fig1

Figure 1. Transseptal puncture. A: AP fluoroscopic projection; B: fusion imaging: LAO fluoroscopic projection with superimposition of the corresponding TEE view (2D bicaval view); C: biplane imaging: the most used views for TSP guidance: bicaval view (left panel) and SAX-B view (right panel). A sharp tenting should be clearly visualized and a superior and posterior localization; D: 3D overhead perspective of the LA clearly highlights the tenting (white arrow); E: TSP simulation on anatomical specimen (pig heart): MV and Ao are clearly visible, while a withe arrow highlights the tenting on the left side of the IAS; F: ME 4-chamber view is used to measure the height between the tenting (puncture site, white arrow) and the annular plane. AP: antero-posterior; RA: right atrium; LA: left atrium; IVC: inferior vena cava; SVC: superior vena cava; Ao: aortic root/valve; MV: mitral valve; IAS: interatrial septum; LAA: left atrial appendage; LAO: left anterior oblique; TEE: transesophageal echocardiography; TSP: trans-septal puncture; SAX: short axis