Closure of an ascending aorta perforation during a transseptal puncture procedure: transcatheter closure with a muscular ventricular septal defect occluder
Transseptal puncture is a technique that is routinely performed during left atrial intervention. Aortic root perforation is one of the worst complications for which there are no safe and effective rescue measures, and patients must undergo surgery. Here, we report a case of transcatheter closure of an ascending aorta perforation via a muscular ventricular septal defect (VSD) occluder.   A 53-year-old female patient with atrial fibrillation (AF) was hospitalized due to a 2-year history of chest tightness and shortness of breath. She was diagnosed with heart failure upon admission. Echocardiography revealed significant mitral stenosis (MS; measuring 0.6 cm 2 ) with mild pulmonary hypertension (PH; pulmonary artery systolic pressure: 42 mmHg) and dilations in both atria (left atrium: 89 mm; right atrium: 70 mm). Percutaneous balloon mitral valvuloplasty (PBMV) was suggested, as the patient had no contraindications. An atrial septal puncture system (Synaptic Medical, China) with an 18 G puncture needle was used for transseptal puncture. However, a guidewire was observed in the aorta after the puncture. Transthoracic echocardiography (TTE) and multiposition radiography indicated that the 8.5 F Swartz sheath catheter (Synaptic Medical, China) had crossed the ruptured aorta due to mistaken identification (Fig. ). Considering the risk of cardiac tamponade, the procedure was immediately suspended. Fortunately, the patient’s vital signs and consciousness were normal. No pericardial effusion was observed via echocardiography. Therefore, transcatheter closure was selected as the primary treatment option. Considering the inherent advantages, as well as the perforation size and clinical experience, we selected an 8-mm muscular VSD occluder. An in vitro test was subsequently performed to confirm the feasibility of advancing an 8-mm muscular VSD occluder (Lifetech, China) with a 7 F sheath in the Swartz sheath with a J-tipped guidewire reserved for other emergency procedures. The muscular VSD occluder was successfully deployed to the perforation, between the right atrium and the ascending aorta (Fig. ). Finally, the 260-cm J-tipped guidewire was easily withdrawn after successful closure, which was confirmed by radiography (Fig. ). An aortogram obtained via a 6 F pigtail tube demonstrated that the right atrium-aortic perforation had been fully closed (Fig. ). The second puncture, guided by TTE and multiposition radiography, was subsequently carried out by a more experienced physician and was successful. PBMV was successfully performed using a 3.0 × 40 mm balloon. The patient recovered well from the procedure and was discharged from the hospital three days later. The patient was followed for one month and reported no discomfort. No pericardial effusion was observed (Fig. ).   Transseptal puncture is a technique that is routinely performed in mitral valvuloplasty, catheter ablation for AF, and left atrial appendage closure. Complications associated with transseptal puncture occur in 1% of procedures. In one report of 3756 patients who underwent transseptal puncture procedures, only three aortic root perforations were observed . Nevertheless, our case demonstrates that transseptal puncture guided by transthoracic ultrasound and radiography remains difficult, owing to the unusual anatomy of the region. Intracardiac echocardiography-guided puncture can be performed to avoid serious complications during transseptal puncture procedures, particularly in patients with a large atrium or unusual anatomy . If a patient has a large atrium, it is also necessary to reshape the needle to provide greater curvature (Fig. ). The coronary sinus catheter and the pigtail catheter in the aortic root can also be used to guide transseptal puncture . Cardiac tamponade may not occur if the sheath is not advanced, thus creating a much larger hole. Unfortunately, we did not perform pressure tracing and instead advanced the Swartz sheath into the ascending aorta, which was not prudent at that stage. Previous studies have shown that cardiac tamponade usually occurs immediately and requires surgical treatment . However, percutaneous management may represent a feasible option in the case of hemodynamic stability. A previous report revealed that a similar perforation was closed via an Amplatzer™ duct occluder . Considering the inherent advantages of the muscular VSD occluder for defects > 6 mm and < 3 mm in size , as well as the perforation size and physician clinical experience, the VSD occluder may better fit the ascending aorta perforation than the Amplatzer™ duct occluder does. Therefore, we selected an 8-mm muscular VSD occluder. An in vitro test revealed that an 8-mm muscular VSD occluder could be used for right atrium-iatrogenic ascending aortic perforation through an 8.5 F (2.8 mm) Swartz sheath. During the observation period, we found that this percutaneous strategy was viable and effective. Reversal of heparinization with protamine sulfate is unnecessary if there is no evidence of active bleeding . In our case, this measure was not considered. Percutaneous closure of ascending aortic perforations via a muscular VSD occluder is a viable treatment approach. Our case highlights the fact that timely evaluation and effective intervention are crucial for avoiding adverse outcomes.   