REVIEW

Transseptal Catheterization: Considerations and Caveats

STYLIANOS TZEIS, M.D.,* GEORGE ANDRIKOPOULOS, M.D.,†
ISABEL DEISENHOFER, M.D.,* SIEW YEN HO, PH.D., ‡ and GEORGE THEODORAKIS, M.D.†
From the *Deutsches Herzzentrum und Medizinische Klinik, Faculty of Medicine, Technischen Universität
München, Munich, Germany; †Cardiology Department, ‘Henry Dunant’ Hospital, Athens, Greece; and ‡Cardiac
Morphology Unit, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital,
London, United Kingdom

Transseptal catheterization is used by interventional cardiologists to gain access in the left atrium. This
technique was initially introduced for left-sided pressure measurements and has been integrated in a
variety of procedures including left atrial ablations and percutaneous mitral valvuloplasties. The estab-
lishment of catheter ablation of atrial fibrillation as an effective treatment strategy has brought transseptal
catheterization back to the limelight. Technique refinements, introduction of adjunctive imaging tools,
and enrichment of available technical equipment have simplified the procedure. In the present article we
review the technique of transseptal catheterization, presenting tips and caveats that could be of value for
safe and successful transseptal punctures. (PACE 2010; 33:231–242)
transseptal catheterization

Introduction the adjacent margin of its muscular rim (limbus),

Transseptal catheterization has been used in
a wide spectrum of interventional procedures, in-
cluding left atrial ablations, left atrial appendage
occlusion, and percutaneous mitral valvuloplasty.
In the era of widespread catheter ablation of atrial
fibrillation, the frequent need for safe left atrial
access has renewed the interest for transseptal
catheterization. Transseptal catheterization is a
technically demanding procedure which necessi-
tates familiarity and an adequate level of exper-
tise in order to avoid associated complications
that may be life-threatening. In the present arti-
cle, we review procedure steps and caveats that
can facilitate the performance of safe transseptal
punctures.
Anatomic Considerations
Thorough knowledge of the anatomy in both
atria and adjacent structures is crucial for transsep-
tal catheterization. It should be emphasized that
the interatrial septum, which represents the
anatomic target in a transseptal puncture, is not
synonymous with septal wall of the right atrium.1
The interatrial septum could be more accurately
defined as the septal structure that can be removed
without exiting from the cardiac cavities and is re-
stricted to the area of the fossa ovalis valve and
Address for reprints: Stylianos Tzeis, M.D., Deutsches Herzzen-
trum München, Lazarettstr. 36, 80636 München, Germany. Fax:
49-89-12184593; e-mail: stzeis@otenet.gr
Received April 29, 2009; revised July 26, 2009; accepted July
28, 2009.
doi: 10.1111/j.1540-8159.2009.02598.x
(Figs. 1 and 2).1 The fossa ovalis has an average
vertical diameter of 18.5 ± 6.9 mm and an average
horizontal diameter of 10.0 ± 2.4 mm, as measured
by intracardiac echocardiography (ICE) and fluo-
roscopy.2 The mean thickness of the fossa ovalis
valve assessed by transesophageal echocardiogra-
phy and measured in anatomical specimens is ap-
proximately 2 mm, whereas aneurismal valves are
thinner.3–5
The area extending superiorly from the fossa
ovalis to the ostium of the superior vena cava is
formed by infolding of the right atrial wall between
the superior vena cava and the right pulmonary
veins and is filled with extracardiac adipose tissue
(Fig. 1). The infolded groove ends at the superior
margin of the fossa ovalis to form a well-defined
superior rim. This slightly protruding rim forms
the superior boundary of the fossa ovalis and is
used as an anatomic landmark during transseptal
puncture to cross the valve of the fossa (Figs. 1
and 2). The portion of the so-called septal wall in
the right atrium that is located superiorly and an-
teriorly to the fossa ovalis, aptly named the aortic
mound, overlies the aorta and not the left atrium.
Therefore, puncture of this area should be avoided
by all means in order to avoid inadvertent damage
to the aorta (Fig. 2).
Although generally depicted as being in the
middle of the septal wall, the location of the fossa
ovalis varies from heart to heart. Consequently, the
proximity of the margins of the fossa to important
structures may show diversity. For example, the
anterior margin of an anteriorly situated fossa may
be immediately behind the aortic root. In cases
where the fossa is situated more superiorly or

C 2009, The Authors. Journal compilation 

 C 2009 Wiley Periodicals, Inc.

PACE, Vol. 33 February 2010 231

 TZEIS, ET AL.

Description of Transseptal Puncture

Figure 1. Anatomy of the interatrial septum. Four-
chamber view of a human anatomic specimen. The fossa
ovalis valve is demarcated with a brace. Please note that
the area extending superiorly from the fossa ovalis is
formed by infolding of the right atrial wall between the
superior vena cava and the right pulmonary veins and
is filled with extracardiac adipose tissue (arrow).
more posteriorly than usual, the risk of exiting the
heart during septal crossing is increased because of
the effacement of the superior or inferior margins,
respectively.
The strategy used for performance of transsep-
tal catheterization may vary in several steps. All
available options have relative advantages and
limitations and selection of a certain combination
is made by each physician based on familiarity
and preference (Table I). The first step in the per-
formance of a transseptal puncture is the proper
positioning of reference anatomic catheters in or-
der to visualize the location of the coronary sinus
and/or the aorta. A steerable catheter is placed in
the coronary sinus (CS). High amplitude ventric-
ular electrograms in the CS catheter should raise
the suspicion of its positioning in a posterolateral
branch which could lead to a false evaluation of
intrathoracic cardiac rotation. In our view, posi-
tioning of an additional catheter for localization
of the aorta is helpful. The aorta can be directly
visualized by advancing a pigtail catheter over a
J-tiped wire in the ascending aorta, but can also be
indirectly tagged by a correctly placed His bundle
catheter. The use of the His catheter is based on
the premise that the His bundle electrogram iden-
tifies the most caudal aspect of the aorta. The use
of a pigtail catheter has the advantage of directly
demarcating the aorta along its length and provid-
ing an online arterial blood pressure recording.
However, arterial access may be associated with
a higher risk for hematomas in the site of arterial
puncture, especially if anticoagulation is admin-
istered during the procedure, as is the case in left
atrial ablations.

Figure 2. Site of transseptal puncture in pathologoanatomic specimens. Photograph of a human

heart anatomic specimen where the site of transseptal puncture is viewed in two different projec-
tions analogous to the fluoroscopic views used in clinical practice. The left panel corresponds to
an LAO projection (slightly tilted) and the puncture site (tip of blue catheter) is situated between
the aorta (Ao) and the coronary sinus (grey catheter). The right panel shows the right atrial septal
wall from an RAO view. The arrow points to the fossa ovalis.

232 February 2010 PACE, Vol. 33

 TRANSSEPTAL CATHETERIZATION: CONSIDERATIONS AND CAVEATS

Table I.
Advantages and Limitations of Available Options in the Transseptal Puncture Approach

Aim—Advantage Limitations

CS catheter Evaluation of intracardiac rotation Limited familiarity by

nonelectrophysiologists
His catheter His electrogram identifies the most caudal aspect of the Indirect tag of the aorta
aorta
Pigtail catheter Demarcation of the aorta along its length Risk of hematomas in the puncture site
Continuous arterial pressure monitoring
Use of BRK-1 Easier entrapment of the sheath–needle assembly under the
needle superior rim of the FO
Overcomes difficult punctures in redo cases14
Steerable sheath Strong support of the distal dilator during sheath–needle Incremental cost
retraction Occasional difficulties in advancing the
Optimal catheter steering in LA sheath through fibrotic FO
Use of guidewire Reduced risk of accidental LA puncture when sheath jumps Occasional difficulties in advancing the
abruptly in the LA guidewire distally in a pulmonary vein
Strong hint for verification of LA access and exclusion of
pericardial/aorta puncture
Use of ICE Validation of proper needle positioning even in anatomically Incremental cost
difficult cases Frequent need for second operator
Visualization of fossa tenting Experience needed in interpreting ICE
Confirmation of successful LA access images
Early recognition of pericardial effusion Additional venous sheath needed
Double puncture Better manipulation of both catheters Need for second transseptal puncture
Lower risk of persistent iatrogenic ASD
Easier access of certain LA portions by placing the second
puncture in a different location of the FO

FO = fossa ovalis; LA = left atrium; ICE = intracardiac echocardiography; ASD = atrial septal defect.

Special attention should be given to the
proper positioning of the pigtail catheter which
should be always positioned as close to the aor-
tic valve as possible. The shaft of the catheter
should course along the posterior wall of the as-
cending aorta and the pigtail should be placed
in the posteriorly located noncoronary sinus of
the aortic valve. Catheter positioning should be
also controlled in a right anterior oblique (RAO)
projection. In this view, the shaft of the catheter
should be leftward to the pigtail, the pigtail should
point to the right of the fluoroscopy screen (ante-
riorly), and the catheter shaft should be smooth
without steep curving. If the pigtail catheter is
not advanced completely to the valve, transseptal
puncture may be performed too cranially. False
positioning of the pigtail may result also in wrong
evaluation of the posterior border of the aorta
and erroneous estimation of an anterior punc-
ture site as safe. After transseptal catheterization
the pigtail can be retracted below the level of
the renal arteries in order to reduce the risk of
thromboembolism.
Once the landmark catheters are positioned,
a long sheath with its dilator is inserted from the
femoral vein and advanced over a long wire up to
the superior vena cava. Then, the wire is removed,
the dilator is flushed and a Brockenbrough (BRK)
needle is inserted in the long sheath. In adult pa-
tients, there is the option of the standard curved
BRK needle (19◦ angle between the distal curved
segment and the needle shaft) and the BRK-1 nee-
dle which has an accentuated curve (53◦ angle).
Although the BRK-1 needle theoretically should
be reserved for patients with dilated right atrium,
it ensures good contact with the fossa ovalis in
almost all patients and also it allows the entrap-
ment of the sheath–needle assembly under the su-
perior rim of the fossa ovalis even if the rim is not
very prominent. The length of the needle (71 cm
or 89 cm) should be selected so that it fits with the
length of the sheath used.

PACE, Vol. 33 February 2010 233

 TZEIS, ET AL.
The BRK needle should be advanced until it
is just proximal to the tip of the dilator. If the
needle is disproportionately advanced, its edge
may protrude from the tip of the dilator and re-
sult in unintentional puncture of the superior
vena cava or even vessel laceration during sheath–
needle retraction. On the other hand, insufficient
advancement may result in suboptimal support of
the distal dilator during its retraction and potential
folding of its tip when it jumps to the fossa ovalis.
If folding of the distal millimeters of the dilator is
unrecognized, advancement of the needle may re-
sult in puncturing a hole at the sidewall of the dila-
tor. A good precaution is to check before the start
of the procedure how long the edge of the needle
pops out of the distal tip of the dilator when fully
advanced. In most cases, the maintenance of a 1–
2 cm safety distance between the proximal edge
of the dilator and the position of the needle when
maximally advanced prevents needle protrusion,
providing at the same time adequate support at the
distal part of the dilator.
Special attention should be paid to the way
the sheath–needle assembly is withdrawn from the
superior vena cava to the puncture site. When in-
tracardiac pressure measurement is also used as
part of the procedure, a pressure recording line is
connected either directly or via a manifold to the
proximal part of the BRK needle (Fig. 3). Before
starting the withdrawal, one should ensure that
the angle of the needle points to the same direc-
tion as the sideport of the sheath and the “side
marker” of the dilator (which corresponds to the
direction of the tip of the dilator) (Fig. 3). It is im-
portant to withdraw the assembly “en bloc,” with-
out changing the relative distance of the sheath
with the needle. This can be achieved by placing
two middle fingers between the dilator and the ar-
row of the needle. In this way, the needle follows
the retraction of the sheath, while ensuring that it
will not accidentally pop out of the dilator. Fur-
thermore, the torque handle at the proximal part
of the BRK needle should always be parallel to the
needle axis (Fig. 3). Unintentional turning during
handling of the sheath–needle assembly will con-
found intracardiac pressure measurement.
The needle and dilator, already positioned in
the superior vena cava, should be rotated toward
the posterior septum, with the arrow of the BRK
needle pointing at 4–5 o’clock, so that the dila-
tor can “fall” into the fossa ovalis when retracted
(Fig. 3). The withdrawal of the sheath–needle as-
sembly can be performed in a left anterior oblique
(LAO) fluoroscopic view with an angulation of 45◦ .
If a His catheter is used, a fine tuning of the angu-
lation can be performed; the tip of the His catheter
should point directly to the fluoroscopy screen.
Theoretically, two jumps of the sheath–needle as-
234 February 2010
sembly are noted before it falls within the fossa
ovalis. The first jump is not prominent and is noted
when the assembly passes the junction of superior
vena cava with right atrium. The second jump is
more accentuated and is due to the assembly drop-
ping underneath the superior muscular rim of the
fossa ovalis. After the second jump, the assembly
should be pushed slightly against the septum so
that it can be “entrapped” within the fossa ovalis
and under its roof which is formed by the superior
muscular rim. Positioning of the sheath–needle be-
tween the pigtail and the CS catheter in the LAO
projection is consistent with a safe puncture site
(Fig. 4). It is then a common proceeding to check
the location of the needle tip in an RAO projec-
tion, for example, RAO 30◦ . In this projection, the
needle should point in a slightly more posterior di-
rection than the CS catheter and should be located
posterior to the pigtail catheter but anterior to the
posterior border of the heart (Fig. 4). In case the
sheath is situated in a nonoptimal site, its loca-
tion can be corrected with proper maneuvers of
the sheath–needle assembly. Clockwise rotation
results in posterior movement of the assembly,
while counterclockwise rotation turns it anteriorly
(Fig. 4).
With the abovementioned projections the lo-
cation of each puncture site is controlled in two
vertical axes, the cranial–caudal and the anterior–
posterior. The location of the assembly in the
cranial–caudal axis is evaluated in the LAO projec-
tion. Transseptal puncture at excessively cranial
(at the level of the aorta) or caudal (near the CS os)
positions are potentially dangerous and should be
avoided. The anteroposterior location of the nee-
dle is controlled in the RAO projection. Inadver-
tent puncture at the posterior pericardium is likely
if the needle is posterior to the spine or the pos-
terior border of the fluoroscopic heart silhouette.
Additionally, in the RAO view, too anterior punc-
ture sites with an overlapping of pigtail and needle
should be avoided due to a high risk of punctur-
ing the aorta. The location of the needle can also
be verified by the injection of a small amount of
contrast media through the BRK needle. This al-
lows the visualization of the characteristic tenting
of the fossa ovalis due to the pressure applied by
the needle. However, the contrast media remain-
ing in the small lumen of the BRK needle may
interfere with the measurement of the transduced
pressures and therefore removal and flushing of
the needle is often necessary.
When a safe needle position is verified in both
RAO and LAO fluoroscopic projections, puncture
of the septum is attempted by controlled push-
ing of the BRK needle under continuous fluoro-
scopic guidance. Several signs are suggestive of
a successful access in the left atrium (Table II).
PACE, Vol. 33
 TRANSSEPTAL CATHETERIZATION: CONSIDERATIONS AND CAVEATS

Figure 3. Transseptal puncture system. Panel I. The illustrated transseptal puncture system
consists of a long sheath (SL0, St. Jude Medical, St. Paul, MN, USA), a Brockenbrough transseptal
needle (BRK-1, DAIG, St. Jude Medical), and a two-port manifold connected with a pressure
recording line (blue line-A) and a line for contrast media injection (B). In the distal end a syringe
with heparinized normal saline is connected for flushing of the needle. Please note that the angle
of the needle, the sideport of the sheath, and the marker of the dilator (red circle) are orientated
in a parallel direction. The torque handle at the proximal part of the transseptal needle (yellow
circle) is kept parallel to the needle axis. Panel II. Baseline orientation of the needle during
retraction of the sheath–needle assembly. The angle of the needle should point at 4–5 o’clock, in
the imaginary clock illustrated in the photograph.

When the septum is punctured, a characteristic
jolt can be felt. If intracardiac pressure measure-
ment is used, then the recorded intracardiac pres-
sure, which was initially a straight line due to
pressure of the needle onto the septum, increases
momentarily when the needle is pushed, and then
shows the characteristic pattern of left atrial pres-
sure (Fig. 5). The location of the needle can also
be verified by injecting contrast media through the
needle. Staining of the left atrium verifies the suc-
cessful transseptal access, while staining of the
pericardium or the aorta documents inadvertent
pericardial or aortic puncture.
A method for enhancing procedural safety is
to use a guidewire for verification of left atrial po-
sitioning and for secure advancement of the sheath
in the left atrium. The operator has either the op-
tion of using a 0.014-inch angioplasty wire through
the BRK needle,6 or a 0.032-inch guidewire
through the sheath dilator after removing the

PACE, Vol. 33 February 2010 235

 TZEIS, ET AL.

Figure 4. LAO and RAO fluoroscopic projections of a transseptal puncture site. Left panel.
Position of sheath–needle assembly in a typical puncture site as viewed in an LAO projection.
The position of the aorta is marked both by a pigtail catheter and by a catheter recording His
bundle electrogram. A catheter is placed within the coronary sinus (CS). The sheath is situated
between the pigtail and the CS catheter and under the His catheter. A tricuspid annuloplasty
ring and a mitral bioprosthetic valve demarcate the anatomic position of the tricuspid and mitral
annulus respectively. Right panel. Position of the sheath–needle assembly in an RAO projection.
The needle points slightly posterior than the direction of the CS catheter and is located posterior
to the pigtail catheter but anterior to the spine. The colored pictures illustrate the manipulations
needed for anterior or posterior reposition of the sheath–needle assembly.

needle. The insertion of the guidewire in a pul-
monary vein beyond the cardiac silhouette (AP
projection for left superior and LAO for left in-
ferior pulmonary vein) confirms left atrial access.
Inability to advance the guidewire beyond the flu-
oroscopic border of the heart should raise suspi-
cion of pericardial puncture. When manipulating
the guidewire for inserting into a pulmonary vein
(usually the left superior which is at the same
upward direction with the transseptal puncture)
it should be kept in mind that the pulmonary
vein ostium is located posteriorly and rather medi-
ally. Therefore, a posterior (clockwise) turning of
the sheath–dilator may be needed. Furthermore,
if the guidewire courses only along the direction
of the aorta, accidental aortic puncture should be
excluded by injecting contrast media.
Once we have confirmed that the needle has
entered the left atrium, the sheath can be ad-
vanced. Although advancement of the sheath over
the needle is safe in the hands of experienced op-
erators, we strongly favor the routine advancement
of the sheath over a guidewire which has been in-
serted distally in a pulmonary vein. With the use of
a guidewire, the direction of the sheath movement
is predefined when entering the left atrium. There-
fore, the likelihood of accidental puncture of the
left lateral wall is minimized especially when the
sheath suddenly jumps through a stiff or fibrotic
fossa ovalis (e.g., in redo punctures).
Another pitfall that may arise after a success-
ful puncture is the difficulty to advance the sheath
in the left atrium through a fibrotic fossa ovalis.
The sheath may bow superiorly in the right atrium,

Table II.
Signs Suggestive of Successful Access in the Left Atrium

• Characteristic palpable “pop” felt when the needle crosses over the fossa ovalis
• Recording of left atrial pressure waveform
• Staining of the left atrium after injection of contrast media
• Advancement of a guidewire in a left pulmonary vein beyond the fluoroscopic border of the heart silhouette
• Withdrawal of oxygenated blood from the transseptal needle (visual inspection or oxygenation measurement)
• Sudden collapse of the tented fossa following needle advancement (under ICE guidance)
• Visualization of the needle in the left atrium (under ICE guidance)
• Appearance of bubbles in the left atrium after saline injection through the needle (under ICE guidance)

236 February 2010 PACE, Vol. 33

 TRANSSEPTAL CATHETERIZATION: CONSIDERATIONS AND CAVEATS

Figure 5. Intracardiac pressure recording during transseptal puncture. Simultaneous ECG, intracardiac pressure, and
electrogram recording during transseptal puncture. From top to bottom leads I, II, III, V1, V6, intracardiac pressure
recording (0–30 mmHg scale), electrograms from coronary sinus distal (CS 1/2) to proximal (CS 7/8) at a sweep
speed of 25 mm/s. Initially, a straight line is recorded due to the contact of the needle with the interatrial septum
which results in lack of oscillation in the transduced pressures. During the transseptal puncture the pressure rises
momentarily above the upper scale limit due to the pushing of the needle against the wall. After gaining access in the
left atrium, a pattern of left atrial pressure waveform is recorded.

instead of crossing the punctured septum, even
if in some cases the cone-shaped dilator has al-
ready been advanced into the left atrium. This
barrier can be overcome by constantly exerting in-
creased force, while simultaneously turning the
sheath posteriorly (clockwise rotation until 9 or
even 12 o’clock). In these cases, extreme caution
is needed when the sheath abruptly jumps into the
left atrium. If no guidewire is used to ensure the
controlled direction of the sheath toward the lu-
men of the pulmonary vein, potentially rupture of
the opposite left atrial wall may occur.
Once the sheath is in the left atrium, the dila-
tor and the guidewire are removed very slowly
in order to avoid air embolism. Several opera-
tors perform the removal while maintaining nega-
tive pressure with a syringe placed at the sideport
of the sheath. Then, aspiration of thrombus and
debubbling of the sheath is necessary. Continuous
flushing of the sheath with heparinized normal
saline should be initiated and systematic anticoag-
ulation should be administered to prevent throm-
botic complications. A proposed anticoagulation
scheme is to give 2500 units of heparin after inser-
tion of the sheaths in the venous circulation and
5000 units of heparin after a successful transsep-
tal puncture combined with continuous heparin
infusion with a target activated clotting time of
300 seconds.
Transseptal Catheterization Guided by ICE
The development of ICE has provided an
ancillary tool for high resolution imaging of
intracardiac structures during interventional
procedures. ICE is widely applicable in elec-
trophysiology laboratories and one of the main

PACE, Vol. 33 February 2010 237

 TZEIS, ET AL.

Table III.
High-Risk Cases for Transseptal Puncture

• Repeat transseptal catheterization (increased thickness of the interatrial septum, local scarring over the previous
puncture site, and distorted interatrial septal anatomy)
• Atrial septal aneurysm (reduced distance between the apex of the tented fossa and the opposite left atrial wall during
puncture)
• Hypertrophied interatrial septum (lipomatous hypertrophy, cardiac amyloidosis)
• Surgically repaired ASD and PFO (altered anatomic landmarks, lack of second jump, occlusion of the anterosuperior
aspect of the interatrial septum, endothelialized and tough patch material)
• Device closure of ASD and PFO (altered anatomic landmarks, device overlapping septum, endothelialized devices)
• Excessive ventricular hypertrophy, hypertrophic cardiomyopathy (abnormal rotation of the cardiac axis)
• Distorted anatomy of interatrial septum due to congenital heart disease
• Severe scoliosis

ASD = atrial septal defect; PFO = patent foramen ovale.

utilizations is the facilitation of transseptal punc-
ture. The ultrasound transducer mounted on the
tip of steerable intravascular catheters is either
a phased array type (linear or circular) or a me-
chanically rotated type. The newer, phased-array,
multiple frequency ICE systems provide good
near-field resolution (in high frequency settings),
satisfactory tissue penetration (in low frequency
settings), and are capable of both pulsed and color
Doppler imaging. The developing technology of
three-dimensional ICE is expected to further en-
hance real-time imaging during electrophysiology
procedures.7,8
ICE can facilitate the performance of safe and
effective transseptal punctures. Its major strength
is the real-time visualization of the interatrial sep-
tum and the validation of proper needle position-
ing even in patients with peculiar anatomic fea-
tures (Table III). The success rate in ICE-guided
transseptal catheterization has been reported to
reach 100%.9,10 Apart from the clear imaging of
the fossa ovalis, ICE allows the visualization of the
tenting of the fossa due to the pressure applied by
the sheath–dilator and the sudden collapse of the
tenting when the needle pops into the left atrium
(Fig. 6). Furthermore, bubble visualization in the
left atrium after saline infusion confirms the po-
sitioning of the needle in the left atrium. ICE also
maximizes procedural safety due to early recogni-
tion of pericardial effusion which enables timely
intervention before occurrence of hemodynamic
compromise. The major shortcomings of ICE are
the incremental cost, the frequent need of a second
operator for manipulation of the ICE probe, and the
experience needed in interpreting ICE images. The
introduction of smaller diameter ICE catheters (8F)

Figure 6. Transseptal puncture guided by intracardiac echocardiography. Left panel. Character-

istic tenting of the fossa ovalis caused by the transseptal sheath. The fossa is pushed toward the
left atrium (LA). Please note the safe distance between the apex of the tented fossa and the left
atrial wall. Right panel. Collapse of the tenting when the needle has inserted in the left atrium.

238 February 2010 PACE, Vol. 33

 TRANSSEPTAL CATHETERIZATION: CONSIDERATIONS AND CAVEATS
has addressed at least partly the issue of sheath-
related vascular complications.
The question remains whether transseptal
puncture should be routinely performed under
ICE guidance. If ICE is implemented into the ap-
proach for catheter ablation of atrial fibrillation,
then it makes sense to use it also for the guidance
of transseptal puncture. In the rest of the cases,
no definite answer can be given. In our opinion,
the decision to use ICE should be individualized
based on the experience of the operator as well as
the difficulties encountered in each patient. Tak-
ing into consideration the low-complication rate of
transseptal punctures (around 1%),11,12 we believe
that the initial approach should be fluoroscopy-
guided, reserving the use of ICE for challenging
cases only. If the procedure is straightforward
(clear jump during assembly withdrawal, typical
needle positioning in fluoroscopic projections),
puncture without ICE guidance is, in our view,
safe and effective even for operators in the initial
phase of their learning curve. ICE should be used
more frequently in high-risk cases (Table III).
Useful Considerations for a Successful
Transseptal Puncture
Several considerations may be useful when
checking for correct positioning of the sheath–
needle assembly in a potential puncture site. The
proper site for transseptal puncture is affected by
age. In older individuals, the puncture site moves
higher and more posterior, as viewed in an RAO
angulation, while in the LAO view the angle of the
direction of the needle decreases with age.13 Punc-
ture site is also higher in redo cases as compared
with the first catheterization.14 Repeat transseptal
punctures are more difficult compared with first
catheterizations and have a lower success rate usu-
ally due to increased thickness of the fossa ovalis,
local scarring over the previous puncture site, or
distorted septal anatomy.5,14,15 The time interval
between first and second procedures could affect
the level of difficulty in redo cases, since with
longer intervening periods, regionally scarring in
the fossa ovalis would have developed fully.14 Ac-
cording to a recent report, a large-curved transsep-
tal needle (BRK-1) should be used in redo cases,
since it has been reported to overcome these dif-
ficulties.14 Manual reshaping and additional cur-
vature of the BRK needle is occasionally needed
after a failed attempt in order to maintain or even
increase the angle between the distal segment and
the shaft.
Double Transseptal Catheterization
In several procedures, including catheter ab-
lation of atrial fibrillation, a double access to
the left atrium may be necessary. This can be
PACE, Vol. 33 February 2010
achieved either by performing two separate punc-
tures in the interatrial septum or by positioning
two catheters in the left atrium through a single
puncture site. In the first approach, the aforemen-
tioned transseptal puncture procedure is followed
twice. Experienced operators are able to perform
the second puncture at a specific section of the
fossa ovalis in order to ease manipulation of the
catheters in a certain portion of the left atrium.
For example, puncture at the inferoposterior site
of the foramen ovale facilitates access to the right
inferior pulmonary vein and the adjacent atrial
myocardium.
In the second approach, the steps described
for the single transseptal puncture are followed
until the insertion of the sheath in the left atrium
via a guidewire placed in a left pulmonary vein.
Then, the sheath is retracted in the right atrium
and the ablation catheter is advanced beside
the guidewire through the single puncture site
(Fig. 7). Key points in achieving effortless cross-
ing of the ablation catheter are the advancement
of the catheter in a parallel orientation with the
guidewire, preferentially controlled in two fluoro-
scopic angulations, and the retraction of the sheath
low in the junction of inferior vena cava with the
right atrium so that it does not impede catheter ma-
nipulation. After inserting the ablation catheter in
the left atrium, the transseptal sheath is advanced
once more over the guidewire through the single
puncture site.
Occasionally, difficulties arise when the
sheath has to be readvanced into the left atrium
through the single puncture hole with the abla-
tion catheter already in place. In our experience,
this hurdle can be overcome by initial dilation of
the transseptal hole by repetitive controlled back-
and-forth movement of the transseptal sheath over
the guidewire and through the hole, before in-
serting the ablation catheter. Another proposed
method is to curve the ablation catheter anteri-
orly and inferiorly toward the mitral valve and
slightly pull it down in order to stretch slightly
the transseptal hole.16 The adoption of a similar
“parking position” for the ablation catheter is also
useful for preventing it from being accidentally
pushed against the left lateral atrial wall or the
left atrial appendage when the sheath is advanced
through the single puncture.
It is an advantage to be familiar with both
techniques for double transseptal catheterization,
since both may be useful on different occasions.
The double puncture technique is usually su-
perior since it provides optimal steering and
manipulation of both catheters. The single
transseptal technique is safer theoretically since
it does not expose the patient to the risk of a
second puncture. However, a second puncture is
239
 TZEIS, ET AL.

Figure 7. Double transseptal access through a single puncture site. Consecutive steps for double transseptal catheter-
ization through a single puncture shown in a series of fluoroscopic images (LAO projection). After the transseptal
puncture, the sheath is moved back and forth over the guidewire (1, 2) and then is retracted in the junction of the in-
ferior vena cava with the right atrium. With the guidewire retained distally in a pulmonary vein, the ablation catheter
is advanced toward the interatrial septum in a direction parallel to the guidewire (3) and then through the initial
puncture site (4). The ablation catheter is curved anteriorly and positioned in the mitral annulus (5). The transseptal
sheath is advanced once more over the guidewire (6). If needed the ablation catheter can be slightly pulled down in
order to stretch slightly the transseptal hole.

considerably facilitated by the presence of the first
sheath which tags the location of a safe puncture
site and guides the manipulation of the second
sheath. Existing data tilt the balance in favor of
the double transseptal technique as far as the
occurrence of persistent iatrogenic atrial septal
defects (ASDs) is concerned.17–20 Hammerstingl
et al., implementing transesophageal contrast
echocardiography, showed a significantly lower
risk of persistent iatrogenic ASDs after double
transseptal puncture compared with double
catheterization through a single puncture site.17
Furthermore, ASDs after double transseptal punc-
ture have been reported to present a high spon-
taneous closure rate and a low rate of paradoxical
embolism.18
Management of Difficult Cases
In a small percentage of cases necessitating
transseptal puncture, the transseptal catheteriza-
tion is demanding due to difficulties encountered
in finding the fossa ovalis under fluoroscopic guid-
ance and/or due to inability to cross the septum
(Table III). The use of transoesophageal or ICE
improves visualization and almost always over-
comes the difficulty of guiding the sheath to the
optimal puncture site.7,21 Right atrial angiography
can also outline regional peculiarities in anatomic

240 February 2010 PACE, Vol. 33

 TRANSSEPTAL CATHETERIZATION: CONSIDERATIONS AND CAVEATS
variants, in patients with extreme cardiac rotation
or diaphragm elevation.22 Emerging technologies
of direct visualization of the interatrial septum are
also promising.23
Apart from the abovementioned imaging
modalities, the use of recently available tools
may facilitate transseptal puncture in selected
cases. Radiofrequency current delivered through
the transseptal needle tip has been used to cross
excessively fibrotic, thickened, or aneurysmal sep-
tums. Radiofrequency energy can be transmitted
either by a conventional ablation catheter touching
the proximal end of the transseptal needle, or with
the use of electrocautery assistance.24–26 Based on
the same premise, a radiofrequency transseptal
system has been developed for piercing resistant
septums (Baylis Medical, Montreal, Canada).27,28
A specific radiofrequency transseptal catheter is
inserted through a dedicated sheath–dilator as-
sembly, then brought into contact with the fossa
ovalis and short bursts of low-voltage energy are
delivered, allowing access in the left atrium. In
case of highly resistant fossae, apart from the
option of radiofrequency puncture, a 0.014-inch,
sharp-tipped, J-shaped transseptal guidewire (Safe
Sept, Pressure Products, Inc., San Pedro, CA,
USA)29 or a more sharp BRK needle type (BRK-1
extra sharp) can be used.
Complications—Contraindications
Transseptal puncture is a reasonably safe
procedure with a complication rate of approxi-
mately 1%.11,12 However, the complications re-
lated to transseptal catheterization could be life-
threatening and the operators should be familiar
with their management. The complications may
occur either during the puncture or during the ad-
vancement of the sheath in the left atrium. The
most usual complications are pericardial effusion,
aortic puncture, perforation of the right or left
atrial wall, thrombus formation, as well as iatro-
genic ASD. In rare cases, transseptal catheteriza-
tion may result in ST-segment elevation in inferior
References
1. Ho SY, Sanchez-Quintana D, Cabrera JA, Anderson RH. Anatomy
of the left atrium: Implications for radiofrequency ablation of atrial
fibrillation. J Cardiovasc Electrophysiol 1999; 10:1525–1533.
2. Hanaoka T, Suyama K, Taguchi A, Shimizu W, Kurita T, Aihara N,
Kamakura S. Shifting of puncture site in the fossa ovalis during
radiofrequency catheter ablation: Intracardiac echocardiography-
guided transseptal left heart catheterization. Jpn Heart J 2003;
44:673–680.
3. Schwinger ME, Gindea AJ, Freedberg RS, Kronzon I. The anatomy of
the interatrial septum: A transesophageal echocardiographic study.
Am Heart J 1990; 119:1401–1405.
4. Shirani J, Zafari AM, Roberts WC. Morphologic features of fossa
ovalis membrane aneurysm in the adult and its clinical significance.
J Am Coll Cardiol 1995; 26:466–471.
5. Tomlinson DR, Sabharwal N, Bashir Y, Betts TR. Interatrial sep-
tum thickness and difficulty with transseptal puncture during redo
PACE, Vol. 33 February 2010
leads with or without transient bradycardia or atri-
oventricular conduction defect. Similar electro-
cardiographic abnormalities are usually attributed
to air embolism in coronary arteries, although a
Bezold–Jarisch-like reflex mechanism may also be
implicated.20,30,31
Absolute contraindications to transseptal
catheterization include the presence of a left atrial
thrombus and the documentation of prolonged In-
ternational Normalized Ratio values (INR > 2.5).
Conditions associated with anatomic peculiarities
which used to represent relative contraindications
for transseptal puncture (e.g., marked rotation of
the heart and great vessels, kyphoscoliosis, exces-
sive dilation of the ascending aorta)32 can be re-
liably overcome with the use of imaging modali-
ties. Similarly, prior surgical or transcatheter clo-
sure of ASD or patent foramen ovale (PFO) was
traditionally considered contraindication for the
performance of transseptal catheterization. How-
ever, transseptal access in these patient groups
has been proven safe and feasible, especially with
the aid of ICE.33,34 In patients with ASD/PFO clo-
sure devices, puncture should be performed at the
portion of the septum located inferior and poste-
rior to the closure device.33 In patients with sur-
gically repaired interatrial septums, puncture can
be performed directly through neighboring native
interatrial tissue, or through the patch itself in
case of pericardial or Dacron patch, but rather
not in case of Gore-Tex patch (W.L. Gore & As-
sociates, Flagstaff, AZ, USA) due to its resistant
texture.33
In conclusion, transseptal puncture is a de-
manding procedure which can be successfully
performed as long as a number of precautions
are taken. Continuous improvement in available
equipment and the implementation of ICE has
contributed in the reduction of complications. In-
cremental experience remains the pivotal factor
for increasing success rate and procedural safety.
Wider use of simulators for training on transseptal
puncture technique may also be helpful.
catheter ablation of atrial fibrillation. Pacing Clin Electrophysiol
2008; 31:1606–1611.
6. Haruta S, Kouno H, Akanuma H, Ichinose H, Shimakura T. The
guidewire technique for transseptal puncture. J Invasive Cardiol
2005; 17:68–70.
7. Mor-Avi V, Sugeng L, Lang RM. Real-time 3-dimensional echocar-
diography: An integral component of the routine echocardiographic
examination in adult patients? Circulation 2009; 119:314–329.
8. Knackstedt C, Franke A, Mischke K, Zarse M, Gramley F, Schimpf
T, Plisiene J, et al. Semi-automated 3-dimensional intracardiac
echocardiography: Development and initial clinical experience of
a new system to guide ablation procedures. Heart Rhythm 2006;
3:1453–1459.
9. Szili-Torok T, Kimman G, Theuns D, Res J, Roelandt JR, Jordaens
LJ. Transseptal left heart catheterisation guided by intracardiac
echocardiography. Heart 2001; 86:E11.
241
 TZEIS, ET AL.
10. Daoud EG, Kalbfleisch SJ, Hummel JD. Intracardiac echocardiog-
raphy to guide transseptal left heart catheterization for radiofre-
quency catheter ablation. J Cardiovasc Electrophysiol 1999; 10: 23.
358–363.
11. Roelke M, Smith AJ, Palacios IF. The technique and safety of
transseptal left heart catheterization: The Massachusetts General
Hospital experience with 1,279 procedures. Catheterization Car- 24.
diovasc Diag 1994; 32:332–339.
12. De Ponti R, Cappato R, Curnis A, Della Bella P, Padeletti L, Raviele
A, Santini M, et al. Trans-septal catheterization in the electrophysi- 25.
ology laboratory: Data from a multicenter survey spanning 12 years.
J Am Coll Cardiol 2006; 47:1037–1042.
13. Hu YF, Tai CT, Lin YJ, Chang SL, Lo LW, Wongcharoen W, Udyavar
AR, et al. Does the age affect the fluoroscopy-guided transseptal 26.
puncture in catheter ablation of atrial fibrillation? PACE 2007; 30:1–
5.
14. Hu YF, Tai CT, Lin YJ, Chang SL, Lo LW, Wongcharoen W, Udyavar
AR, et al. The change in the fluoroscopy-guided transseptal punc- 27.
ture site and difficult punctures in catheter ablation of recurrent
atrial fibrillation. Europace 2008; 10:276–279.
15. Marcus GM, Ren X, Tseng ZH, Badhwar N, Lee BK, Lee RJ, Foster
E, et al. Repeat transseptal catheterization after ablation for atrial 28.
fibrillation. J Cardiovasc Electrophysiol 2007; 18:55–59.
16. Yamada T, McElderry HT, Epstein AE, Plumb VJ, Kay GN. One-
puncture, double-transseptal catheterization manoeuvre in the 29.
catheter ablation of atrial fibrillation. Europace 2007; 9:487–489.
17. Hammerstingl C, Lickfett L, Jeong KM, Troatz C, Wedekind JA, Tie-
mann K, Lüderitz B, et al. Persistence of iatrogenic atrial septal
defect after pulmonary vein isolation—an underestimated risk? Am 30.
Heart J 2006; 152:362.e1–e5.
18. Rillig A, Meyerfeldt U, Birkemeyer R, Treusch F, Kunze M, Jung
W. Persistent iatrogenic atrial septal defect after pulmonary vein
isolation: Incidence and clinical implications. J Interv Card Electro-
physiol 2008; 22:177–181. 31.
19. Obel O, Mansour M, Picard M, Ruskin J, Keane D. Persistence of
septal defects after transeptal puncture for pulmonary vein isolation
procedures. Pacing Clin Electrophysiol 2004; 27:1411–1414.
20. Fagundes RL, Mantica M, De Luca L, Forleo G, Pappalardo A, Avella 32.
A, Fraticelli A, et al. Safety of single transseptal puncture for abla-
tion of atrial fibrillation: Retrospective study from a large cohort of 33.
patients. J Cardiovasc Electrophysiol 2007; 18:1277–1281.
21. Chierchia GB, Capulzini L, de Asmundis C, Sarkozy A, Roos M,
Paparella G, Boussy T, et al. First experience with real-time three-
dimensional transoesophageal echocardiography-guided transsep-
tal in patients undergoing atrial fibrillation ablation. Europace 2008; 34.
10:1325–1328.
22. Rogers DP, Lambiase PD, Dhinoja M, Lowe MD, Chow AW. Right
atrial angiography facilitates transseptal puncture for complex abla-
242 February 2010
tion in patients with unusual anatomy. J Interv Card Electrophysiol
2006; 17:29–34.
Thiagalingam A, D’Avila A, Foley L, Fox M, Rothe C, Miller D,
Malchano Z, et al. Full-color direct visualization of the atrial septum
to guide transseptal puncture. J Cardiovasc Electrophysiol 2008;
19:1310–1315.
McWilliams MJ, Tchou P. The use of a standard radiofrequency en-
ergy delivery system to facilitate transseptal puncture. J Cardiovasc
Electrophysiol 2009; 20:238–240.
Bidart C, Vaseghi M, Cesario DA, Mahajan A, Fujimura O, Boyle
NG, Shivkumar K. Radiofrequency current delivery via transseptal
needle to facilitate septal puncture. Heart Rhythm 2007; 4:1573–
1576.
Knecht S, Jais P, Nault I, Wright M, Matsuo S, Madaffari A, Lel-
louche N, et al. Radiofrequency puncture of the fossa ovalis for
resistant transseptal access. Circ Arrhythmia Electrophysiol 2008;
1:169–174.
Sakata Y, Feldman T. Transcatheter creation of atrial septal perfora-
tion using a radiofrequency transseptal system: Novel approach as
an alternative to transseptal needle puncture. Catheter Cardiovasc
Interv 2005; 64:327–332.
Sherman W, Lee P, Hartley A, Love B. Transatrial septal catheteriza-
tion using a new radiofrequency probe. Catheter Cardiovasc Interv
2005; 66:14–17.
de Asmundis C, Chierchia GB, Sarkozy A, Paparella G, Roos M,
Capulzini L, Burri SA, et al. Novel trans-septal approach using a
Safe Sept J-shaped guidewire in difficult left atrial access during
atrial fibrillation ablation. Europace 2009; 11:657–659.
Arita T, Kubota S, Okamoto K, Kuma F, Nakasuga K, Koga H, Ito
H, et al. Bezold-Jarisch-like reflex during Brockenbrough’s proce-
dure for radiofrequency catheter ablation of focal left atrial fibril-
lation: Report of two cases. J Interv Card Electrophysiol 2003; 8:
195–202.
Efremidis M, Letsas KP, Xydonas S, Koutras K, Sideris A, Kardaras
F. ECG findings of acute myocardial infarction and atrioventricular
block during a transseptal procedure for left atrial ablation. Hellenic
J Cardiol 2008; 49:284–287.
Ross J Jr. Transseptal left heart catheterization a 50-year odyssey. J
Am Coll Cardiol 2008; 51:2107–2115.
Lakkireddy D, Rangisetty U, Prasad S, Verma A, Biria M, Beren-
bom L, Pimentel R, et al. Intracardiac echo-guided radiofrequency
catheter ablation of atrial fibrillation in patients with atrial septal
defect or patent foramen ovale repair: A feasibility, safety, and effi-
cacy study. J Cardiovasc Electrophysiol 2008; 19:1137–1142.
El-Said HG, Ing FF, Grifka RG, Nihill MR, Morris C, Getty-
Houswright D, Mullins CE. 18-year experience with transseptal
procedures through baffles, conduits, and other intra-atrial patches.
Catheter Cardiovasc Interv 2000; 50:434–439.
PACE, Vol. 33