Descending Aorta Perforation During Transseptal Puncture for Left Atrial Appendage Closure

Figure 1. Transesophageal Views During and Direct After the First TSP (A) Atypical views used for the TSP due to the unusual echocardiographic windows likely related to the hepatomegaly. (B) After the first TSP, a structure appeared between the transesophageal echocardiography probe and the left atrium (yellow arrow) raising concern for an esophageal perforation. TSP = transseptal puncture.

Visual Summary. Descending Aorta Perforation During Transseptal Puncture for Left Atrial Appendage Closure CT = computed tomography; IMC = intermediate care unit; TEVAR = thoracic endovascular aortic repair.

Figure 2. Echocardiographic Evaluations Looking for Pericardial Effusion Over Time (A) End-procedural transesophageal echocardiography; (B) transthoracic echocardiography (TTE) before the transfer from the intermediate care unit (IMC) to the ward; (C) TTE after readmission to the IMC.

Figure 3. Computed Tomography Scan Showing Massive Mediastinal Hematoma The red dotted circle indicates the site of active bleeding from the descending aorta.

Figure 4. Transseptal Puncture Simulation on CT After Multiplanar Reconstruction (A) Reconstruction of a short axis view of the aorta with the interatrial septum on the left. (B and C) The CT scan planar reconstruction based on TOE (B is equivalent to the right and C to the left TOE view in D). The yellow lines in (a), (b) and (c) show the tenting of the interatrial septum shortly before the TSP using RF: one can see the proximity with the descending aorta. The white line in the right panel of (D) probably represents the LA posterior wall. Asc Ao = ascending aorta; CT = computed tomography; Desc Ao = descending aorta; LA = left atrium; LV = left ventricle; RA = right atrium; RF = radiofrequency; TOE = transesophageal echocardiography; TSP = transseptal puncture.