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Dissertation zugänglich unter
Safety and Outcome Analysis of Transseptal Puncture Facilitated by Phased-Array Intracardiac Echocardiography
Sicherheits- und Auswirkungsanalyse der Transseptalen Punktion Unterstützt durch die Phased-Array Intrakardiale Echokardiographie
Dokument 1.pdf (2.553 KB)
Elektrophysiologie , Hochfrequenz-Katheterablation , Vorhofflimmern
Freie Schlagwörter (Deutsch):
Transseptale Punktion , Intrakardiale Ultraschallkardiographie
Freie Schlagwörter (Englisch):
Intracardiac Echocardiography , Transseptal Puncture , Electrophysiology, Catheter Ablation , Atrial Fibrillation
Kuck, Karl-Heinz (Prof. Dr.)
Tag der mündlichen Prüfung:
Kurzfassung auf Englisch:
Historically, transseptal puncture (TP) was utilized by interventional cardiologists for the assessment of left atrial (LA) hemodynamics in the setting of mitral valvular disease and to allow hemodynamic assessment of the left ventricle in patients with aortic valve prostheses. Prior reports from experienced large volume centers suggested a major procedural complication rate of approximately 1.3%. Continued advancements in the understanding of the mechanism of atrial fibrillation (AF), along with a persistent evolution of ablation approaches for treatment of this arrhythmia, has led to an ever growing need for LA access. In fact, the ubiquitous nature of AF in addition to the acknowledgement that the vast majority of curative endocardial ablation approaches for the treatment of AF are now performed within the LA, have virtually ensured that the TP procedure will remain an integral part of the procedural armamentarium of the interventional cardiac electrophysiologist for the unforeseen future. The current practice at many centers is to still utilize fluoroscopy as the sole form of imaging employed for visualization during performance of TP. It is clear that there are distinct inherent limitations regarding the accuracy of intracardiac catheter placement and manipulation when utilizing only fluoroscopic visualization. These potential inaccuracies may be further amplified in patients with significant structural heart disease or derangements of chamber dimensions. Use of intracardiac echocardiography (ICE) imaging to facilitate TP not only aids in a potentially more accurate placement of the transseptal sheath within the LA, but also provides incrementally greater and possibly more accurate imaging data regarding the interatrial septum/fossa ovalis, surrounding adjacent cardiac structures, and a more immediate ability to assess for complications.
Due to a paucity of data in larger cohorts of patients regarding the impact of ICE imaging during TP, this study sought to assess the feasibility and influence of phased-array ICE guidance on the outcome of TP during ablation procedures in the electrophysiology (EP) laboratory.
This study found that catheterization facilitated by ICE is a feasible and safe alternative to a traditional fluoroscopic approach with a similar rate of complications in patients referred for first-time or redo procedures. This finding appears to be maintained regardless of whether the TP procedure is performed by an experienced invasive electrophysiologist or a physician-in-training under staff supervision. Despite underlying cardiac anatomic abnormalities or increased BMI, it appears that this approach confers a safety profile comparable to centers intimately familiar with the traditional approach to TP. ICE may offer the advantage of direct visualization and optimal positioning of the TP sheath within the LA, as well as providing a wealth of adjunctive imaging data. Importantly, TP facilitates early recognition of potential life-threatening complications. In addition, it may serve best the operator with little experience in TP or centers with low numbers of procedures necessitating a transseptal approach. In order to prove superiority of ICE facilitated over traditional TP, a large-scale prospective head-to-head comparison would be needed in the future.