jugular vein
approach (ten horses), a transhepatic approach (two horses) or both (six
horses). Radiofrequency energy was applied on a guidewire to perforate
the FO and allow sheath advancement under intracardiac and transthoracic
echocardiographic guidance. Puncture lesions were inspected post-mortem.
Results: Transseptal puncture was successful in 17/18 horses,
of which 15/16 jugular vein approaches and 5/8 transhepatic approaches.
Failure was due to technical malfunction, inability to advance the
guidewire towards the heart and inability to advance the sheath through
the FO. Intracardiac echocardiography was essential to safely guide the
puncture process. Atrial arrhythmias caused by the TSP occurred in 13/18
horses. Puncture lesions were found in the right atrium in the FO
region, and in the left atrium ventral to pulmonary vein ostium III.
Main limitations: As in several horses two approaches were
tested consecutively, it cannot be excluded that the second TSP was
performed at the previous puncture site. Due to the developmental nature
of the study the approaches were not randomized and did not allow
comparison. Conclusion: Transseptal puncture is feasible in
horses using ultrasound guidance and allows for electrophysiological
exploration of the left heart. Further studies are needed to evaluate
post-operative follow-up.