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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3590_Библиотеки_им_академика_М_И_Перельмана
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4—HEMODYNAMICS FOR THE STRUCTURAL INTERVENTIONALIST 55
Exercise
Rest
–19 mmHg
–26 mmHg
–48 mmHg
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Risk
stratify
? severe AS
Gradient
<40 mmHg (±10%)≥40 mmHg (±10%)
Symptomatic
Operate
Valve area
2
(±20%) ≤1.0 cm2 (±20%)
>1.0 cm
Observe
High pretest
probability
for severe AS
Valve
stress
testing
Exercise
Nitroprusside
Dobutamine
225
175
125
75
25
Gredient
Velve FFR
Valve area
Diagnosis: HFpEF and pseudo-severe AS
225
175
125
180
130
Rest
75
25
Gredient
Velve FFR
Valve area
Diagnosis: HFpEF and pseudo-severe AS
80
30
Gredient
Velve FFR
Valve area
225
175
125
75
25
–14 mmHg
–0.91
–0.9 cm
–20 mmHg
–0.87
–0.7 cm
–30 mmHg
–0.75
–0.4 cm
Diagnosis: Severe AS
Gredient
Velve FFR
2
Valve area
225
175
125
75
25
Gredient
Velve FFR
2
Valve area
180
130
80
30
Gredient
Velve FFR
2
Valve area
Nitroprusside
–0.91
–1.2 cm
–0.78
–1.0 cm
–0.68
–0.5 cm
2
2
2
Fig. 4.10 Approach to aortic stenosis gradient. In patients with clinical concern for severe aortic stenosis
(AS), the gradient must be measured—if high, this confirms severe AS. If the gradient is low, the aortic valve
area (AVA) should be evaluated, but interpreted with caution, given its greater variability and flow dependence.
Then, with a low gradient, if the AVA is small, valve stress testing using dobutamine, nitroprusside, or exercise
should be performed to differentiate pseudosevere from severe AS. Even if the AVA is large, further testing
may still be warranted if clinical suspicion is high. (Reproduced from Reddy YNV, Nishimura RA. Evaluating
the severity of aortic stenosis: A re-look at our current ‘gold standard’ measurements. Eur Heart J.
2018;39[28]:2656-2658.)
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References
1. Cigarroa RG, Lange RA, Williams RH, Bedotto JB, Hillis LD. Underestimation of cardiac output by
thermodilution in patients with tricuspid regurgitation. Am J Med. 1989;86(4):417-420.
2. Narang N, Thibodeau JT, Levine BD, et al. Inaccuracy of estimated resting oxygen uptake in the clinical
setting. Circulation. 2014;129(2):203-210.
3. Opotowsky AR, Hess E, Maron BA, et al. Thermodilution vs estimated Fick cardiac output measurement
in clinical practice: An analysis of mortality from the Veterans Affairs Clinical Assessment, Reporting, and
Tracking (VA CART) program and Vanderbilt University. JAMA Cardiol. 2017;2(10):1090-1099.
4. Reddy YNV, El-Sabbagh A, Nishimura RA. Comparing pulmonary arterial wedge pressure and left
ventricular end diastolic pressure for assessment of left-sided filling pressures. JAMA Cardiol. 2018;3(6):
453-454.
5. Nishimura RA, Rihal CS, Tajik AJ, Holmes DR Jr. Accurate measurement of the transmitral gradient in
patients with mitral stenosis: A simultaneous catheterization and Doppler echocardiographic study. J Am
Coll Cardiol. 1994;24:152-158.
6. Reddy YNV, Nishimura RA. Evaluating the severity of aortic stenosis: A re-look at our current ‘gold
standard’ measurements. Eur Heart J. 2018;39(28):2656-2658.
e1
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Abstract: Invasive hemodynamic assessment is a crucial component of the diagnostic evaluation
of the complex patient with structural heart disease. In this chapter, we will review the indications
for invasive assessment and interpretation of data obtained from a right and left heart catheterization
in a patient with structural heart disease.
Keywords: Invasive hemodynamics, catheterization, pulmonary hypertension, valve area
CHAPTER 5
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Techniques of Transseptal Puncture
Mohamad Alkhouli David R. Holmes Jr.
Transseptal catherization was first described by Ross, Braunwald, and Morrow in 1959 as a feasible
method to obtain direct left atrial (LA) pressure measurements.
puncture (TSP) for hemodynamic assessment had since declined due to the wider application of
right heart catheterization, TSP is currently considered an essential component of many valvular
and nonvalvular structural heart disease (SHD) interventions (Fig. 5.1).
overview of contemporary TSP techniques, with a special emphasis on challenging anatomies and
procedural complications.
1
Although the use of transseptal
2
This chapter provides an
Transseptal Puncture Toolbox
The basic TSP kit consists of a transseptal sheath and a transseptal needle (Fig. 5.2). However,
several ancillary tools can be utilized to increase the safety and success of TSP:
1. Transseptal sheaths: Fixed-curve sheaths are usually utilized in the majority of procedures
requiring TSP. Steerable sheaths offer superior maneuverability, which facilitates navigating difficult anatomies and achieving site-specific LA access, but they are more expensive
than the traditional fixed-curve sheaths. Table 5.1 summarizes the most commonly used
transseptal sheaths and their characteristics.
Fig. 5.1 Illustration of the contemporary applications for transseptal structural heart interventions.
(A) Percutaneous mitral balloon valvuloplasty. (B) Transcatheter mitral valve repair (MitraClip). (C) Mitral
valve–in–valve implantation. (D) Transcatheter mitral valve replacement. (E) Mitral paravalvular leak closure.
(F) Pulmonary vein isolation. (G) Percutaneous left ventricular assist device placement. (H) Left atrial appendage closure. (Reprinted with permission from Alkhouli M, Rihal CS, Holmes DR Jr. Transseptal techniques
for emerging structural heart interventions. JACC Cardiovasc Interv. 2016:26;9[24]:2465-2480.)
57
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Fig. 5.2 Commonly used transseptal sheaths and needles. (A) Fixed-curve sheath. (B) Steerable sheath
(Agillis). (C) BRK (Brockenbrough) transseptal needle. (D) Safesept wire. (E) NRG radiofrequency needle.
(Reprinted with permission from Alkhouli M, Rihal CS, Holmes DR Jr. Transseptal techniques for emerging
structural heart interventions. JACC Cardiovasc Interv. 2016:26;9[24]:2465-2480.)
2. Transseptal needles: Stainless steel needles (e.g., Brockenbrough needle, Medtronic, Min-
neapolis, MN; BRK, St. Jude Medical, St. Paul, MN) are inexpensive and available in
multiple lengths and curves, and thus are considered the “work horse” of transseptal needles. Needles utilizing radiofrequency energy (e.g., Baylis, Montreal, Canada) allow controlled puncture and may enhance the safety and efficacy of TSP in patients with fibrotic
or thickened fossa ovalis (FO) (Fig. 5.3). Commercially available transseptal needles and
their features are listed in Table 5.2.
3. Ancillary tools: In patients with a fibrotic, thickened, or aneurysmal intraatrial septum
(IAS), needle-wire systems (e.g., Safesept wire, Pressure Products, San Pedro, CA) allow
safe traversing into the LA. The Safesept is a 120-cm, 0.0140 Nitinol guidewire that has a
sharp but floppy tip, which prolapses immediately into a “J” shape upon entry into the LA
(see Fig. 5.3). The wire can be then advanced safely into a pulmonary vein, and the trans-
septal sheath/needle assembly is railed over the wire into the LA. If upon advancing the
Safesept wire, an undesirable puncture is recognized (e.g., into the pericardium), the wire
can be safely retracted without sequelae. Pigtail wire systems can be utilized to achieve and
maintain stable access into the LA. A major advantage of these wires is the avoidance of
stiff wire placement in the pulmonary vein during sheath exchanges, eliminating the small
TABLE 5.1 n Commercially Available Transseptal Sheaths and Their Characteristics
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Transseptal
Sheath Manufacturer Steerable
Radiopaque
Tip
Side
Holes
Sheath Curve Angle
(degree) Inner Diameter
Usable Length
(cm)
Mullins Medtronic No No No 180 (Mullins Style) 7-8F 60 0.032
Performer Mullins Cook No Yes No 180 (Mullins Style) 4-16F 63-75-85 0.038 (.6F)
Performer
Cook No Yes No 45 double curve 9-12F 75 0.038
Hausdorf
Adelante Breeze-
Oscor No Ye s Ye s 55, 70, 90, 120 8-10F 60-79 0.038
way
Fast-Cath St. Jude No Ye s No 180 (Mullins style) 8-10F 63 0.032
Fast-Cath SL
St. Jude No Ye s Ye s 45, 50, 90 10F 63-81 0.032
series
Swartz (SL0-SL4) St. Jude No Yes Yes 45, 50, 90, 135, 180 8-8.5F 63-81 0.032
Swartz Braided
St. Jude No Ye s Ye s 45, 90, 135 8-8.5F 63-81 0.032
LAMP
Across Interlock
St. Jude No Ye s Ye s 45, 90 8.5F 63-81 0.032
System
TorFlex Baylis Medical No Yes Yes 37, 45, 55, 90, 135 8-8.5F 63-81 0.032
HeartsSpan Merit No Ye s Yes 15, 30, 55, 90, 120,
8 5F 60-80-101 0.035
150
TSX Boston S No Yes Yes 15, 30, 55, 90, 120,
8 5F
60-80-101 0.035
150
Preface Biosense No Yes Ye s 55, 90, 120, 150 8F 62-77 0.035
Super Arrow-Flex Teleflex No Ye s No 180 (Mullins style) 8F 61 0.035
a
Flexcath
Agilis NxT St. Jude Yes Yes Yes Three Curls (16.8,
Medtronic Yes Yes Ye s One Curl 12F 65 0.032, 0.035
8.5F 61-71 0.032
22.4, 50 mm)
HeartSpan
Steerable
Dexterity Spirus Ye s Yes Ye s One curl (two steering
Merit Yes Yes Yes Three curls (16.4, 22.4,
36 mm)
8.5F 74 0.032
9F, 14F 65-75-105 0.035
locations)
Direx Interlock
System
Boston S Yes Yes Yes Three curls
(17, 22, 50 mm)
9-12F 67-71 0.038
Guidewire
Compatibility
(inch)
5—TECHNIQUES OF TRANSSEPTAL PUNCTURE 59
LAMP, Left atrial multipurpose.
a
135 maximum deflection.
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Fig. 5.3 Ancillary tools for difficult-to-navigate transseptal puncture. (A) Safesept needle-wires system.
(B) Radiofrequency transseptal needle. (Reprinted with permission from Alkhouli M, Rihal CS, Holmes DR Jr.
Transseptal techniques for emerging structural heart interventions. JACC Cardiovasc Interv. 2016:26;9[24]:
2465-2480.)
TABLE 5.2 n Commercially Available Transseptal Needles and Their Characteristics
Transseptal
Needle Manufacturer
Brocken-
Medtronic 56, 71 30 21 18
Length
(mm)
brough
BRK Series St. Jude 71, 89, 98 BRK, BRK1
BRK XS
St. Jude 71, 89, 98 BRK, BRK1
Series
TSX Boston S 71, 89, 98 50, 86 21 18 Transparent
Heart Span Biosense 56, 71, 89 50, 86 21, 22 18 Transparent
Cook TSN Cook 56, 71 30 21 18
NRG RF Baylis 71, 89, 98 C0, C1 (30, 60) 21 18 Radiofre-
a
Steeper primary bevel angle and two back bevels that combine to form a distinct point at the tip of the needle.
b
Pediatric curves are BRK and BRK2.
c
Allows direct visualization of bubbles before they travel distally.
Needle Curve
Angle
(degree)
a
(30, 55)
(30, 55)
Distal Tip
(Gauge)
Proximal
Tip (Gauge)
Special
Feature
21 18 Bevel angle
50 degrees
21 18 Bevel angle
30 degrees
c
handle
c
handle
quency
energy
b
5—TECHNIQUES OF TRANSSEPTAL PUNCTURE 61
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but significant risk of pulmonary vein injury/bleeding. These wires are available in a 0.0250
platform (e.g., TorayGuide, Toray, Tokyo, Japan; Protrack pigtail wire, Baylis, Montreal,
Canada), but comparable 0.0350 wire systems can be used off-label for the same purpose
(e.g., Confida wire, Medtronic; Safari wire, Boston Scientific, Marlborough, MA).
Transseptal Catheterization Step by Step
SIMPLE TSPs
Transseptal catheterization is preferably performed via a right transfemoral venous access. After
that, partial anticoagulation with 2000 to 5000 IU of intravenous heparin is administered. The
transseptal sheath (most commonly the Mullins sheath or the SL-1 sheath) is then advanced over
a wire into the superior vena cava (SVC) in the anterior-posterior (AP) fluoroscopic projection.
Although some transseptal sheaths are compatible with 0.0350 wires, the majority require a 0.0320
guidewire (see Table 5.1). The transseptal needle is then advanced inside the sheath but kept 1
to 2 cm proximal to its distal tip. The sheath and dilator are grasped with the index finger and
thumb and the needle is grasped with the remaining fingers to ensure a constant relationship between the needle and sheath. The orientation of the needle and sheath must be maintained by
matching the metal arrow on the needle’s hub to the direction of the sheath’s sidearm.
needle assembly is then retracted to the junction of the SVC/right atrium (RA) as a single unit with
a slight clockwise rotation, such that system is pointing toward 3- or 4-o’clock. Two characteristic
“jumps” of the dilator tip are usually appreciated by the operator: one as the tip passes under the
aortic knob and one as the tip passes under the muscular septum into the FO. The location of the
transseptal sheath dilator on the FO can be confirmed either with fluoroscopy (AP, lateral projections), transesophageal echocardiography (TEE; bicaval and short-axis views), or intracardiac
echocardiography (ICE; septal view). The needle tip is then advanced into the LA, and an LA
position can be verified before advancing the sheath by aspirating oxygenated blood, measuring LA
pressure, injecting contrast into the LA, or advancing a coronary or a Safesept wire into a pulmonary
vein. The sheath/dilator apparatus is then advanced over the needle into the LA in two steps: first,
the dilator is advanced over the needle; and second, the sheath is advanced over the needle/dilator
assembly into the LA. If two LA accesses are needed, two wires can be advanced inside the sheath
into the LA; J-shaped wires (e.g., Amplatz Extra-stiff ) need to be advanced into a pulmonary vein
to provide adequate support for sheath advancement, whereas pigtail wires (e.g., Protrack) can be
kept in the body of the LA. The sheath is removed, and the two desired LA sheaths are advanced
side to side over the two wires into the LA. Alternatively, a dedicated puncture via a separate venous
access can be obtained for the second LA access to minimize the size of the resultant atrial septal
3
defect.
The FO often requires balloon dilation to facilitate crossing of large sheaths/guiding catheters, such as during transcatheter mitral valve repair or transseptal mitral valve–in–valve procedures.
Peripheral angioplasty balloons (7 to 10 mm 3 40 mm) are usually utilized for this purpose.
3
The sheath/
CHALLENGING TSPs
Patients referred for SHD interventions often have an extremely challenging IAS to cross. Those
patients may have had prior transcatheter or surgical interventions involving the intraatrial
septum, which as a result can be patched, oversewn, fibrotic, or calcified.
tortuosity, congenital anomalies or occlusions, and extreme rotation of the heart can lead to
significant challenges at different stages of the TSP procedure.
Difficulty With Venous Access
1. Advancement of the transseptal needle through the sheath can be quite challenging and
often hazardous if significant tortuosity of the iliac veins is present. In such cases, the
2,4
In addition, venous
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sheath can be exchanged over an extra-stiff wire with a 30- to 45-cm-long sheath that is
2F larger in diameter. The transseptal sheath can then be reinserted inside the larger
sheath to avoid the venous tortuosity.
2. Although the presence of an inferior vena cava filter does not preclude transseptal large-
bore access to the LA, indwelling filters are often associated with a large infrafilter thrombus burden and/or occluded vena cava. Thus we perform angiography of the iliocaval veins
in patients with remote vena cava filters to exclude the presence of significant thrombus
and/or occlusion.
3. If the inferior vena cava or the iliac veins are occluded, TSP can be successfully performed
via alternative venous access: left femoral, right internal jugular, or hepatic vein. However,
these approaches hinder the ability to achieve site-specific puncture on the FO and require
manual modifications of the transseptal needle curvature.
3
Difficulty With FO Engagement
Establishing and maintaining contact between the transseptal sheath assembly and the FO can
be challenging in patients with kyphoscoliosis, enlarged atria, rotated heart, or dilated aorta. In
these patients, using a larger-curve transseptal needle, adding proximal and/or distal secondary
bends to the needle, and utilizing echocardiographic guidance are often necessary to overcome
these challenges.
Difficulty With Needle Advancement
1. Thickened, fibrotic, or scarred FO are often encountered in patients who had prior TSP
or cardiac surgery. Techniques to facilitate crossing the highly resistant FO in these patients include the use of a large-curved needle (e.g., BRK-1), advancement of a transseptal
needle stylet or a needle-wire (e.g., Safesept) through the needle, or the utilization of radiofrequency (RF) needles. Also, RF energy can be applied via an electrocautery system
connected to the proximal end of a stainless steel transseptal needle if a dedicate RF needle
is not available.
2. If the IAS is aneurysmal, significant tenting of the FO can occur while attempting to
advance the needle across the septum, leading to a greatly reduced distance between the
tip of the tented FO and the opposite LA wall. Forcing the needle across this highly tented
FO may lead to inadvertent puncture of the free LA wall. In such cases, gentle twisting of
the sheath/needle assembly, using an RF needle or advancing the needle over a Safesept or
a coronary wire, may be necessary to lessen the risk of LA perforation.
3. In the majority of patients with surgically repaired intraatrial septa, TSP is feasible but
often requires ancillary tools (Safesept wire, RF needles, etc.) to aid traversing the resistant
surgical patch. One exception is in patients with a Gore-Tex patch (Gore, Flagstaff, AZ).
These patches are highly resistant, and hence their puncture can be particularly challenging. In patients with percutaneous septal occluders, TSP can be performed in adjacent
portions of the intraatrial septum, although successful direct puncture of various septal
occluders has been reported.
2
IMAGING GUIDANCE FOR TSP
1. Fluoroscopy-guided TSP: With this method, the base of the aortic root is marked with a
pigtail catheter inserted via arterial access into one of the aortic cusps, while the lateral and
posterior borders of the atria are identified with the cardiac silhouette. We use an AP or
slightly right anterior oblique projection while descending the transseptal sheath/needle
from the SVC to the FO (Fig. 5.4A). We then confirm the trajectory of the sheath/needle
with a left anterior oblique projection (Fig. 5.4B). If uncertainty persists, the FO can be
5—TECHNIQUES OF TRANSSEPTAL PUNCTURE 63
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Fig. 5.4 Fluoroscopic projections for transseptal puncture guidance. Ao, Aorta; AR, aortic root; AV,
aortic valve; CS, coronary sinus; FO, fossa ovalis; LA, left atrium; LAA, left atrial appendage; LAO, left anterior
oblique; LV , left ventricle; PA , pulmonary artery; RA, right atrium; RAO, right anterior oblique; RV, right ventricle; TV, tricuspid valve. (Reprinted with permission from Alkhouli M, Rihal CS, Holmes DR Jr. Transseptal
techniques for emerging structural heart interventions. JACC Cardiovasc Interv. 2016:26;9[24]:2465-2480.)
stained by injecting 1 to 2 cc of contrast through the tip of the needle. Also, a Safesept wire
can be advanced through the needle into the LA for additional confirmation before advancing the sheath.
2. Ultrasound-guided TSP: Both TEE and ICE allow direct high-quality imaging of the FO
and its adjacent structures, providing both assurance of needle contact with FO and the opportunity to select a specific FO puncture location, especially in patients with a challenging
anatomy. Intracardiac echocardiography has the advantages of not requiring a second operator or general anesthesia, but requires an additional venous access and lacks biplane or 3D
imaging capabilities. If TEE is selected to guide the TSP, the bicaval view (90 degrees) allows
superior/inferior localization, and the short-axis view (0 to 30 degrees) provides AP localization. Biplane imaging offers simultaneous display of both views, allowing fine changes of the
transseptal needle location on the FO (Fig. 5.5). In ICE-guided TSP, a phased-array ICE
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