HRCR November 2019 Quiz

Editorial note: The following quiz is related to the article Complication prevention in ablation procedures: How to perform transseptal puncture safely in case of atrial septum aneurysm by Stöckigt et al, from the November 2019 issue of Heart Rhythm Case Reports.

Question 1: The above figure shows a transesophageal echocardiography in systole (a) and diastole (b) of a patient scheduled for atrial fibrillation ablation (IAS = interatrial septum; RA = right atrium; SVC = superior vena cava). Which is the correct statement referring to the figure?

a. The arrow points toward an unremarkable IAS.
b. An aneurysm of the IAS is a common finding in the majority of all patients.
c. The excursion of the IAS indicates presence of an aneurysm and the operator should be aware of difficulties regarding the transseptal puncture.
d. The ablation procedure after transseptal puncture in this patient should be performed without systemic anticoagulation since the risk for cardiac injury is high throughout the whole procedure.
e. Transseptal puncture in this patient should not be performed.

Question 2: What is the correct answer with regard to the guidewire (arrow) during the introduction of a transseptal sheath in figure panels a and c? Panel b shows the left atrial angiogram of the same patient.

a. The optimal position is the left inferior pulmonary vein as indicated in figure panel a.
b. There is no optimal position; all pulmonary veins are equally possible.
c. Figure panel a shows the complication of cardiac perforation, since the guidewire is outside the cardiac silhouette.
d. Figure panel c shows the optimal position of the guidewire in the left superior pulmonary vein.
e. The angiogram in figure panel b shows that the optimal guidewire position would have been the right superior pulmonary vein.

Question 3: Which of the following answers is not correct? Useful tools for difficult transseptal punctures in case of septum aneurysm are:

a. Radiofrequency needle
b. Transseptal guidewire (SafeSept)
c. Deep inspiration maneuver
d. Using the inner stylet of the Brockenbrough needle
e. Choosing a puncture site at the superior rim of the fossa ovalis