Bailout Atrial Balloon Septoplasty to Overcome Challenging Left Atrial Transseptal Access for Catheter Ablation of Atrial Fibrillation

Jackson J. Liang, Sanghamitra Mohanty, Joe Fahed, Daniele Muser, David F. Briceno, J. David Burkhardt, Jeffrey S. Arkles, Gregory E. Supple, David S. Frankel, Saman Nazarian, Fermin C. Garcia, David J. Callans, Sanjay Dixit, Luigi Di Biase, Andrea Natale, Francis E. Marchlinski, Pasquale Santangeli

Research output: Contribution to journalArticle

Abstract

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.

Original languageEnglish (US)
JournalJACC: Clinical Electrophysiology
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Catheter Ablation
Atrial Fibrillation
Punctures
Pulmonary Veins
Atrial Septum
Fluoroscopy
Heart Ventricles
Dilatation
Outcome Assessment (Health Care)
Equipment and Supplies

Keywords

  • angioplasty
  • atrial fibrillation
  • balloon
  • catheter ablation
  • septoplasty
  • septostomy
  • transseptal

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Bailout Atrial Balloon Septoplasty to Overcome Challenging Left Atrial Transseptal Access for Catheter Ablation of Atrial Fibrillation. / Liang, Jackson J.; Mohanty, Sanghamitra; Fahed, Joe; Muser, Daniele; Briceno, David F.; Burkhardt, J. David; Arkles, Jeffrey S.; Supple, Gregory E.; Frankel, David S.; Nazarian, Saman; Garcia, Fermin C.; Callans, David J.; Dixit, Sanjay; Di Biase, Luigi; Natale, Andrea; Marchlinski, Francis E.; Santangeli, Pasquale.

In: JACC: Clinical Electrophysiology, 01.01.2018.

Research output: Contribution to journalArticle

Liang, JJ, Mohanty, S, Fahed, J, Muser, D, Briceno, DF, Burkhardt, JD, Arkles, JS, Supple, GE, Frankel, DS, Nazarian, S, Garcia, FC, Callans, DJ, Dixit, S, Di Biase, L, Natale, A, Marchlinski, FE & Santangeli, P 2018, 'Bailout Atrial Balloon Septoplasty to Overcome Challenging Left Atrial Transseptal Access for Catheter Ablation of Atrial Fibrillation', JACC: Clinical Electrophysiology. https://doi.org/10.1016/j.jacep.2018.04.003
Liang, Jackson J. ; Mohanty, Sanghamitra ; Fahed, Joe ; Muser, Daniele ; Briceno, David F. ; Burkhardt, J. David ; Arkles, Jeffrey S. ; Supple, Gregory E. ; Frankel, David S. ; Nazarian, Saman ; Garcia, Fermin C. ; Callans, David J. ; Dixit, Sanjay ; Di Biase, Luigi ; Natale, Andrea ; Marchlinski, Francis E. ; Santangeli, Pasquale. / Bailout Atrial Balloon Septoplasty to Overcome Challenging Left Atrial Transseptal Access for Catheter Ablation of Atrial Fibrillation. In: JACC: Clinical Electrophysiology. 2018.
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abstract = "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.",
keywords = "angioplasty, atrial fibrillation, balloon, catheter ablation, septoplasty, septostomy, transseptal",
author = "Liang, {Jackson J.} and Sanghamitra Mohanty and Joe Fahed and Daniele Muser and Briceno, {David F.} and Burkhardt, {J. David} and Arkles, {Jeffrey S.} and Supple, {Gregory E.} and Frankel, {David S.} and Saman Nazarian and Garcia, {Fermin C.} and Callans, {David J.} and Sanjay Dixit and {Di Biase}, Luigi and Andrea Natale and Marchlinski, {Francis E.} and Pasquale Santangeli",
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AU - Liang, Jackson J.

AU - Mohanty, Sanghamitra

AU - Fahed, Joe

AU - Muser, Daniele

AU - Briceno, David F.

AU - Burkhardt, J. David

AU - Arkles, Jeffrey S.

AU - Supple, Gregory E.

AU - Frankel, David S.

AU - Nazarian, Saman

AU - Garcia, Fermin C.

AU - Callans, David J.

AU - Dixit, Sanjay

AU - Di Biase, Luigi

AU - Natale, Andrea

AU - Marchlinski, Francis E.

AU - Santangeli, Pasquale

PY - 2018/1/1

Y1 - 2018/1/1

N2 - 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.

AB - 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.

KW - angioplasty

KW - atrial fibrillation

KW - balloon

KW - catheter ablation

KW - septoplasty

KW - septostomy

KW - transseptal

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