Intracardiac Echocardiography-Guided Transseptal Puncture Invisible by Transesophageal Echocardiography After Secundum Atrial Septal Defect Closure

An 81-year-old woman who underwent secundum atrial septal defect (ASD) closure using a 16-mm Amplatzer Septal Occluder (Abbott, St. Paul, MN) 2 years ago experienced palpitations for 1 year, due to drug-refractory persistent atrial fibrillation, so catheter ablation was performed. A transthoracic echocardiogram revealed dilation of the left atrium (LA; 54 mL/m²) without severe valvular disease. Preprocedural transesophageal echocardiography (TEE) demonstrated that the ASD closure device was well positioned, at a sufficient distance from the fossa ovalis' posteroinferior edge (Fig. 1A). Transseptal puncture (TSP) was planned posteroinferior to the device, to minimize deformation, instead of through the closure device, and catheter ablation was performed under general anesthesia. After intubation, the TEE probe was guided into the mid-esophagus. TSP was performed at the posteroinferior edge of the fossa under fluoroscopic and TEE guidance. The Swartz Braided Transseptal Guiding Introducer Sheath (Abbott, St. Paul, MN) was advanced to just beneath the closure device, and the 0.032-inch guidewire included as an accessory with the Swartz sheath was swapped for a radiofrequency needle, which was finely adjusted to the posteroinferior edge of the fossa under fluoroscopic guidance (Fig. 1B). We attempted to confirm the position of the Swartz sheath tip by TEE, but TEE could not confirm this (Fig. 1C). Therefore, intracardiac echocardiography (ICE; SoundStar, Biosense Webster, Diamond Bar, CA) was performed. After confirming that the Swartz sheath tip was at the posteroinferior edge, and advancing the needle, tenting was verified under ICE and fluoroscopic guidance, and TSP was performed (Fig. 1, D and E; Video 1 , view video online). Following needle replacement with a 0.032-inch guidewire in the superior left pulmonary vein, TEE still could not visualize the TSP site, as it was too close to the atrial wall (Fig. 1F). An ablation catheter (THERMOCOOL SMARTTOUCH Surround Flow, Biosense Webster) within a deflectable sheath (VIZIGO sheath; Biosense Webster) was advanced from the TSP site into the LA (Fig. 1G). With 2 sheaths (Swartz; Vizigo) inserted into the LA, we achieved pulmonary vein isolation successfully, without complications (Fig. 1H). During the 6-month follow-up, atrial fibrillation recurrence and late complications, including device deformation and severe shunt, were not observed.

Figure 1.

Preoperative and intraoperative transesophageal echocardiography (TEE), intraoperative intracardiac echocardiography (ICE), and fluoroscopic images of the catheter ablation procedure. (A) Preprocedural TEE revealed that the distance from the closure device (Amplatzer Septal Occluder; Abbott, St. Paul, MN) to the posteroinferior edge of the fossa was sufficient. (B) The Swartz sheath (Abbott) tip at the posteroinferior edge of the fossa. (C) TEE could not confirm the position of the Swartz sheath (Abbott) tip. (D, E) Transseptal puncture was performed under fluoroscopic and ICE guidance. (F) TEE was unable to visualize the transseptal puncture site. (G, H) Pulmonary vein isolation was achieved successfully with 2 left-atrial sheaths. 16-mm Amplatzer Septal Occluder (Abbott); Vizigo (Biosense Webster, Diamond Bar, CA). AP, anterior to posterior; LAO, left anterior oblique.

Our procedure follows that described in previous reports that demonstrate the feasibility of TEE- and ICE-guided TSP.^1,2 Building upon these studies, our case further illustrates the importance of having both TEE and ICE as viable options, each having different strengths and weaknesses. Moreover, Figure 2 illustrates the mechanism that explains why ICE was particularly beneficial due to the short tenting height and the proximity to the atrial wall, which complicates visibility with TEE from a distant probe position. In particular, Figure 2C shows that the proximity to the atrial wall prevents TEE visualization of the TSP site. ICE was more suitable for visualization in our case, due to the short tenting height and the proximity to the atrial wall. On the other hand, ICE is unsuitable for preprocedural evaluation, and TEE excels in providing precise measurement of the distance from the closure device to the posteroinferior edge. Utilization of both ICE and TEE is crucial for safely performing TSP in patients with prior ASD closure devices.

Novel Teaching Points.

• •Utilizing both transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) is crucial for safely performing TSP in patients with prior atrial septal defect closure devices, as each modality has distinct advantages at different procedural stages.
• •ICE offers superior visualization for transseptal puncture in cases where the proximity to the atrial wall complicates TEE imaging, highlighting its importance in specific anatomical scenarios.

Figure 2.

The schema of transseptal puncture (TSP), explaining the visualization of the puncture sites with transesophageal echocardiography and intracardiac echocardiography (ICE). (A, B) If TSP is performed at the usual site, at a reasonable distance from the edge of the fossa, the tenting height and distance to the atrial wall will be sufficient, allowing for a clear view of the puncture site with both transesophageal echocardiography and ICE. (C, D) If TSP is performed at the posteroinferior edge of the fossa (as in this case), the tenting height or distance to the atrial wall may not be sufficient. Consequently, the puncture site may be adequately evaluated only using ICE, as the probe is closer to the site. 16-mm Amplatzer Septal Occluder (Abbott, St. Paul, MN).

Supplementary Material

Video 1

We performed a transseptal puncture at the posteroinferior edge of the fossa ovalis guided by intracardiac echocardiography.