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Preventing complicated transseptal puncture with intracardiac echocardiography: case report

DOI: 10.1186/1476-7120-3-5

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Abstract:

A case of a patient with paroxysmal atrial fibrillation and atrial flutter, and distorted intracardiac anatomy is presented. Intracardiac echocardiography showed a small oval fossa abouting to an enlarged aorta anteriorly. A very small distance from the interatrial septum to the left atrial free wall was seen. The latter two conditions were predisposing to a complicated transseptal puncture. According to fluoroscopy the transseptal needle had a correct position, but the intracardiac echo image showed that it was actually pointing towards the aortic root and most importantly, that it was virtually impossible to stabilize it in the fossa itself. Based on intracardiac echo findings a decision was made to limit the procedure only to ablation of the cavotricuspid isthmus and not to proceed further so as to avoid complications.This case report illustrates the usefulness of the intracardiac echocardiography in preventing serious or even fatal complications in transseptal procedures when the cardiac anatomy is unusual or distorted. It also helps to understand the possible mechanisms of mechanical complications in cases where fluoroscopic images are apparently normal.Since the advent of ICE in the electrophysiology practice it proved its value in guiding transseptal procedures with providing an extra safety margin for the patients. The possibility to visualize the oval fossa, the LA free wall and the aortic root helps in preventing mechanical complications. ICE can visualize also intracardiac thrombus and spontaneous echocontrast, which is helpful in avoiding thromboembolic complications. Although the value of ICE is well known, it is rather hard to admit that it is a universal tool for achieving uncomplicated access to the left atrium. The aim of this case presentation is to show that ICE can lead to interruption of a transseptal procedure due to the presence of risk factors for mechanical complications when the fluoroscopic image is seemingly satisfying.A seventy-year-old

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