Figure 1. Intracardiac echocardiography-guided workflow for achieving transseptal access.
Images obtained with the ICE probe placed in the right atrium with added simplified graphic image in each panel for clarification. Panels A to H show consecutive steps in achieving transseptal access. The guide wire is marked with a red arrow in ICE images and represented with the red line in graphic images, the tip of the dilator is marked with a purple arrow in ICE images and represented with a purple line in graphic images, the tip of the transseptal needle is marked with a white arrow ICE images and represented with a black line in graphic images, the tip of the long sheath is marked a green arrow in ICE images and represented with a bolded green line in graphic images. VCS superior vena cava, PA pulmonary artery, RA right atrium, LA left atrium, FO oval fossa, LSPV left superior pulmonary vein.
A The guide wire is inserted into the VCS. B The long sheath with the dilator inserted is advanced into the VCS over the guide wire. C The guide wire is replaced with the transseptal needle and the long sheath / dilator / transseptal needle assembly is withdrawn toward the interatrial septum. D The tip of the dilator falls on the oval fossa and its “tenting” can be seen. E The transseptal needle is pushed through the dilator and advanced into the LA cavity together with the tip of the dilator. F The transseptal needle is withdrawn and the tip of the dilator remains in the LA cavity. G The guide wire is advanced through the dilator into the LSPV. H The long sheath and the dilator are advanced over the guide wire into the LA cavity. The guide wire and the dilator are withdrawn with the tip of the long sheath remaining in the LA cavity.