Author + information
- Received December 18, 2017
- Revision received February 26, 2018
- Accepted April 5, 2018
- Published online August 20, 2018.
- Jackson J. Liang, DOa,
- Sanghamitra Mohanty, MD, MSa,
- Joe Fahed, MDa,
- Daniele Muser, MDa,
- David F. Briceno, MDa,
- J. David Burkhardt, MDb,
- Jeffrey S. Arkles, MDa,
- Gregory E. Supple, MDa,
- David S. Frankel, MDa,
- Saman Nazarian, MD, PhDa,
- Fermin C. Garcia, MDa,
- David J. Callans, MDa,
- Sanjay Dixit, MDa,
- Luigi Di Biase, MD, PhDb,c,
- Andrea Natale, MDb,
- Francis E. Marchlinski, MDa and
- Pasquale Santangeli, MD, PhDa,∗ ()
- aDivision of Cardiology, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- bTexas Cardiac Arrhythmia Institute, Austin, Texas
- cMontefiore Medical Center, Albert Einstein College of Medicine, New York, New York
- ↵∗Address for correspondence:
Dr. Pasquale Santangeli, Division of Cardiology, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion–Cardiology, 3400 Spruce Street, Philadelphia, Pennsylvania 19104.
Objectives This study reports outcomes of bailout atrial balloon septoplasty (ABS) to overcome challenging left atrial (LA) access in patients undergoing atrial fibrillation (AF) ablation.
Background Transseptal puncture (TSP) and LA access for AF ablation can be challenging in patients with prior atrial septal surgery, percutaneous closure, or scarred septum due to multiple prior TSPs.
Methods The study identified patients who underwent AF ablation at 2 ablation centers from 2011 to 2017 with challenging TSP in whom bailout percutaneous ABS was performed to allow LA access. Following TSP, the transseptal sheath could not be advanced to the LA despite multiple attempts or approaches including use of a stiff wire sequentially in the left and right pulmonary veins, use of a stiff pigtail exchange wire advanced in the LA or left ventricle, or sequential dilation with progressively larger diameter long dilators. ABS was performed using a noncompliant balloon (diameter 4 to 10 mm) advanced over a stiff wire deployed in the left superior pulmonary vein, allowing passage of the transseptal sheaths for completion of the AF ablation procedure.
Results Fifteen patients (mean age 54.4 ± 15.5 years, 9 women) with challenging TSP (7 patients with prior surgical ASD repair, 2 with percutaneous ASD closure devices, and 13 with ≥1 previous TSP) underwent bailout ABS for AF ablation. After TSP (radiofrequency assisted in 10 cases), ABS was successful and permitted access to the LA for ablation in all patients. Mean time required to perform ABS was 21.3 ± 19.4 min, and mean total procedure time was 241.1 ± 114.6 min (fluoroscopy time 62.0 ± 29.9 min). There were no procedural complications.
Conclusions In patients undergoing AF ablation with difficult transseptal access due to scarred, surgically, or percutaneously repaired atrial septum, ABS is a safe and effective bailout strategy to obtain transseptal access.
Dr. Nazarian has served as a consultant for Biosense Webster, CardioSolv, and Siemens; and has received research grant support from Biosense Webster. Dr. Di Biase has served as a consultant for Biosense Webster, Stereotaxis, Boston Scientific, and Abbott; and has received speaker/travel honoraria from Medtronic, Pfizer, and Biotronik. Dr. Natale has received consulting fees/honoraria from Biosense Webster, Inc., St. Jude Medical, Medtronic, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received December 18, 2017.
- Revision received February 26, 2018.
- Accepted April 5, 2018.
- 2018 American College of Cardiology Foundation
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