As interventional electrophysiology makes the technique of transseptal catheterization imperative, there is a growing need for more accessible training in the procedure. This was the impetus behind a new interactive CD-ROM, which offers an educational resource encompassing textbook information and live lab demonstrations. Prior to the creation of this CD, clinicians needed to search numerous textbooks, papers, and other resources for information before they could begin learning the technique. This CD brings all of the information to one readily accessible place, helping prepare clinicians to be proctored.

The transseptal technique was first employed over 40 years ago as an alternative to passing stiff catheters retrograde via the aorta to reach the left atrium. The potential complications created by transaortic catheterization were numerous, including the dislodgement of atheromatous material, dissection of the arterial wall, and possible damage to the aortic valve. With transseptal catheterization, physicians can access the left atrium, pulmonary veins, and left ventricle without entering the aorta. This lays the foundation for effective ablation of left ventricular tachycardias, left atrial ectopic tachycardias, and of course, atrial fibrillation (AF).

The Transseptal Catheterization CD uses live action video, animation and fluoroscopy to clearly demonstrate the procedure.

An Idea Born from Experience
As a highly respected electrophysiologist and practitioner of the transseptal technique, the most common request Dr. Shivkumar received was to familiarize physicians and fellows with transseptal catheterization. Widely varying levels of experience and familiarity with the technique made this process difficult, because a clinician must have a firm understanding of cardiac anatomy, imaging, and technical concepts underlying the procedure before he or she can be effectively proctored in the technique. From that experience he realized that there was a great need for comprehensive, targeted training materials.

TEE view of sheath assembly tenting near the anterior limbus

Dr. Shivkumar brought this idea to St. Jude Medical. Their clinical knowledge and expertise in manufacturing high-quality guiding sheaths and transseptal needles made them an ideal partner for collaboration. Together, they decided to create an interactive CD-ROM which could be used by operators of any level as an educational resource on transseptal catheterization.

Tenting of the fossa ovalis prior to passing needle and sheath assembly through the septum.

Pulling it all Together
Creating such a resource is an immense undertaking. After creating an outline which would guide creation of the CD, Dr. Shivkumar provided volumes of written information from papers, textbooks, journals, and numerous other sources. Video footage was taken of Dr. Shivkumar and his staff preparing equipment and performing the procedure in the lab. He also began accumulating motion fluoroscopy and TEE video from numerous cases to provide CD users with a realistic view of what they may encounter during a procedure. This allows them to virtually look over the physician’s shoulder as he prepares the equipment, safely inserts a BRK™ transseptal needle and guiding sheath, locates the exact spot where the septum can be crossed, and makes the puncture to gain left atrial access.

Successful passage of the sheath assembly across the septum

St. Jude Medical’s Field Clinical Engineers (FCEs), experts who have trained and worked for many years in labs across the country, helped communicate the raw ideas and information to the programmers, designers and writers who built the CD-ROM. This process spanned a period of many months and involved hundreds of hours editing the program screen by screen, and frame by frame. From start to finish, the creation of the Transseptal Catheterization CD-ROM took over one year. But the collaborative efforts of Dr. Shivkumar and the FCEs resulted in a program designed with the detail, accuracy, and interactivity which are integral to preparing clinicians for learning such an intricate technique.

PA view of needle positioned properly inside sheath assembly.

PA view of sheath crossing the septum.

A Complete Picture of the Technique
The core curriculum of the CD includes all prerequisites for performing a transseptal catheterization procedure in the electrophysiology lab: anatomy, equipment, preparation, and a step-by-step description of the procedure. Throughout these sections, live-action video, motion fluoroscopy and animation illustrate the complex maneuvers and techniques required for successful execution of the procedure.

The program offers a comprehensive discussion of cardiac anatomy, including embryology, gross anatomy and fluoroscopic anatomy.

This information is supplemented with a section on special issues, including special sheaths, double transseptals, left ventricular access, and numerous other topics encountered when performing transseptal catheterization. A bibliography is also provided for users wishing to learn more detail on specific topics. These elements combine to create a resource which is perfect for beginners but offers perspective and detail that will interest even the most experienced operator.

A section on preparation encompasses prerequisites, preparation for the technique, and assembly review.

However, the program’s applications go way beyond educating primary operators in enhancing the skills of the full lab staff. Their contribution to successful execution of transseptal catheterization is extremely important. The program discusses issues including pressure monitoring, stabilizing sheaths and equipment preparation — functions without which even the most experienced clinician would not be able to safely and effectively perform a transseptal procedure.

PA view of needle positioned properly inside sheath assembly.

Interaction is the Key
Due to the complexity of the information, it was imperative that the program be interactive. This allows users to direct their own learning experience, review sections if necessary, and utilize the additional animation and fluoroscopy provided. A system of tabs enables users to jump back and forth from section to section, moving quickly to the area which is pertinent to their needs. Throughout the program there are links which take users to even more specific information, animation, fluoroscopy and references which offer impressive depth to the CDs resource capabilities. That complexity and detail, combined with user friendly, interactive design, makes the Transseptal Catheterization program much more than a one-time resource. People can work through the information at their own pace, then return at any time for reminders or tips.

A Delicate Undertaking
The transseptal technique has always been important to cardiac medicine, in valvular diagnostics, mitral valvuloplasty and pediatric cardiology. However, it has gained special prominence in interventional electrophysiology in recent years for diagnosis and ablation of left heart arrhythmias, especially AF.
Attempting to perform transseptal catheterization is no light undertaking. The fossa ovalis offers a small area through which to penetrate the septum, and missing it can result in life-threatening complications. A centimeter off in any direction can result in pericardial tamponade, aortic puncture, or pulmonary vein perforation. Because of the potential complications, every step of the procedure must be executed with complete attention to detail. The Transseptal Catheterization program describes and demonstrates each phase of the procedure slowly and thoroughly, emphasizing the importance and possible consequences of every step. Fluoroscopic images and troubleshooting tips assist in preparing clinicians for sights and situations they may encounter in the catheterization lab.
Educational programs such as this mean a great deal to everyone: physicians, lab staff, and companies such as St. Jude Medical. By working together to create them we achieve a common goal — to help patients by advancing the field of electrophysiology.

To request a copy of the Transseptal Catheterization CD-ROM, contact your local St. Jude Medical
representative.