Cardiac Rhythm Management
Articles Articles 2013 October

Letter from the Editor in Chief

DOI: 10.19102/icrm.2013.041001

John Day, MD, FHRS, FACC

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Dear Readers,

Many years ago when I first came out of fellowship, I remember laying awake at night, sleepless, worrying about the transseptal catheterization I would be performing in the morning for an atrial fibrillation ablation procedure. I distinctly remember one case in particular. The patient was a 55-year old man with symptomatic lone paroxysmal atrial fibrillation refractory to flecainide. It was one of my first cases coming out of fellowship. While I had been trained to perform transseptal catheterizations blindly (without intracardiac echo), it was still a procedure that scared me to death.

I tried to act cool and calm without letting on to my fellow or EP lab staff that I was literally sweating bullets from the fear of doing the procedure. Even one small mistake could lead to a life-threatening perforation of the aorta or myocardium. If cardiac tamponade resulted, would I be able to quickly perform a pericardiocentesis to save the patients’ life? What would I tell his wife and his children? Would I lose my job if a disastrous complication occurred?

Fortunately, the procedure went well without any complications. However, I felt that just the stress alone of doing this aspect of the procedure caused me to age several years.

Knowing that I could not begin my career with so much stress and anxiety before each case, I quickly looked for a better way to do these procedures. Fortunately, intracardiac echocardiography (ICE) had just come of age. I quickly latched onto this new technology. No longer was I “blindly” performing these procedures. I studied everything I could get my hands on to learn this new “ICE anatomy”, to make the procedure safer and to keep my sanity.

In the early days I was just happy to get across the septum. Who cares where the sheath ended up—as long as it was in the left atrium I was happy. Fortunately, after nearly 8,000 transseptal catheterizations I have yet to experience a complication. Indeed, with time and more advanced ICE skills, it became advantageous to perform site-specific transseptal catheterizations (i.e. anterior, posterior, superior, or inferior access sites) depending on what type of a procedure I was doing.

Fast-forward to today and the transseptal catheterization is something that does not even register on my radar screen. It has become so automatic and so safe. In fact, I have become so reliant on ICE that I don’t even use fluoroscopy for the transseptal puncture. Who needs fluoroscopy when you can see everything clearly with ICE.

Stick around a PFO or ASD closure device, no problem. Stick across the septum of a patient with an ACT of 300-400 who had already undergone many prior AF procedures with a scarred up septum, once again never a problem. Place a large sheath across the septum for an appendage closure device, not even an issue. Regardless of the anatomy, most transseptal procedures are done within one to two minutes at most.

However, to get to this point required thousands and thousands of transseptal catheterization procedures. The transseptal catheterization has now become a requisite of every electrophysiologist. This approach is critical for atrial fibrillation ablations, ventricular tachycardia ablations, left-sided pathways, appendage closure procedures, etc.

In this issue of the Journal, Drs Merchant and DeLurgio from Emory take us through a step-by-step process of how to perform site-specific transseptal catheterizations. Indeed, in today’s current era it could argued that all transseptal procedures should be done under ICE guidance both for safety and to improve procedural success by site-specific transseptal access. Even in the era of cost containment, ICE adds minimal extra cost to the procedure as the catheters can be resterilized and used over and over.

I highly commend this article to anyone who performs transseptal procedures. Study the excellent guidance provided in this article. As always, I hope that this issue of the Journal has been very beneficial to you and your practice. Do you use ICE for transseptal guidance? I welcome your comments and suggestions.

Warm regards,


John Day, MD, FHRS, FACC
The Journal of Innovations in Cardiac Rhythm Management
Director of Heart Rhythm Services
Intermountain Medical Center
Salt Lake City, UT