A 3D Echo Technique to Guide Transseptal Puncture: The RATLe-90 Maneuver
Introduction
Transseptal puncture (TSP) is a critical step in many structural heart interventions, including:
• Mitral valve repair (MitraClip)
• Balloon mitral valvuloplasty
• Left atrial appendage (LAA) closure
Despite its routine use, TSP remains technically demanding and highly dependent on accurate imaging.
Traditionally, 2D transesophageal echocardiography (TEE) has been used. However, it is limited by its planar nature, making catheter tracking difficult.
With the evolution of real-time 3D TEE, a new standardized approach was developed:
👉 The RATLe-90 maneuver
📄 Original Research Article
Read the full study here:
👉
🎥 Watch the RATLe-90 Maneuver (Free Video Tutorial)
To clearly understand and apply this technique in practice, watch this open-access CIC lecture:
👉 https://ciceg.net/courses/online-advanced-echocardiography-course/lessons/how-to-image-the-inter-atrial-septum-using-3d-tee-ratle-90-maneuver/
🎯 This video shows:
• Step-by-step acquisition of 3D TEE dataset
• How to perform RATLe-90 maneuver
• Real clinical imaging examples
• Practical tips for daily cath lab use
What is the RATLe-90 Maneuver?
The RATLe-90 maneuver (Rotate–Anticlockwise–Tilt Left 90°) is a standardized technique used to obtain an:
➡️ Anatomically oriented en face view of the interatrial septum (IAS) from the right atrial perspective
This allows:
• Clear visualization of the fossa ovalis
• Precise catheter guidance
• Improved communication between echocardiographer and interventionist
This technique was introduced in our pilot study
Step-by-Step Technique
1. Start with Standard 2D View
• Mid-esophageal bicaval view (~90°)
• Visualize SVC, IVC, and IAS
2. Activate 3D Zoom
Include:
• Superior vena cava (SVC)
• Inferior vena cava (IVC)
• Aortic root
• Entire interatrial septum
3. Apply RATLe-90 Maneuver
• Rotate anticlockwise → 90° (Z-axis)
• Tilt left → 90° (Y-axis)
🎯 Result:
➡️ True anatomical en face view of IAS
As illustrated in the figure on page 2, this reorientation transforms the view into a clinically intuitive perspective
Why is This Technique Important?
✅ 1. Anatomical Visualization
You see the septum in its real anatomical orientation—not as slices.
✅ 2. Accurate Localization of Fossa Ovalis
Gain reduction creates a dropout artifact highlighting the thin septal region
(demonstrated in page 3 images)
✅ 3. Real-Time Catheter Navigation
The catheter can be tracked continuously:
• From IVC → SVC
• Then down to the fossa
(shown in procedural images on page 3)
Key Results of the Study
In 20 patients:
• ✅ Successful visualization in 100% of cases
• ⏱ Acquisition time: ~20 seconds
• ⏱ Time-to-tent:
o 64.8 sec vs 139.9 sec (traditional methods)
• 🔽 Less probe manipulation
• 🔽 Reduced fluoroscopy time
• ❌ No complications
These findings confirm improved efficiency and safety
Clinical Applications
The RATLe-90 maneuver is especially useful in:
• MitraClip / TEER procedures
• LAA closure
• Balloon mitral valvuloplasty
• Any transseptal-based intervention
It also creates a shared spatial language between the echo and cath teams.
Why 3D Echo is the Future
This technique represents a major shift:
👉 From 2D imaging limitations
👉 To 3D anatomical navigation
With 3D TEE:
• Septum + catheter + target are all in one view
• Less guesswork
• More precision
🎓 Learn Advanced 3D TEE & Structural Echo
If you want to master:
• 3D TEE acquisition
• Transseptal guidance
• Structural heart imaging
• Real cath lab applications
👉 Explore CIC Online Echocardiography Courses:
🔗 https://ciceg.net/cic-courses/
✔️ On-demand access
✔️ Real clinical cases
✔️ Step-by-step expert teaching
✔️ Designed for cardiologists worldwide
Conclusion
The RATLe-90 maneuver is a simple yet powerful advancement in echocardiographic guidance of transseptal puncture.
By providing a true anatomical 3D view, it enhances:
• Accuracy
• Efficiency
• Safety
It is a clear example of how advanced echocardiography is transforming interventional cardiology.
Check the paper: https://onlinelibrary.wiley.com/doi/10.1155/2015/174051
