Introduction: Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the incidence and predictors 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 (C=0.83) examined predictors of TRCT (OR (95% CI)).
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%). 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 BRK, p>0.1) or puncture sheath (Swartz vs Mullins vs Agilis vs Cryosheath, all p>0.1) did not predict TRCT. Adjusting for operator, indication, 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), use of transoesophageal echocardiogram (TOE: OR 0.51 (0.11-0.94), p=0.023), and use of the SafeSept wire (OR 0.22 (0.08-0.62), 0.001) reduced TRCT risk. An increase in SafeSept wire use over time (2018: 20.4%, 2019: 37.5%, 2020: 60.2%) correlated with an annual reduction in TRCT (R2=0.85, p=0.017) and was associated with a relative risk reduction of 70% (total cost to prevent a TRCT: £4,600).
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. The SafeSept wire offers minimally traumatic septal perforation and safe advancement into the left atrium to support sheath access; it will be adopted routinely for fluoroscopy-guided TSP in an effort to improve patient safety.