Difficult transseptal puncture
Anticipation and definition of difficult TSP is challenging even with
additional preprocedural cardiac imaging. Previous AF ablation
procedures and prior surgical or percutaneous interventions in the IAS
area increase the risk for difficult TSP (5, 15, 16). Although punctures
with the aid of the RF needle technique that could be considered
difficult in our study were low, we experienced no safety or efficacy
issues with fluoroless ICE-guided approach. There were two patients in
whom difficult TSP could be anticipated: one had previous transseptal
access for AF ablation and second had prior surgical procedure on IAS.
On the other hand, we can speculate that direct visualization of soft
tissue structures and anatomical variations with ICE provides better
reassurance of optimal puncture site compared to fluoroscopy and reduces
the number of potentially difficult TSPs. Consequently, difficult cases
could be reduced to just cases with stiff or thickened IAS / oval fossa
where RF needle technique can be utilized to increase safety and
efficacy (10).