Legend for supplemental videos and images



Legend for supplemental videos and images.

Background

These images were recorded from a patient who underwent an electrophysiological study followed by ablation of a left sided accessory pathway. The radiofrequency ablation catheter was delivered to the mitral valve annulus via a transeptal sheath. This series of videos demonstrates the important stages of the transeptal puncture that is described in the main article. All videos and figures are taken at 30° in the left anterior oblique projection except video 1 which is posterior-anterior and video 3 which is at 40°in the right anterior oblique projection.

Image 1: intra cardiac catheters

This fluoroscopic image shows diagnostic electrophysiology catheters with four electrodes (quadripolar) positioned on the Bundle of His (His) and at the apex of the right ventricle (RVA). A decapolar catheter is in the coronary sinus (CS) which runs along the epicardial aspect of the mitral valve annulus. The transeptal assembly (TS) is seen on the superior aspect of the intra atrial septum in the right atrium.

Video 1: position sheath in superior vena cava

The electrophysiology intra cardiac catheters are already in place. A 135cm 0.032” J tipped guide wire has been advanced from the right femoral vein up to the superior vena cava (SVC). In the video the sheath and dilator are advanced over the guide wire into the SVC.

Video 2: pull transeptal assembly down to the intra atrial septum

The Brockenbrough needle has been inserted inside the transeptal dilator with its tip 2cm inside the distal end of the dilator. The whole assembly is withdrawn smoothly towards the patient’s feet while observing the catheter movement on X-ray, demonstrated in this video. The first lateral movement seen is the catheter falling into the right atrium from the SVC and then a second more subtle movement is looked for as the catheter falls from the thicker muscular intra atrial septum into the fossa ovalis. The assembly is then gently advanced to try and catch the lip of the fossa, however in this video it does not and the assembly rides superiorly over the intra atrial septum.

Video 3: checking needle position in RAO

The His catheter is a surrogate marker for the aortic root. The tip of the transeptal assembly is seen posterior to this, and also the mouth of the coronary sinus (marked by the decapolar catheter). In addition the direction of the transeptal needle is approximately parallel with the coronary sinus catheter. If the needle is advanced in this position there is no danger of puncturing the aortic root.

Video 4: transeptal puncture

Using the right hand the needle is advanced into the transeptal sheath which is held steady with the left hand. This is observed on X-ray as the needle emerges out of the transeptal dilator. Often a small jump is seen as the tension of the fossa ovalis is released however this is not seen here.

Video 5: dye check

In this example the position of the transeptal needle appeared to be more superior than expected. As there was doubt the pressure line was removed and dye injected into the lumen of the transeptal needle using a Luer lock syringe. The roof of the left atrium is clearly defined and this demonstrates beyond doubt that the tip of the needle is within the lumen of the left atrium.

Video 6: advance dilator into left atrium

The needle is held firm and the dilator and sheath are together advanced over the needle into the left atrium.

Video 7: advance sheath into left atrium

The needle and dilator are held firm and the sheath is advanced over the needle and dilator into the left atrium. The needle and dilator are then removed from the catheter. The transeptal catheter is then aspirated and flushed and is ready to deliver an ablation catheter into the left atrium.

Image 2: successful ablation site

This fluoroscopic image shows the radiofrequency ablation catheter (RF), entering the left atrium via the transeptal sheath (TS), in contact with the lateral mitral valve annulus at the site of the accessory pathway. Energy was delivered here and pre excitation on the ECG disappeared.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download