A New Proposal for Crossing Two or More Sheaths through Single Trans-Septal Puncture in Ablation of Atrial Fibrillation: Experience with Steerable Introducer

Introduction: We have sometimes experienced difficulty in crossing two or more sheath through one septal puncture for catheter based pulmonary vein isolation. Methods: Subjects were 32 consecutive patients (25 men and 7 women) ranging from age 43 to 76 with paroxysmal or sustained atrial fibrillation, who underwent extensive pulmonary vein isolation. After the Brockenbrough puncture using a Daig SL0 dilator sheath system, the sheath dilator was pulled back into the right atrium leaving the 0.035 inch guide wire in the left atrium. In the initial 19 patients, we attempted to put the second Daig SL0 sheath in the left atrium using the electrode catheter. In the 13 subsequent patients, we used the SL0 sheath dilator in 6 and a newly developed steerable introducer in 7 patients. The sheath dilator was aligned with the anchored first guide wire under the guidance of biplane fluoroscopy. After advancing the second dilator system in the left atrium, the system was pulled back leaving the second guide wire in the left atrium. The third sheath system was positioned in the same manner. Results: In the two of the 19 conventional cases, the second sheath with electrode did not pass the septum and needed another Brokenbrough puncture. In the 13 subsequent cases using the new method, the sheath dilator systems were successfully positioned in all cases with no major complications. The steerable sheath was very useful for aiming at the puncture site. In conclusion, the new technique was very useful and simple for crossing two or more sheaths through a single trans-septal puncture.