Transesophageal Echocardiography-Guided Transseptal Puncture Reduces Pericardial Tamponade in Electrophysiological Procedures

<b>Background</b>: Transseptal puncture (TSP) is a critical step in electrophysiological (EP) procedures, as a misdirected TSP can result in life-threatening complications. Although TSP is predominantly performed under fluoroscopic guidance in EP procedures, transesophageal echocardiography (TEE) offers more precision and certainty in the localization of the transseptal needle at the interatrial septum. Despite the widespread use of TSP, evidence supporting the added value of TEE-guided TSP in EP procedures remains limited. This study evaluates the impact of additional TEE guidance on TSP-associated complications during EP procedures. <b>Methods</b>: This study enrolled patients who underwent left atrial or left ventricular procedures with TSP, performed either without (fluoroscopy group) or with additional TEE guidance (TEE group), at the University Heart Center Ulm, Germany. <b>Results</b>: A total of 932 patients were included: 443 in the TEE group (mean age 68.1 ± 11.8 years, 40.6% female) and 489 in the fluoroscopy group (mean age 68.8 ± 11.0 years, 38.2% female). The mean number of transseptal accesses per patient was 1.18 ± 0.38 in the TEE group and 1.14 ± 0.34 in the fluoroscopy group (<i>p</i> = 0.101). Pericardial tamponade occurred significantly less in the TEE group (0.5%) than in the fluoroscopy group (1.8%; <i>p</i> = 0.046). Logistic regression revealed a 91.8% lower risk of pericardial tamponade with TEE-guided TSP compared to fluoroscopy guidance alone. The overall TEE complication rate was low (0.9%). <b>Conclusions</b>: TEE guidance during TSP significantly reduces the risk of pericardial tamponade in EP procedures, indicating that TSP should be performed with additional sonographic guidance to increase patient safety.