5 Proven Steps for a Successful Transseptal Puncture (TSP)

There are limited opportunities for electrophysiologists and interventional cardiologists to practice the transseptal procedure in the clinical setting. The procedure requires a trained hand and working knowledge, so without the opportunity to practice before performing it in a live setting, even simplicity can feel daunting. ‍

Confirming proper needle position prior to puncture is a safety essential step. This positioning can be verified by TEE/ICE and fluoroscopy. Knowing what positions to use while maintaining steady hand control of the needle, however, are the biggest challenges of the procedure. Not using imaging modalities to ensure needle position may result in an accidental puncture of the aortic artery or the atrium wall, sending the patient into cardiac tamponade.

The challenge is only intensified with an aneurysmal or fibrotic fossa, which can make the procedure unpredictable and time-consuming. Being prepared for the worst-case scenario is essential for patient safety. As healthcare workers, we naturally strive to prevent these obstacles; however, sometimes they will occur.

There are steps you can take to ensure optimal outcomes.

Steps for a Successful Transseptal Puncture

Step #1: Access both groins

It is recommended that both groins are prepared for access. The right groin is the most common access site used. The left should be prepared for use of a pigtail catheter insertion and in case of complications.

Step #2: Sheath insertion

Using fluoroscopy in the AP projection, advance a 0.032-inch J tip guidewire to the superior vena cava (SVC). Using transesophageal echo (TEE) to confirm guidewire placement in the SVC. Advance the sheath until it is approximately 3-4 cm superior to the cavoatrial junction (CAJ), remove the 0.032 wire.

Step #3: Needle Insertion

Insert the needle, with stylet in place, into the sheath. When the needle is positioned approximately 4 cm from the tip of the sheath, remove the stylet. Connect the luerlock of the needle to the pressure link and flush the needle with saline.

Step #4: Pullback

Hold the sheath together with the Brockenbrough needle at 5-6 o’clock. Use TEE to see the posterior wall of the septum and the AO to ensure that neither structures get punctured. Using TEE visualization, pull the needle and sheath back until they fall into the fossa. Applying gentle forward pressure, tenting can be seen and position checked using TEE. This is to avoid puncture of the AO and pericardium and to determine height of puncture site on septum.

Step #5: Puncture and advancing into the LA

Move TEE into the SAX view. Fluoroscopy should be in the AP projection. Using gentle forward pressure, advance the needle while keeping the transseptal sheath in place. As gentle forward pressure is applied to the needle, fossa/septal “tenting” is observed on the TEE.

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Increase Patient Safety

With practice and preparation, we are better equipped to make the right decision for the patient’s well-being. The need to practice any procedure prior to the procedural setting is one that the Mentice team recognizes, and as a result, has developed a TSP simulation solution.

With step-by-step instructions built in, anatomical labels, and detailed metrics, trainees can learn in their own time, taking the care needed to ensure a steady outcome.

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