TEE guidance can also be helpful during pulmonary
TEE guidance can also be helpful during pulmonary vein cryoablation for AF. Kerut et al.  described their first 20 cases of cryoablation for AF using TEE and found TEE to have better overall procedural imaging and monitoring for pericardial effusion or thrombus formation. They found TEE monitoring to be helpful with positioning for interatrial septum (IAS) puncture, catheter tip avoidance of the left atrial appendage (LAA), and guidance of the balloon catheter into each PV, with proper positioning within each PV orifice and documentation of PV occlusion for the cryoballoon procedure. Use of TEE monitoring resulted in a perceived reduction in radiopaque diindolylmethane agent use and fluoroscopy time. In our study, we aimed to demonstrate the added value of routine TEE use for correctly positioning the transseptal system in the FO, thus potentially preventing complications during fluoroscopy-guided TP, and for assessing the optimal puncture site within the FO according to the expected procedure type. Although there was a trend toward higher complication rates in the fluoroscopy-guided group, the differences between the groups were not statistically significant. This is probably because of lower complication rates in both groups and the small study size. Kautzner et al.  reported that a retrospective analysis of 1692 TP procedures guided by ICE between 2006 and 2009 revealed no complications associated with the puncture and they added that this provides indirect evidence that the use of online imaging may increase procedural safety, especially in anatomical variants of the intraatrial septum, which make the procedure challenging. They also emphasized that the use of echocardiographic guidance enables puncture site selection within the FO according to the expected procedure type (e.g., a more anterior puncture for ablation of an accessory pathway at the mitral annulus or for ablation of ventricular tachycardia and a lower and more posterior puncture for ablation of AF). They stated that even 1-cm difference in the puncture site location can make a significant difference in mapping and ablation catheter maneuverability, and this seems to be even more important when using “one-size-fits-all” devices such as a cryoballoon. In general, a posterior crossing is optimal when targeting posterior LA structures (e.g., the pulmonary veins during AF ablation). For patients undergoing AF ablation with either magnetic navigation or balloon technologies, it may be more favorable to puncture the fossa in a more anterior and inferior location. An anterior and inferior fossa approach for balloon pulmonary vein ablation greatly facilitates access to the right inferior pulmonary vein. Su et al.  also recommended a low anterior TP that was near or on the limbus of the septum to allow more space for the balloon to be rotated posteriorly to the right inferior PV as well as mechanical advantages while accessing the other PVs. They noted that without sufficient distance between the puncture site and the right inferior PV, optimal balloon positioning and occlusion might be difficult. The authors also emphasized that a low puncture location improved balloon contact with the inferior aspects of the PVs. They highly recommended using ICE to improve the safety of transseptal catheterization, and they reported that ICE would also provide early detection of complications (e.g., catheter-related and pericardial thrombus) in ablation cases. The authors concluded that the location of transseptal access was best at the lower third of the septum, and anterior reach at the plane of ICE, where the mitral valve was in view and bending of the distal 15-cm portion of the typical transseptal needle could improve transseptal needle engagement with the anterior portion of the septum. In our study, the shorter total procedural time and total fluoroscopy time can be related to the easy access to the pulmonary veins by using TEE guidance. Importantly, TP facilitates cryoablation of the inferior pulmonary veins. LIPV and RIPV cryoablation time was significantly shorter and the numbers of LIPV and RIPV applications were significantly fewer in the TEE-guided group.