Intracardiac echocardiography-guided transseptal puncture
To facilitate TSP, ICE or TEE are used as additional imaging tools when difficult anatomy is encountered during fluoroscopy-guided TSP (5,6). Although cost-effectiveness in routine practice compared to TEE is unclear, ICE has additional advantages of not requiring a second operator, general anesthesia and provides better acoustic window. Furthermore, integration of ICE with 3D EAM systems enabled CA procedures of various arrhythmias without the use of fluoroscopy (7,11). There are several reasons to adopt radiation-reducing strategies in CA procedures. The ALARA (as low as reasonably achievable) principle is based on the hypothesis that there is no threshold below which ionizing radiation is free from harmful effects for the operator and the patient (12). Furthermore, patient radiation risk from CA procedures may highly exceed radiation risk from common radiological procedures (13).
There is limited data regarding feasibility and safety of ICE-guided TSP in CA of left-sided arrhythmias without the use of fluoroscopy. Recently, Baykaner al. (9) demonstrated efficacy and safety of zero fluoroscopy TSPs in 646 AF patients using multiple procedural approaches at 5 high-volume centers. Our results extend these finding with a more simplified fluoroless transseptal approach which was also used in a pediatric population, in patients with CIEDs, and in various left-sided arrhythmias not only AF.