A conservative approach to performing transseptal punctures without the use of intracardiac echocardiography: Stepwise approach with real-time video clips

Atrial transseptal puncture as a means of accessing the left heart is a critical component of catheter ablation procedures for atrial fibrillation, left-sided accessory pathways, and access to the left ventricle in patients with certain types of prosthetic aortic valves. Although this technique has been performed successfully since the 1950s, severe and potentially life-threatening complications can still occur, including cardiac tamponade and/or death. Some have adopted the use of intracardiac echocardiography, but our laboratory and many others throughout the world have successfully relied on fluoroscopic imaging alone. The aim of this brief report is to describe in detail our technique for performing transseptal punctures during catheter ablation procedures for atrial fibrillation. We employ a similar approach when targeting left-sided accessory pathways, although only a single transseptal is performed in those cases. Utilizing a series of real-time video clips, we describe our technique of double transseptal puncture and illustrate in detail ways in which to avoid common pitfalls.