Is ICE the key to success?
Both the aforementioned approaches seem safe and feasible, although it
has to be underlined that 3 patients (4.7%), all in the same cohort,7 had an inadvertent epicardial puncture during the
transseptal access. In these 3 cases, although the device diameter
ranged from 28 to 34 mm, a non-echocardiography guided TSP across the
native interatrial septum (posteroinferior to the ASD closure device)
was performed. After the epicardial puncture, 2 patients underwent TSP
across the device in the same procedure, while in one case the procedure
was rescheduled under transesophageal echocardiography (TEE) guidance.
This percentage of epicardial puncture during a fluoroscopy-guided
transseptal approach is extremely high (3 out of 9 patients), especially
if we consider that procedures were performed in a high-volume center by
skilled operators. As stated by Santangeli et
al .6, intracardiac echocardiography (ICE) guidance is
crucial to identify the portion of the native septum not covered by the
ASD closure device (generally posteroinferior to the device), that
should be preferentially targeted during TSP. In their cohort, if ICE
failed to recognize a portion of the interatrial septum not covered by
the device, mostly due to oversizing with respect to the interatrial
septum or in cases with a device diameter ≥ 26mm, a direct puncture of
the closure device was performed. Although Sang et
al. 8 reported no procedural complications without
ICE, suggesting that real-time monitoring of catheter movement may be
sufficient to assess the optimal puncture site even when the device
diameter is ≥ 26mm, in our opinion ICE guidance remains crucial to
improve safety and to avoid unnecessary attempts to TSP by identifying
unfavorable anatomies in which a straight puncture of the device should
be performed. Real-time 3D-TEE has also shown to provide an accurate
anatomic definition of the native septum during TSP11and may represent a valuable alternative, although ICE-guidance is
corroborated by more robust data in this scenario and its use should be
encouraged in routine practice.