Dataset Information

Management of ascending aorta perforation during transseptal puncture for left atrial appendage closure: a case report.

ABSTRACT:

Background

An 82-year-old female with a history of atrial fibrillation and repeated episodes of major bleeding on direct oral anticoagulant therapy, with a high risk for thromboembolism and was referred for left atrial appendage closure.

Case summary

During the procedure, an unrecognized puncture of the aorta by the transseptal puncture (TSP) needle and inadvertent advancement of the sheath resulted in ascending aorta perforation. This perforation was closed percutaneously using an Amplatzer™ Duct Occluder (ADO). Reversal of heparinization with protamine sulphate was given to avoid intractable bleeding. However, this resulted in thrombus formation and subsequent embolization causing an ST-elevation myocardial infarction. This was treated with balloon dilatation and thrombus aspiration with subsequent Thrombolysis in Myocardial Infarction 3 flow.

Discussion

Inadvertent ascending aorta perforation is a rare yet serious complication that can occur during TSP. Percutaneous closure using an ADO is a viable management option. The reversal of heparin carries a risk of thrombus formation and should be avoided in cases where there is no evidence of overt bleeding.

SUBMITTER: Schamroth Pravda N

PROVIDER: S-EPMC8188860 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:AimsThis study was performed to compare the usability, efficiency, and safety of a modified angioplasty guidewire-assisted transseptal puncture (TSP) technique vs. the conventional approach in facilitating access into the left atrium during left atrial appendage occlusion (LAAO) procedures for the treatment of atrial fibrillation.Methods and resultsThe ADVANCE-LAAO trial (Angioplasty Guidewire-Assisted vs. Conventional Transseptal Puncture for Left Atrial Appendage Occlusion) was an investigator-initiated, prospective, multicentre, randomized controlled trial (NCT05125159). Patients with atrial fibrillation who underwent LAAO were prospectively enrolled from four centres and randomly assigned to an angioplasty guidewire-assisted TSP group (n = 131) or to a conventional Brockenbrough needle TSP group (n = 132). The primary endpoint was the one-time success rate of TSP. We also analysed the TSP procedure time, failure rate of the assigned TSP type, radiation dose, contrast dose, and procedural complications in both groups. All patients in the guidewire-assisted group underwent successful TSP, whereas five in the standard conventional group switched to the guidewire-assisted approach. The guidewire-assisted puncture improved the one-time success rate (92.4 vs. 77.3%, P = 0.001), shortened the TSP procedure time (109.2 ± 48.2 vs. 120.5 ± 57.6 s, P = 0.023), and tended to have a higher rate of good coaxial orientation of the sheath with the left atrial appendage during the LAAO procedure (66.4 vs. 54.5%, P = 0.059). No TSP-related complications occurred in the guidewire-assisted TSP group, whereas two complications occurred in the conventional TSP group. There was no significant difference in the failure rate of the assigned TSP type, the total procedure time, the total radiation dose, the rate of successful LAAO implantation, or the procedural complication rate between the two groups (all P > 0.05).ConclusionThis study confirmed that angioplasty guidewire-assisted puncture can effectively improve the success rate of TSP during LAAO procedures. This novel technique has high potential for application in interventional therapies requiring TSP.