Transseptal catheterization with transesophageal guidance in high risk patients

Atrial transseptal catheterization is usually performed with fluoroscopic guidance of the needle. We report our experience with both fluoroscopic and transesophageal guidance in patients who would otherwise have been at risk by using only fluoroscopy. A total of eleven procedures were performed during a 4 year period. The relative contraindications (some patients had several contraindications) included prior valve replacement (5 patients), prior myocardial revascularization (4 patients), severe dilatation of the left atrium (4 patients), severe dilatation of the ascending aorta (4 patients), and kyphoscoliosis (3 patients). All eleven patients had the transesophageal guided transseptal catheterization performed without complications and without significantly prolonging the procedure. The results of this preliminary, small, and retrospective study suggest that transesophageal echocardiography may enhance the safety of transseptal catheterization in high risk patients. Further prospective studies are needed

Ablation of left free-wall accessory pathways using radiofrequency energy at the atrial insertion site: transseptal versus transaortic approach

INTRODUCTION: Transcatheter ablation of the left free-wall atrioventricular accessory pathways (AP) by delivery of radiofrequency current at the ventricular insertion site has been shown to be effective. The efficacy of such a technique targeting the atrial insertion site of the AP was evaluated. METHODS AND RESULTS: One hundred consecutive patients with left free-wall APs and symptomatic supraventricular tachyarrhythmias were included. APs were manifest in 55 patients and concealed in 45. There were 55 men and 45 women with a mean age of 35 years. A total of 107 left free-wall APs were identified in these patients. In these 100 patients, successful ablation was accomplished in all by using a transseptal (45 patients) or transaortic (54 patients) technique. In one patient, ablation was accomplished from within the coronary sinus. Seven patients required a repeat ablative procedure, which was performed successfully. During 107 ablative procedures, six were associated with nonfatal complications including pericardial effusion (hemopericardium) in two patients, mild mitral regurgitation in two patients, swelling of the left arm in one patient, and staphylococcal bacteremia in one patient. Eighty-two (82%) patients underwent a repeat electrophysiologic study 6 to 8 weeks after successful ablation and were found to have no functioning AP or inducible supraventricular tachycardia. During a mean follow-up of 20 +/- 8 months, none of the 100 patients had a recurrence of tachyarrhythmias. CONCLUSION: These data indicate that the atrial insertion site of the AP can be successfully ablated in the majority of patients with left free-wall APs by using either a transseptal or transaortic approach. Furthermore, both techniques are associated with minimal morbidity and no mortality