Transseptal puncture via a superior access as an alternative to the conventional femoral route

Introduction: Congenital heart disease (CHD) patients represent a challenge for ablation procedures and may require unusual procedural techniques. An example is the absence of femoral venous accesses that makes a conventional TSP approach impossible. Objective: We report a series of 6 procedures in which transseptal puncture (TSP) was performed via the jugular vein approach using a radiofrequency (RF) needle visualized on the electroanatomical mapping (EAM) system. Methods and results: Ablation procedures for either atrial fibrillation and left-sided atrial tachycardia were performed in 3 patients (54-53-29years) with congenital disease and blocked femoral approach (interrupted inferior vena cava with azygos continuation (2 ​pts), bilaterally blocked femoral venous access due to previous interventions (1 ​pt)). Using the right jugular(n ​= ​5) and left jugular vein(n ​= ​1) we performed a single TSP using a combination of fluoroscopy and EAM guidance with 3D visualisation of the RF needle tip. The main difficulties encountered and solutions are described. In four procedures, remote magnetic navigation was subsequently used. Left atrial access was gained in all cases without complications. Overall procedural time was 373 [321–458] min, with a median fluoroscopy time of 16 [8–26] min and median radiation dose of 1442 [348–3007] μGym2. Conclusion: TSP via superior access is feasible in patients with complex congenital cardiac anatomy. Pre-procedural imaging, EAM and the 3D visualisation of the transseptal needle are tools that greatly facilitate the procedural success