* The use of a radiofrequency needle improves the safety and
efficacy of transseptal puncture for atrial fibrillation ablation
Roger A. Winkle, MD, FHRS, R. Hardwin Mead, MD, FHRS, Gregory Engel, MD, Rob A. Patrawala, MD
From Cardiovascular Medicine and Cardiac Arrhythmias, East Palo Alto, California, and Sequoia Hospital, Redwood
City, California.
BACKGROUND Atrial fibrillation (AF) ablation requires transseptal puncture to gain entry to the left atrium (LA). On rare occasions, LA entry cannot be achieved or cardiac perforation results in
pericardial tamponade.
OBJECTIVE This study sought to compare a new radiofrequency
(RF) transseptal needle with the standard needle.
dence of improved operator experience that might explain the
superior RF results. For the standard needle, there was no trend for
.794) or fewer tamponades
improved septal crossing rates (P
(P .456) with more operator experience. Instrumentation time
was shorter for the RF needle (27.1
10.9 vs. 36.4
17.7
minutes, P .0001).
METHODS We evaluated 1,550 AF ablations in 1,167 patients. We
compared 975 transseptal punctures done using a standard needle
to 575 done using a new electrode-tipped needle attached to an
RF perforation generator.
CONCLUSION Our data suggest that the RF needle is superior to
the standard transseptal needle. It results in shorter instrumentation times, a greater efficacy in transseptal crossing, and fewer
episodes of pericardial tamponade.
RESULTS The rate of failure to cross the atrial septum was lower
for the RF needle (1 of 575 [0.17%] vs. 12 of 975 [1.23%], P
.039) and there were fewer pericardial tamponades with the RF
of 575
[0.00%] vs.
of 975 [0.92%],
P transseptal
.031).
needle
This (0
study
compared
the9 outcomes
of 975
Multivariate analysis showed the RF needle use was the only
punctures done with a standard mechanical needle to
variable associated with a lower incidence of tamponade (P
theBecasuse
outcomes
transseptal
punctures
done with
.04).
the of
RF 575
needle
was used later
in our series,
we a
radiofrequency
(RF)
needle.
examined our 975 standard needle punctures over time for evi-
KEYWORDS Atrial fibrillation; Atrial fibrillation ablation; Transseptal catheterization
Comparaison between RF Needle and Standard Needle (%)
ABBREVIATIONS AF
LA left atrium; RF
1.5
attack
atrial fibrillation; BMI body mass index;
RF Needle
radiofrequency; TIA transient ischemic
Standard Needle
(Heart Rhythm 2011;8:1411–1415) © 2011 Heart Rhythm Society.
All rights reserved.
1.0
The RF needle was 7.2 times more likely to cross challenging
5– 8
puncture.
This needle is connected to a radiofrequency (RF)
Introduction
septum compared to the mechanical needle.
puncture
generator
rather than the standard RF ablation genRecent interest in atrial fibrillation (AF) ablation has resulted
in a resurgence of transseptal catheterization to enter the left
erator. The clinical use of this RF needle has only been de-
atrium
There
were fewer incidents of pericardial tamponade with scribed
0.5 in case reports9 in 1 small series.10 We describe our
(LA). Transseptal catheterization was first described by
2
theetRF
(0%)
compared
to the
mechanical
needle experience with the safety and efficacy of this RF needle in a
Ross
al1needle
and Cope
in 1959.
After early
improvements
in the
3
(0.92%).
large cohort of patients undergoing AF ablation and compare
equipment and technique, there has been little subsequent
change to the transseptal equipment. Monitoring improvements
The such
instrumentation
time forfluoroscopy,
the procedure
was shorter
as the use of biplanar
intracardiac
and for
transesophageal
placement
of a pigtailtocatheter
in the
the RF needleecho,
(27.1and
minutes)
compared
the mechanical
4
aortic
root(36.4
haveminutes).
helped improve the safety of the technique.
needle
Recently, a new insulated needle with a small blunt-tipped
has concludes
been developed
for RF
accomplishing
transseptal
electrode
The study
that the
needle is superior
to the
mechanical needle for doing transseptal punctures.
None of the authors have any connection to Baylis Medical Inc. Dr. Mead
is on the Advisory Boards of Medtronic, iRhythm, Proteus Biomedical, Voyage Medical, and InnerPulse; holds stock options for iRhythm, Proteus Biomedical, and InnerPulse; and is Director for iRhythm. Drs. Winkle and
Patrawala are investigators for Cardio Robotics and CABANA Trial. Dr.
Patrawala is a consultant and holds stock options for Voyage Medical; and is
a Speaker for St. Jude Medical. Dr. Engel is a Speaker for Medtronic. All
authors are investigators for Medtronic, Cameron Health, and Sanofi-Aventis.
Address reprint requests and correspondence: Dr. Roger A. Winkle, Cardiovascular Medicine and Cardiac Arrhythmias, 1950 University Avenue,
Suite 160, East Palo Alto, CA 94303. E-mail address: [email protected].
*©(Received
2011 Heart
Rhythm
Society.
AllApril
rights29,reserved.
April
2, 2011;
accepted
2011.) doi:10.1016/j.
hrthm.2011.04.032.
this needle to our experience with the traditional sharp trans0.0puncture needle.
septal
Methods
Tamponade
Patient population
The subjects were consecutive symptomatic patients underTime (Min)
going AF ablation at Instrumentation
Sequoia Hospital,
Redwood City,
California, from October 10, 2003, to February 18,
2011.
RF Needle
All signed written informed consent. DataStandard
analysisNeedle
was
40
retrospective and approved by the hospital internal review
board. AF type was categorized as paroxysmal (lasting 1
week), persistent (lasting 1 week, and 1 year or requir30
ing pharmacological or electrical cardioversion in 1 week)
and longstanding persistent (lasting 1 year).11
20
Ablation
protocol
General anesthesia was used in 97.2% of ablations. All
patients had a femoral or radial arterial line. Venous access
1547-5271/$ -see front matter © 2011 Heart Rhythm Society. All rights reserved.
CAR1027
Failure to cross
10
0
doi:10.1016/j.hrthm.2011.04.032
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