What is the classic appearance of a transseptal puncture on Transesophageal Echocardiography (TEE) 3D?

Classic Appearance of a Transseptal Puncture on 3D TEE

The classic appearance of a transseptal puncture on 3D TEE is characterized by tenting of the interatrial septum at the fossa ovalis, with direct visualization of the needle tip creating this tenting effect before puncture through the septum. 1

Key Features of Transseptal Puncture on 3D TEE

Optimal Imaging Views

• Mid-esophageal short-axis view (30-60°) and bicaval view (90°) are the primary views used for transseptal puncture guidance 1
• These views can be simultaneously displayed using biplane imaging with 3D probes
• 3D zoom with a large field of view provides an en face view of the interatrial septum from the right atrial perspective 1, 2

Characteristic Findings

• Tenting of the fossa ovalis by the transseptal needle is the hallmark appearance (seen in 50% of cases) 1, 3
• The needle tip is identified by the deformation it creates on the adjacent septum rather than by direct visualization of the needle itself 1
• After puncture, contrast material can be visualized in the left atrium to confirm successful access 3

Anatomical Landmarks

• The fossa ovalis is clearly distinguishable from surrounding structures 4
• The aorta is visualized to avoid inadvertent puncture 3
• The puncture site should be positioned 3.5-4.0 cm above the mitral leaflets 1
• Optimal position is in the posterior-mid aspect of the fossa in a posterior and superior direction 1

Technical Considerations

Optimal Puncture Location

• For mitral valve interventions: superior-posterior position of the fossa ovalis 1
• For left atrial appendage procedures: typically posterior and inferior, though location varies depending on the relative height and orientation of the LAA ostium 1

Advantages of 3D TEE Guidance

• Provides direct en face visualization of the fossa ovalis in a 3D perspective 4
• Reduces the risk of pericardial tamponade (91.8% lower risk compared to fluoroscopy alone) 5
• Allows fast and safe transatrial access with a single puncture attempt 4
• Minimizes the need for multiple TEE probe manipulations 2

RATLe-90 Maneuver for Optimal Visualization

A specific technique for obtaining anatomically oriented en face view of the interatrial septum:

• Rotate
• Anti-clockwise
• Tilt
• Left
• 90 degrees This provides clear visualization of the interatrial septum from the right atrial aspect 2

Clinical Pearls and Pitfalls

Safety Considerations

• Biplane fluoroscopy is essential for safe performance of transseptal puncture, particularly in small patients 1
• Single-plane fluoroscopy should only be used under extenuating circumstances and by highly experienced operators 1
• If the position of the catheter is suboptimal, the needle should be repositioned prior to puncturing the septum 1

Common Pitfalls to Avoid

• Inadvertent puncture of the aorta or atrial wall 5
• Puncturing too low or anterior, which can make subsequent catheter manipulation difficult 1
• Failure to recognize anatomical variations of the interatrial septum 1
• Inadequate visualization of the needle tip position relative to surrounding structures 1

By using 3D TEE for transseptal puncture guidance, operators can achieve more precise and safer access to the left atrium, which is critical for successful interventional procedures and reducing complications.