Highlights
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Transseptal puncture is commonly performed in both interventional cardiology and electrophysiology procedures, however complications occur in approximately 1% of cases.
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Complications are potentially life-threatening and require emergency diagnosis and management.
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This case demonstrates the importance of early appreciation of the occurrence of a complication and the initial successful conservative management of the patient.
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We also illustrate a potential long-term complication that was successfully treated percutaneously which was associated with resolution of patient symptoms.
A 65-year-old man presented with increasing dyspnoea in New York Heart Association (NYHA) class III. His past cardiac history included permanent atrial fibrillation, insertion of an implantable cardioverter defibrillator (ICD) and coronary artery bypass grafting (CABG). He also suffered from severe chronic obstructive pulmonary disease, hypertension and chronic renal failure (creatinine: 2.01 mg/dL). His EuroSCORE was calculated at 36.9%.
A resting transthoracic echocardiogram (TTE) demonstrated an ejection fraction of 35%, left ventricular dimensions of 58 mm (diastole) and 50 mm (systole) and severe mitral regurgitation (MR). Invasive angiography confirmed patent bypass grafts with no target for further percutaneous revascularisation. After Heart Team discussion, in view of his multiple comorbidities and favourable mitral valve anatomy, he was referred for percutaneous mitral valve repair.
The initial procedure was complicated by accidental puncture of the aortic root by the Brockenbrough needle and advancement of an 8 French (Fr) Mullins sheath (Medtronic, Minneapolis, MN). The patient remained haemodynamically stable, with no evidence of a pericardial collection on TTE and the procedure was abandoned. The patient was managed conservatively and made an uneventful recovery and was discharged home after three days of observation. Two months later, the patient returned electively and underwent successful percutaneous mitral valve repair with the placement of three Mitraclip devices (Abbott Vascular, Santa Clara, CA) with 2 + residual MR and a left appendage occlusion device (Amulet device, St Jude Medical, Minneapolis, MN) implantation.
At follow-up, the patient remained symptomatic in NYHA class III. A TTE confirmed improvement in the severity of MR but a significant aorta-to-right atrium fistula had developed at the site of the previous aortic puncture with a calculated Qp:Qs ratio of 1.8 ( Fig. 1 A , Video 1 ). In view of this being a likely cause of his on-going symptoms, we decided to treat this percutaneously.
