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Transseptal Access Using Balloon-Assisted Tracking Technique
Case Presentation
An 80-year-old female with a history of heart failure with reduced ejection fraction, hypertension, and chronic kidney disease presented with worsening dyspnea and fatigue for 6 months despite being on optimal guideline-directed medical therapy. An echocardiogram revealed an ejection fraction of 30%-35% and severe mitral valve regurgitation. A coronary angiogram revealed no significant obstructive coronary artery disease. After discussing different options with the patient, it was opted to proceed with mitral valve repair using MitraClip (Abbott Vascular).
Crossing the interatrial septum was challenging. Although we were able to cross the interatrial septum with a transseptal needle, advancing the sheath across the fossa ovalis was difficult. Several maneuvers such as rotating and redirecting the sheath were not successful. Pre-dilation of the septum with 5 mm x 40 mm balloon did not allow for insertion of the MitraClip guide across the interatrial septum. At this point, we elected to use the balloon-assisted tracking (BAT) technique. Using a 7 mm x 40 mm balloon that was inflated to 10 atmospheres (atm) at the tip of the guiding catheter, we were able to advance the sheath through interatrial septum (Figures/Videos 1-3). Subsequently, a G4 XTW MitraClip was successfully deployed in the central position. A post procedure transesophageal echocardiogram showed mild mitral regurgitation.
Video 1. Inchworming technique.
Video 2. Sheath entering through the interatrial septum.
Video 3. MitraClip prior to deployment.
Discussion
Transseptal access is essential for many procedures including transcatheter mitral valve interventions, pulmonary vein isolation, left atrial appendage closure, and percutaneous left ventricular assist devices. However, there are many scenarios that one might face that can make transseptal access challenging. These include but are not limited to difficult engagement of the fossa ovalis, needle advancement, and sheath and guide advancement.1 In our case, MitraClip guide advancement was challenging. We were able to overcome this using the BAT or the ‘inchworming’ technique. This technique was originally described to overcome tortuosity, or a small-caliber or spastic radial artery during a transradial approach.2 We describe a new implication for the inchworming technique. The conical shape of the inflated balloon provides flexibility, minimizes trauma, and allows atraumatic transseptal access.
Conclusion
Balloon-assisted tracking offers a safe and effective approach to advancing a large sheath across the interatrial septum.
References
1. Alkhouli M, Rihal CS, Holmes DR Jr. Transseptal techniques for emerging structural heart interventions. JACC Cardiovasc Interv. 2016 Dec 26; 9(24): 2465-2480. doi: 10.1016/j.jcin.2016.10.035. PMID: 28007198.
2. Patel T, Shah S, Pancholy S. Balloon-assisted tracking of a guide catheter through difficult radial anatomy: a technical report. Catheter Cardiovasc Interv. 2013 Apr;81(5):E215-8. doi: 10.1002/ccd.24504
Disclosures: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Ninad Nadkarni, MD, at nadkarni_ninad@yahoo.com or ninad.nadkarni@sanfordhealth.org
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