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).