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    • In the cardiac catheterization room the patient was sedated

    2019-05-27

    In the cardiac catheterization room, the patient was sedated with propofol. Then, electrode catheters were placed in the coronary sinus from the right subclavian vein, in the right atrial appendage, and in the superior vena cava from the left femoral vein. A pressure line was inserted from the right femoral artery. A 60-cm 8-Fr transseptal sheath (FAST-CATH; St. Jude Medical, MN, USA), a 63-cm 8-Fr sheath (SL0; St. Jude Medical, MN, USA), and a 61-cm 8.5-Fr sheath (Agilis NxT; St. Jude Medical, MN, USA) were inserted over the wires from the right femoral vein. A RT3D-TEE probe (X7-2t TEE probe; Philips Medical System, Andover, MA) was inserted into the different experience to the level of the LA. The patient did not seem uncomfortable during probe insertion. RT3D-TEE permitted the accurate visualization of the fossa ovalis as well as the appreciation of the orientation of the Brockenbrough needle in 3 dimensions (Fig. 3). We positioned the Brockenbrough needle and the sheath in the superior vena cava; we then withdrew the system under RT3D-TEE and fluoroscopic imaging guidance and placed it in the fossa ovalis. No classic jump feeling into the fossa was experienced. We confirmed that the Brockenbrough needle was tenting in the fossa ovalis and carefully pushed the needle through to the LA. We confirmed that the needle was placed through the atrial septum (Fig. 3), and the RT3D-TEE probe was pulled out. The duration of RT3D-TEE was 18min. Thereafter, PVI was performed successfully using the CATRO system (Fig. 4). After 3 day\' observation, the patient was discharged without complications.
    Discussion The technique of transseptal puncture that is commonly used today was originally described by Ross and Cope in 1959 and Brockenbrough and Braunwald in 1960 [2–4]. The complications of transseptal catheterization include inadvertent perforation of the heart or the surrounding vascular structures, which results in pericardial effusion and cardiac tamponade, and thromboembolism. Transseptal puncture can be performed without echocardiographic guidance in most patients. Tao et al. reported the case of a patient with straight back syndrome with concomitant AF, who underwent catheter ablation. A “pancake” deformity of the LA was found using 64-slice multislice CT and 3D reconstruction imaging. A transseptal puncture was performed 3 times under fluoroscopic guidance, but failed. Then, hand-injected contrast was detected in the pericardium and the subsequent ablation was canceled [5]. Here, we show that RT3D-TEE is a very helpful imaging technique to access the LA. Some reports have previously described that two-dimensional transesophageal echocardiography (2D-TEE) and intracardiac echocardiography (ICE) are useful for high-risk transseptal puncture [1,6]. Faletra et al. reported that RT3D-TEE may provide better guidance for transseptal puncture than 2D-TEE. Although 2D-TEE can help visualize the atrial septum in several planes, due to the “tomographic” nature of this technique, the planes always intersect the septum perpendicularly. Consequently, this structure is imaged as a linear echo, which may be thicker around the fossa ovalis (muscular rim) and thinner at the level of the floor. Moreover, the spatial relationship with the surrounding cardiac structures is difficult to appreciate because this technique lacks the third dimension. Tracking the intracardiac catheter and establishing its position relative to the fossa ovalis may be difficult with 2D-TEE because multiple views and continuous imaging adjustments are required. In contrast, RT-3D images of the atrial septum and surrounding atrial wall can be obtained by RT3D-TEE from any possible 2D angle [1]. Compared to TEE, ICE is an invasive tool that requires central venous access and provides only 2D imaging [7]. This case demonstrates the ability of RT3D-TEE to image relevant intracardiac landmarks during transseptal catheterization, to provide immediate 3D feedback, and to effectively guide transseptal puncture. The disadvantage of TEE is that the probe may obscure the fluoroscopic view [8]. It is difficult to maintain the TEE probe in the esophagus for a long period in non-sedated or lightly sedated patients due to the considerable discomfort associated with the technique [6]. In this patient, we were able to perform the procedure in a short period, and the patient did not seem uncomfortable under sedation.