Electrosurgery in pediatric catheter interventions

ABSTRACT

Electrosurgery refers to the use of high-frequency alternating current in continuous mode to cut tissues by generating heat through vaporization of water molecules to hydrogen and hydroxide ions. This aids in transcatheter procedures to open atretic valves or atretic vessels, recanalize occluded blood vessels and conduits, and create new communication between adjacent cardiac chambers that have wide application in different structural and congenital heart diseases. This review aims to provide information on the physics behind electrosurgery, terminology used, and different clinical applications and finally details the practical techniques to be followed in the catheterization laboratory using the commonly available gadgets and catheters.

INTRODUCTION

Alternating current in the radiofrequency (RF) range (~500 KHz) delivered to tissues in continuous mode breaks down polar molecules such as water into hydrogen and hydroxide ions, which creates intense heat that cuts tissue.[1] When using a Brockenbrough needle or coronary guidewire, these tools can quickly and easily penetrate tough tissues. Proper insulation must be maintained up to the tip by employing catheters, microcatheters, and flushing with nonionic fluids such as dextrose solution (that replaces the ions) to prevent unwanted dispersal in blood (which may cause clot formation) or in adjacent tissues (which may lead to charring).[2] Dedicated RF systems, including VersaCross transseptal access solutions (Boston Scientific, Marlborough, MA, USA), NRG needle, 0.016” Nykanen RF guidewire, or 0.035” PowerWire (all from Baylis Medical Co, Montreal, Canada), are not always accessible.[3] Understanding how to effectively utilize electrosurgery, especially in pediatric catheterization procedures, can provide cardiologists with new opportunities to perform these specialized interventions efficiently.

TERMINOLOGY

Alternating current within the RF range, when delivered continuously without pulses, vaporizes and cuts tissue. This method, known as “cutting mode,” is employed in electrosurgery. In contrast, pulsed delivery – termed “coagulation mode” or “electrocautery” – results in greater desiccation with less cutting, thereby cauterizing tissue and achieving hemostasis.[2] A third mode used in electrophysiological RF ablation aims to create nonconductive lesions by carefully controlling temperature elevation, rather than vaporizing tissue.[4]

PHYSICS

Electric energy induces dielectric breakdown of polar water molecules, resulting in the formation of hydrogen and hydroxide ions. Continuous delivery of alternating current does not stimulate nerves or muscles, nor does it cause pain, muscle spasms, or ventricular fibrillation.[5] Tissues lacking water content – including bone, calcified regions, and polytetrafluoroethylene grafts – demonstrate increased resistance to vaporization and cutting. As pulsed waveforms allow intermittent cooling, they promote greater coagulation, thus increasing risk of thromboembolism. Moreover pulsed waveforms also reduce the effectiveness of cutting, and are therefore avoided in endovascular procedures. Additionally, pulsed currents can char tissues, further increasing their resistance to vaporization. For precise targeting, it is essential to concentrate the electrical current on the desired tissue by insulation using microcatheters and nonionic fluid flushes delivered via the tip of a needle or guidewire.

EQUIPMENT

Cautery equipment such as Valleylab (Medtronic, Minneapolis, MN) is frequently used for these procedures. Continuous current delivery is marked “yellow,” and pulsed mode is “blue” for easy identification. Coronary guidewires with high tip load, such as the Astato 20 (Asahi Intecc, Seto, Japan) with a 0.014” diameter, 300 cm length, and 20-g tip load, are preferred to prevent prolapse during perforation. Flushing a microcatheter with 5% dextrose exposes only the wire tip, minimizing unwanted current dispersal; the same applies to a transseptal sheath exposing just the tip of a Brockenbrough needle. Alternative wires, such as the Conquest Pro 12, offer utility but are limited to 180 cm in length. Unipolar current delivery uses the needle or guidewire as the active electrode, with a dispersive indifferent electrode patch affixed near the thigh or gluteal region.

STEP-BY-STEP PROCEDURE

Choice of perforating tool – coronary guidewire or Brockenbrough needle – depends on the clinical context. The Brockenbrough needle is preferred for thick atrial septum, surgical patches, or occluded straight vessels, while most other cases use coronary guidewires. An indifferent electrode should be firmly attached to dry skin near the thigh, away from radiation; loose electrodes on hairy surfaces can cause burns. 5% dextrose flushes help guide transseptal sheath placement using echocardiographic bubbles. The Brockenbrough needle is advanced with dextrose flushes to provide chemical insulation. If a straight pathway is anticipated, the needle is manually straightened to reduce the curve of the tip. Once the needle tip touches the target, current is delivered for 1–5 s while applying forward pressure. After breakthrough, a floppy coronary wire is inserted to prevent trauma. Astato wire is advanced through shaped guide catheters, insulated by microcatheter, with power set at 40–60 W for 1–5 s. After the electrosurgical perforation using the coronary wire, advance a compatible microcatheter over the coronary wire and then exchange it for an extra support wire. Once the extra-support wire provides a firm support, a 2–3 mm coronary balloon is introduced to dilate the track which will allow the guide catheter to follow the deflated balloon through the perforated area.

APPLICATIONS IN PEDIATRIC AND CONGENITAL HEART DISEASES

Electrosurgical applications in pediatric and congenital heart applications can be broadly divided into three groups: (i) open atretic valves or vessels, (ii) create communication between cardiac chambers, and (iii) recanalize occluded vessels and conduits [Table 1].

Table 1.

Electrosurgical procedures in pediatric and congenital heart diseases

Types of procedures	Examples of procedures
Open atretic valves and vessels	Pulmonary atresia with intact ventricular septum*
	Tetralogy of Fallot with pulmonary atresia#
	Atretic coarctation of aorta$
Create communication between cardiac chambers	Interatrial communications for atrial septostomy in pulmonary arterial hypertension*
	Iatrogenic inferior vena caval drainage to left atrium after secundum atrial septal defect surgery#
	Iatrogenic superior vena caval drainage to left atrium after sinus venosus defect surgery#
	Creation of de novo ventricular septal defect in idiopathic pulmonary arterial hypertension$
	Reopen closed surgical ventricular septal defect patch in progressive pulmonary hypertension#
	Reopen closed or ligated ductus arteriosus$
	Reversed Potts shunt by creating communication between thoracic aorta and left pulmonary artery*
	Creation of bidirectional Glenn shunt by creating communication between superior vena cava and pulmonary artery#
	Creation of Fontan completion by connecting inferior vena cava to pulmonary artery$
	Fontan fenestration creation by perforating between pulmonary artery and atrium$
Recanalize occluded vessels	Occluded central vein recanalization*
	Occluded Blalock–Taussig shunts$
	Occluded Fontan conduits$

*Established indications, ^$Emerging indications, ^#Experimental indications

Atretic valves

Nykanen RF wire is typically used to manage pulmonary atresia with an intact ventricular septum.[6] If this wire is not available, clinicians often use 0.014” chronic total occlusion coronary wires with a sharp tip and high tip load, such as the Conquest Pro (Asahi Intecc, Seto, Japan), for perforation. However, tetralogy of Fallot with pulmonary atresia (TOF-PA) and a longer atretic segment cannot be treated with these simple perforation methods. Although it is less conventional, transcatheter intervention for TOF-PA cases with extremely underdeveloped pulmonary arteries may promote arterial growth.[7] During electrosurgical procedures, the path of the guidewire should be directed by a selective aortopulmonary collateral angiogram that highlights the central pulmonary arteries [Figure 1].

Figure 1.

After computed tomographic delineation (a) of the atretic pulmonary valve in tetralogy of Fallot with pulmonary atresia, right ventricular outflow tract (RVOT) angiogram (b) shows the atretic membrane and selective collateral angiogram (c) shows the central pulmonary arteries (PAs). After electrosurgical perforation and stenting, a direct communication (d) is established between RVOT and PA. RVOT: Right ventricular outflow tract, PA: Pulmonary artery, RPA: Right pulmonary artery, LPA: Left pulmonary artery, MPA: Main pulmonary artery

Atretic arteries

Atretic aortic coarctations feature a gap between the proximal and distal segments. In adults, surgery is challenging due to extensive collateral vessels that increase bleeding risk. Electrosurgical recanalization connects these segments to establish an arterio-arterial circuit from the radial to femoral artery before placing a covered stent.[8] The optimal fluoroscopic angle for profiling the atretic segment is determined by preprocedural computed tomography (CT) imaging [Figure 2].

Figure 2.

Atretic coarctation visualized on computed tomogram (a) confirmed by simultaneous distal arch and descending aortic stump injections (b) is electrosurgically perforated with a guidewire from a femoral catheter and snared by the radial catheter (c). A balloon dilatation using a 2 mm coronary balloon (d) facilitates advancement of a long sheath a long sheath for a covered stent angioplasty. Poststent angiogram in lateral (e) and anteroposterior (f) view shows complete relief of the coarctation. Arrow points to the atretic segment of coarctation

PERFORATION OF THICK ATRIAL SEPTUM

Electrosurgical perforation of pericardial atrial septal patches may be required prior to implantation of atrial flow regulators in cases of progressive pulmonary arterial hypertension [Figure 3] or left heart failure.[9,10] Hemodynamic markers identify patients with pulmonary arterial hypertension who are at elevated risk for periprocedural mortality.[11] Electrosurgery is often necessary before procedures such as left atrial appendage occlusion, electrophysiological pulmonary vein isolation, management of postoperative pulmonary vein stenosis following total anomalous pulmonary venous return repair, and decompression of the left atrium in mitral atresia or hypoplastic left heart syndrome.

Figure 3.

Progressive pulmonary arterial hypertension following surgical atrial septal defect pericardial patch closure required Brockenbrough needle perforation aided by electrosurgery (a) to allow implantation of atrial flow regulator (b)

REDIRECTING ANOMALOUSLY DRAINING CAVAL VEINS

Surgery for oval fossa defects with a deficient inferior margin can mistakenly divert the inferior vena cava to the left atrium if the Eustachian valve is misidentified [Figure 4]. Electrosurgical perforation of the pericardial patch, followed by covered stent placement from the inferior vena cava to the right atrium, restores normal venous return.[12] The same approach applies to superior sinus venosus defect closure leading to diversion of the superior vena cava; perforation and stenting redirect flow to the right atrium.[13]

Figure 4.

Iatrogenic diversion of inferior vena cava (IVC) to the left atrium after surgical atrial septal defect closure shown on sagittal (a) and coronal (b) computed tomographic images is managed by electrosurgical puncture of the pericardial surgical patch (c) followed by covered stent redirection toward right atrium (RA) shown on IVC (d) and superior vena caval angiogram (e). Postprocedural computed tomography (f) confirms the redirection of IVC blood to RA. Arrow indicates hepatic veins. RUPV: Right upper pulmonary vein, IVC: Inferior vena cava, LA: Left atrium, RA: Right atrium, SVC: Superior vena cava

CREATION OF VENTRICULAR SEPTAL DEFECTS

Creating a ventricular septal defect may help patients with severe pulmonary hypertension and suprasystemic right ventricular pressures, despite concerns about arrhythmias during septal perforation. This technique was used in a patient with a previous pericardial patch for ventricular septal defect repair who developed worsening pulmonary vascular disease; the patch was perforated to lower right ventricular pressures to systemic levels [Figure 5].[14] A similar direct myocardial perforation in the mid-trabecular muscular septum is also possible in idiopathic cases without surgical patches [Figure 6].

Figure 5.

Left ventricular angiogram in left anterior oblique projection (a) after surgical closure of hypertensive ventricular septal defect shows intact surgical patch. As the pulmonary pressures are suprasystemic, electrosurgical guidewire perforation of the patch (b) is followed by small coronary balloon dilation (c) before advancing a larger guidewire and larger 16 mm balloon (d) to create a right ventricular decompression. LV: Left ventricular, RV: Right ventricular

Figure 6.

Severe progressive pulmonary arterial hypertension after device closure of atrial septal defect shows a squashed underfilled left ventricle (a). After electrosurgical guidewire perforation (b) of the trabecular interventricular septum and formation of an arteriovenous circuit, stent angioplasty across the interventricular septum (c) decompresses the suprasystemic right ventricle and improves left ventricular filling (d). IVS: Interventricular septum, LV: Left ventricular, RV: Right ventricular

RECANALIZATION OF CLOSED OR LIGATED ARTERIAL DUCTS

For patients with idiopathic pulmonary arterial hypertension, syncope, right ventricular dysfunction, and suprasystemic pulmonary pressures, a patent arterial duct can allow decompression of the pulmonary artery into the descending thoracic aorta. If the duct is closed, electrosurgical perforation followed by veno-arterial circuit formation and covered stent placement can restore this pathway [Figure 7]. Similar recanalization can be performed even years after ductus arteriosus ligation or device closure in childhood to address pulmonary hypertension.[15,16] This approach also applies to adult cyanotic heart disease with severe hypoxia and pulmonary oligemia. Although electrosurgical perforation poses risks in neonates and infants, it may be suitable for older patients if imaging confirms close proximity of the ductal ampulla and pulmonary artery.

Figure 7.

Aortogram in lateral view after many years of ductal ligation shows absence of residual flows (a). Electrosurgical guidewire perforation of the ligated region and snaring the wire (b) in the pulmonary artery allows a circuit formation to facilitate positioning a stent across the ligated duct (c) whose expansion establishes a reversed Potts shunt (d) to decompress the suprasystemic right ventricle. PA: Pulmonary artery, Ao: Aorta

REVERSED POTTS SHUNT

Mechanical treatment options for severe pulmonary arterial hypertension include balloon atrial septostomy and reversed Potts shunt. Balloon atrial septostomy improves cardiac output but may lead to cerebral hypoxia, whereas the reversed Potts shunt mitigates upper body desaturation. However, the reversed Potts shunt is suitable only for patients with suprasystemic pulmonary artery pressures, in contrast to balloon septostomy or atrial flow regulators, which can be utilized in most patients presenting with syncope. The transcatheter reversed Potts shunt is established by electrosurgical perforation of the left lateral wall of the descending thoracic aorta, adjacent to the left pulmonary artery, followed by veno-arterial circuit formation and covered stent placement.[17] Deployment involves advancing a deflectable Agilis sheath (Abbott Medical, Plymouth, MN, USA) within the descending thoracic aorta and directing it leftward toward an open snare positioned in the left pulmonary artery, guiding the perforating wire energized via electrosurgery [Figure 8].

Figure 8.

Aortogram in anteroposterior view (a) in idiopathic severe pulmonary arterial hypertension identifies the potential puncture zone on the left wall of descending thoracic aorta adjacent to the left pulmonary artery (LPA) where a snare is placed to catch the electrosurgically advanced aortic guidewire (b) to form a circuit (c) that allows stenting between LPA and aorta thereby establishing reversed Potts shunt (d). PA: Pulmonary artery, LPA: Left pulmonary artery, Ao: Aorta

FENESTRATION CREATION IN FAILING FONTAN

Fontan surgery often leads to venous congestion and reduced cardiac output. When high venous pressure causes protein-losing enteropathy or effusions, decompression can be achieved by creating a fenestration. In extracardiac conduit Fontan, this is done by puncturing either the polytetrafluoroethylene conduit toward the right atrium or the floor of the right pulmonary artery near the left atrium through the transverse pericardial sinus.[18] Prior surgical adhesions make bleeding rare and the procedure safe. Electrosurgery with a Brockenbrough needle facilitates the puncture, after which a covered stent is placed to decompress the circuit, reducing congestion and improving cardiac output [Figure 9].

Figure 9.

Pulmonary angiogram (a) through a failing Fontan conduit shows right pulmonary artery (RPA) and left pulmonary artery. Electrosurgical Brockenbrough needle perforation of the floor of RPA (b) allows placement of a stent (c) that creates a fenestration between the RPA and atrium (d). RPA: Right pulmonary artery, LPA: Left pulmonary artery

DE NOVO FONTAN CREATION AFTER GLENN SHUNTS

Glenn shunt is ideally performed between 3 and 12 months to prevent chronic ventricular volume overload. Electrosurgical attempts to create nonsurgical Glenn shunts are not currently active.[19] The Glenn procedure prepares for Fontan surgery, typically planned at 4–10 years. Delaying Fontan completion increases pulmonary resistance due to hypoxia and polycythemia, which is worsened by nonpulsatile Glenn flows. Late presentation after Glenn shunt raises risks for Fontan completion due to advanced age and high filling pressures. Early extubation and ambulation post-Fontan improve venous blood flow to the lungs. The transcatheter Fontan procedure facilitates early extubation and ambulation [Figure 10]. Electrosurgical perforation of the pulmonary artery followed by stent placement from the inferior vena cava to the pulmonary artery is another approach.[20]

Figure 10.

Right jugular sheath angiogram (a) after Glenn shunt shows right and left pulmonary arteries, while a simultaneous femoral venous access catheter angiogram shows superior vena caval stump. Snare in the pulmonary artery (PA) catches a guidewire advanced through an electrosurgically advanced Brockenbrough needle (b) and forms a circuit. A long covered stent advanced in this circuit is partially expanded in PA (c) and after confirming position, fully expanded (d) to create a transcatheter Fontan completion from the inferior vena cava and PA. RPA: Right pulmonary artery, LPA: Left pulmonary artery, SVC: Superior vena cava, PA: Pulmonary artery, IVC: Inferior vena cava

RECANALIZATION OF OCCLUDED VEINS

Repeated central venous cannulation for catheterization procedures in patients with complex congenital heart disease, as well as hemodialysis cannulation in those with end-stage renal disease, frequently result in progressive venous occlusions. Electrosurgical techniques may be utilized to recanalize these vessels. The remnants of jugular or subclavian veins can be accessed and recanalized in order to reintroduce hemodialysis catheters into the right atrium via chronically occluded veins [Figure 11].

Figure 11.

After multiple hemodialysis through various neck veins for many years, a complete venous occlusion of the right subclavian vein (a) is electrosurgically recanalized (b) using a guidewire to form a channel (c) that allows placement of a new hemodialysis cannula (d) in a patient with end-stage renal disease. SVC: Superior vena cava

RECANALIZATION OF OCCLUDED ARTERIES

Ductal site stenosis of the pulmonary arteries, often seen during pre-Fontan cardiac catheterization after bidirectional Glenn shunts in complex univentricular hearts, is treated with pericardial patch enlargement at cavopulmonary anastomosis. Unlike pulsatile biventricular flow, nonpulsatile flow after Glenn shunt can lead to undetected pulmonary arterial occlusion due to low echocardiographic velocities. Late detection results in single lung circulation and worsens univentricular physiology [Figure 12]. Electrosurgical recanalization and covered stent placement can restore two-lung circulation.

Figure 12.

A complete occlusion of the left pulmonary artery (LPA) many years after Glenn shunt is identified on transjugular angiogram (a) that shows a good-sized right pulmonary artery. Electrosurgical perforation of the occluded artery (b) is followed by LPA stent angioplasty (c) allowing a two-lung circulation (d) from the superior vena cava. LPA: Left pulmonary artery, RPA: Right pulmonary artery, SVC: Superior vena cava

RECANALIZATION OF OCCLUDED CONDUITS

The modified Blalock–Taussig shunt is frequently utilized as a palliative procedure in cyanotic patients. However, it is associated with an adverse natural course, characterized by progressive thrombotic occlusion over time. When pulmonary arterial dimensions are inadequate for biventricular repair, patients are considered unsuitable candidates for definitive surgical intervention. Electrosurgical techniques may be applied to recanalize chronically occluded polytetrafluoroethylene conduits, thus enhancing oxygen saturation in hypoxic pediatric patients. A comparable thrombotic occlusion, although uncommon, can occur in large Fontan conduits and may manifest as protein-losing enteropathy. Management of such cases involves electrosurgical perforation of the obstructed Fontan conduits using straightened Brockenbrough needles advanced via the femoral veins, followed by deployment of covered stents [Figure 13].

Figure 13.

A failing Fontan circulation investigated many years after surgery with a jugular access angiogram (a) shows an occluded extracardiac Fontan conduit while a transfemoral venous angiogram (b) confirms suprahepatic complete occlusion of the inferior vena cava (IVC). Electrified Brockenbrough needle (c) recanalizes the occluded conduit (d) to allow covered stent angioplasty (e) and decompresses the IVC (f). IVC: Inferior vena cava

COMPLICATIONS: OVERPENETRATION

The Brockenbrough needle utilizes both electric cutting and mechanical force, potentially resulting in overpenetration into the opposing wall. Advancement through the atrial septum may place the needle in close proximity to the posterior left atrial wall or the descending thoracic aorta, thereby increasing the risk of injury to these structures [Figure 14]. Prompt identification of such complications, reversal of heparin with protamine, and preparation for closure of aortic perforations using coils are essential management strategies. Similarly, directing the needle tip toward the left wall of extracardiac Fontan conduits when creating a fenestration may inadvertently puncture a large adjacent vessel, such as the ascending aorta, presenting comparable risks [Figure 15]. Elevated pressures in the aortic root can result in persistent shunting from the aorta to either the atrium or the pulmonary artery, necessitating closure with appropriate devices [Figure 16].

Figure 14.

Transseptal puncture needle for entering left atrium (LA) from right atrium to address severe pulmonary venous anastomotic obstruction after surgery for total anomalous pulmonary venous drainage pushes the septum posteriorly (a). After puncture, a coronary guidewire fails to enter freely into a cardiac chamber (b). Injection from transseptal sheath shows mediastinal contrast spill from LA roof injury and filling of descending thoracic aorta (c) as explained in the cartoon (d). LA: Left atrium, RA: Right atrium, PV: Pulmonary vein

Figure 15.

Attempts to fenestrate a failing Fontan procedure with a Brockenbrough needle from right jugular vein (a) result in perforation of aortic (Ao) root with guidewire tip in the ventricle (b). Aortogram (c) confirms fistulous communication from Ao root to right pulmonary artery, selectively entered with a guide catheter (d) to allow its closure with an Amplatzer duct occluder II device (e). The cartoon (f) explains the proximity of the Ao root to the conduit. Ao: Aortic, PA: Pulmonary artery

Figure 16.

In the patient shown in Figure 15, a second attempt is made through a transfemoral Brockenbrough needle (a) from the inferior vena cava after sealing the aortic (Ao) perforation with a device. This attempt (b) also results in sheath entry into the Ao root despite transesophageal echocardiographic guidance. This second perforation was sealed with a Piccolo device (c). As the sheath was withdrawn, a guidewire was introduced into the atrium (d) to expose a stent partially across the fenestration (e) before its full expansion (f). IVC: Inferior vena cava, Ao: Aortic, PA: Pulmonary artery

COMPLICATIONS: UNDERPENETRATION

Unlike the Brockenbrough needle, which can overpenetrate, electrified coronary wires may not penetrate enough due to lack of force. If, during a transcatheter reversed Potts shunt procedure, the electrified wire passes through the left wall of the descending thoracic aorta but does not reach the nearby left pulmonary artery, it can drift into the mediastinum and cause a hematoma. Once partial penetration occurs, charring of the mediastinal tissue can halt vaporization and stop further cuts in the adjacent wall of the left pulmonary artery. Even after protamine reversal, an aortic perforation causing mediastinal bleeding is treated with sealing occlusive coils [Figure 17].

Figure 17.

After ventricular septal defect surgical closure, progressive pulmonary arterial hypertension warranted a reversed Potts shunt between aorta (Ao) and left pulmonary artery separated by a small gap of 2 mm shown on simultaneous angiogram from both sides (a). An electrified guidewire from an Agilis sheath in Ao increases the distance as it fails to enter the pulmonary artery (b) confirmed on simultaneous injection (c). Injection showed a self-contained contrast spill (d) following protamine reversal. LPA: Left pulmonary artery, Ao: Aorta, PA: Pulmonary artery

TIPS TO AVOID COMPLICATIONS

Using nonionic dextrose solutions and insulating microcatheters to fully insulate the needle or guidewire prevents current and heat from dispersing. If insulation is insufficient, the entire system may overheat. Tissue charring at the tip can lead to thrombus formation; however, maintaining adequate activated clotting time helps prevent thromboembolism. Securing the indifferent electrode properly avoids skin burns where the patch is attached. Transseptal punctures of calcified pericardial patches are safe when guided by transesophageal echocardiography. Before recanalizing completely blocked arteries, veins, shunts, or conduits, it is essential to carefully review preprocedural CT scans to plan the guidewire trajectory. It is important to understand that there is a learning curve, limited large-scale data, outcome variability based on operator expertise, and potential publication bias favoring successful procedures while neglecting complications.

CONCLUSIONS

A comprehensive understanding of electrosurgery is essential for interventional cardiologists performing pediatric and structural heart procedures. Electrosurgery facilitates the opening of atretic valves and arterial occlusions, enables the creation of connections between cardiac chambers and adjacent blood vessels, and supports the recanalization of occluded vessels and surgical conduits. The equipment for electrosurgical techniques is readily available in most catheterization laboratories and does not require highly specialized hardware or advanced technology. Applied knowledge of insulating perforating guidewires or needles with microcatheters, as well as the use of insulating media such as dextrose solution, can be particularly valuable when addressing atypical anatomical findings during cardiac catheterization.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.