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.