The use of balloon atrial septostomy to facilitate difficult transseptal access in patients undergoing catheter ablation for atrial fibrillation.

INTRODUCTION: With the increasing number of patients undergoing repeat catheter ablation procedures for atrial fibrillation, it is not uncommon to encounter a fibrotic interatrial septum that resists the conventional manual advancement of the transseptal sheath. Forceful advancement of the transseptal apparatus can reduce fine control and potentially lead to a higher rate of perforation. CASE: We report a case where adjunctive balloon atrial septostomy was used to facilitate transseptal access in a patient with fibrotic interatrial septum. Using a small-caliber angioplasty balloon and under direct fluoroscopic and transesophageal echocardiogram visualization, balloon septostomy was performed with hand inflation until a "waist" was seen. This technique provides a safe way to control the size of the transseptal access created, and allows the passage of a relatively soft-tipped transseptal sheath across a resistive septum. To our knowledge this is the first published use of balloon atrial septostomy during transseptal puncture for left atrium access in a catheter ablation procedure. CONCLUSION: Balloon atrial septostomy should be considered as an alternative technique for safe transseptal cannulation in select patients in the electrophysiology laboratory or other interventional procedures requiring left atrial access or delivery of large-caliber catheters or sheaths.

Homocysteine hypothesis for atherothrombotic cardiovascular disease: not validated.

Homocysteine has been implicated in promoting atherosclerotic and thrombotic vascular disease. During the last decade, the utility of homocysteine in predicting risk for atherothrombotic vascular disease has been evaluated in several observational studies in a large number of patients. These studies show that the overall risk for vascular disease is small, with prospective, longitudinal studies reporting a weaker association between homocysteine and atherothrombotic vascular disease compared to retrospective case-control and cross-sectional studies. Furthermore, randomized controlled trials of homocysteine-lowering therapy have failed to prove a causal relationship. On the basis of these results, there is currently insufficient evidence to recommend routine screening and treatment of elevated homocysteine concentrations with folic acid and other vitamins to prevent atherothrombotic vascular disease. This review outlines the metabolism and pathophysiology of homocysteine, highlights the results of homocysteine observational and interventional trials, and presents areas of uncertainty and potential future work.