Transseptal puncture for left atrial ablation: risk factors for cardiac tamponade and a proposed causative classification system. (3rd October 2022)

• Record Type: Journal Article
• Authors: Roelas, M; Vyas, R; Maclean, E; Mahtani, K; Butcher, C; Ahluwalia, N; Honarbakhsh, S; Finlay, M; Chow, A; Earley, M J; Sporton, S; Lambiase, P D; Schilling, R J; Hunter, R J; Segal, O R
• Is Part Of: European heart journal. Volume 43(2022)Supplement 2
• Publication Date: 2022-10-03
• Subjects: Cardiology -- Periodicals; Heart -- Diseases -- Periodicals; 616.12005
• DOI: 10.1093/eurheartj/ehac544.448
• Languages: English
• ISSNs: 0195-668X

Abstract

Abstract: Background: Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). Purpose: We examined the associations of TSP-related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our centre from 2016–2020. Methods: Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinised to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. Results: 3, 239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP-related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above-median age (OR 2.4 (1.19–4.2), p=0.006) and those undergoing re-do procedures (OR 1.95 (1.29–3.43, p=0.042) were at higher risk of TRCT. Of the operator-dependent variables, choice of transseptal needle (Endrys vs Brockenbrough, p>0.1) or puncture sheath (Swartz vs Mullins vs Agilis vs Vizigo vs Cryosheath, all p>0.1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk (OR 4.42 (2.45–8.2), p=0.001), whilst top quartile operator experience (OR 0.4 (0.17–0.85, p=0.002), transoesophageal echocardiogram (TOE prevalence: 26%, OR 0.51 (0.11–0.94), p=0.023), and use of the SafeSept guidewire (OR 0.22 (0.08–0.62), p=0.001) reduced TRCT risk. An increase in SafeSept wire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R2=0.72, p<0.001) and was associated with a relative risk reduction of 70%. Conclusions: During left atrial ablation, the independent predictors of TRCT were patient age, re-do procedure, operator experience, unsuccessful first pass, TOE-guidance, and use of the SafeSept wire. A novel classification system for the causes of cardiac tamponade is proposed (table 1); this may be of interest to clinical trialists or auditors evaluating patient safety. Funding Acknowledgement: Type of funding sources: None.