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Transseptal puncture for structural heart intervention: an old technique with new indications
  1. Alec Vahanian,
  2. Eric Brochet
  1. Department of Cardiology, Hôpital Bichat, Paris, France
  1. Correspondence to Professor Alec Vahanian, Department of Cardiology, Hôpital Bichat, Huchard, 75018 Paris, France; alec.vahanian{at}bch.aphp.fr

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Learning objectives

To learn how to:

  • Select the candidates for the technique

  • Optimise the use of equipment

  • Carry out the procedure

  • Adapt the procedure to specific subsequent structural interventions

  • Manage the complications

Introduction

Transseptal catheterisation was introduced in the late 50s1 and gained popularity with the introduction of the electrophysiological and structural heart interventions.2–10 Here, we shall describe the use of transseptal puncture (TSP) technique in the main transcatheter structural, and especially valve, interventions.

Indications

In current practice, the use of TSP has shifted from a diagnostic procedure, which is now used only exceptionally, to the first step before percutaneous interventions.

Transseptal puncture has been used worldwide for percutaneous mitral commissurotomy (PMC). More recently, it is increasingly performed for transcatheter interventions on the mitral valve (MitraClip procedure, annuloplasty or valve implantation: valve in valve, valve in a ring, valve in massive annular calcification), left atrial appendage closure and paravalvular leak closure. Finally, very recently it was also used for the new techniques of transcatheter mitral valve implantation.6 7 Its use for percutaneous aortic valve intervention has been almost entirely abandoned.10

Contraindications

The main contraindications to be excluded before TSP are as follows:

  • Left atrial thrombosis is an absolute contraindication for TSP if it is in the atrial cavity or on the septum. In patients with organised thrombosis localised in the apex of the left atrial appendage, TSP may be performed in exceptional cases where there is no therapeutic alternative. Left atrial myxoma also constitutes a contraindication. As a consequence, the performance of transoesophageal echocardiography (TOE) is recommended to exclude left atrial thrombosis before transseptal catheterisation. TOE should be performed immediately, or only a few days before the procedure depending on the intervention planned.11

The other following contraindications are relative:

  • Bleeding disorders.

If the patient receives vitamin K blockers, there is …

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