How to reduce the risk of inadvertent aortic root puncture during transseptal puncture?

The case report by Nema et al. described an unexpected aortic root perforation during transseptal puncture (TSP), which was successfully managed with percutaneous closure.1 Certain aspects of this case offer valuable lessons worth discussing. First, to confirm left atrial (LA) entry, pressure confirmation after needle puncture should be performed. The omission of this step was acknowledged but deserves greater emphasis, as it led to the chain of events that was critical. LA entry, as confirmed by pressure transduction or LA contrast injection, should be a nonnegotiable step before advancing the dilator/sheath into the LA. Attaching a three-way connector can facilitate pressure recording and/or contrast injection. The use of a pigtail wire (Jalebi wire) to cross, not only confirms LA entry but also provides excellent support for a tough septum. Another approach is to pass a J-tipped wire through the needle tip and, with slight clockwise torque, advance it into the left superior pulmonary vein to confirm LA entry Figure 1. The coronary sinus catheter can also be a useful landmark for guiding to the fossa ovalis.2 Anatomically, a needle may enter the aorta to the non-coronary sinus, or to the sinotubular junction, or into the ascending aorta (highest risk of tamponade as it enters the transverse sinus).3Figure 1: Schematic diagram indicating inadvertent aortic entry and best practices during transseptal puncture (TSP). Numbered scenario 1–3, 1 = needle in fossa ovalis (correct approach), 2 = needle wrongly entering noncoronary sinus, 3 = Needle entering ascending aorta. Scenario 3 carries the highest risk of cardiac tamponade as the needle enters the transverse sinus. (Inset A) shows a catheter crossing the septum in intracardiac echo, and (Inset B) shows the use of the electrophysiology catheters (Quadripolar at His and decapolar in the coronary sinus), which are used as a landmark in TSP for left atrial access for cryoablation. ICE: Intracardiac echo, NCS: Noncoronary sinus, LA: Left atrium, PV: Pulmonary veinOften, a tough septum requires the operator to push, which can cause the needle to slide upward. Radiofrequency or electrocautery applied to the needle can help cross a tough septum with ease, but there is limited evidence for this technique. Dedicated transseptal crossing systems are not widely available. Fluoroscopic imaging in right and left anterior oblique can confirm that the needle is sufficiently posterior and low. Adjunctive imaging, particularly intracardiac echocardiography, should be strongly considered in anatomically ambiguous cases. Reliance on a single fluoroscopic projection should be avoided, and the needle dilator assembly should be visualized in anteroposterior, right anterior oblique, and left anterior oblique views. Further, the authors describe the “third jump,” an additional jump beyond the traditional 2 jumps. This tactile feedback should be distinguished from a false, pulsatile jump, which occurs when the needle advances toward the aorta. The authors’ adherence to the principle of not withdrawing the sheath immediately and using it as a temporary plug aligns with the best-described management strategies and likely contributed to the favorable outcome. The electrocardiogram (ECG) was initially interpreted as showing a right free wall pathway, but since it was not fully preexcited, its diagnostic value is limited. Certain clues suggest a left lateral accessory pathway (AP). Lead V1 shows an isoelectric to positive delta and early precordial transition, suggesting a left-sided AP. The absence of a QS pattern and the lack of a small r followed by S in V1 exclude right septal or free wall locations. Recent algorithms, such as SMART WPW and EASY WPW, also localize the ECG to the left lateral pathway.4,5 However, these interpretations assume exact chest lead placement and maximal pre-excitation, which have practical limitations. In a young patient with no structural heart disease, a retrograde aortic approach is an alternative strategy, avoiding transseptal access altogether. Percutaneous device closure should remain as a life-saving option when expertise and resources are available, and prevention should be the key. This report also emphasizes the need for standardized protocols to manage TSP-related complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.