Intracardiac echocardiography-guided transseptal puncture
First, the ICE probe was advanced from the femoral vein into the right
atrium. ICE probe was then further advanced into the right ventricle and
the right ventricular outflow tract to visualize left atrial appendage
and exclude the presence of possible thrombotic masses. Subsequent
entirely ICE-guided workflow for achieving transseptal access is shown
in Figure 1.
ICE was used to visualize the position of the guide wire and later the
position and the course of the long sheath / dilator / transseptal
needle assembly during the pull-down maneuver. Amid this maneuver the
aortic root, pulmonary veins and the interatrial septum were used as
landmarks which were repeatedly visualized with a slight clockwise or
counterclockwise rotation of the ICE probe. Postero-inferior part of the
oval fossa just opposite to the posterior aspect of the left pulmonary
vein antrum was the target for landing the dilator tip in preparation
for the TSP. ICE was also used to confirm the presence, orientation and
exact location of the transseptal needle tip, the dilator tip, the long
sheath tip and the guide wire in the left atrial cavity during different
stages of transseptal puncture.
In addition, ICE was used to monitor the pericardial space during the
procedure in a case of chest discomfort or arterial pressure drop. This
was achieved with advancing the ICE probe into the right ventricle and
rotating it clockwise until left ventricular cavity and surrounding
pericardial space were visualized.