Trans-septal route may be hazardous

Trans-septal approach has to be performed by trained cardiologists, and even after the obligatory learning curve it entails some risky complications. Sometimes the dilator and the introducer sheat passes through a narrow foramen ovale and glides into the left atrium without needle puncture. This seems to be a convenient and harmless way to push the introducer into the left atrium, avoiding the risk of puncturing structures outside the atrium. By doing so, we experienced two times a passage of the trans-septal introducer set between the leaflets of the ostium primum and secundum into the septal and anterior wall of the left atrium causing partial dissection and haematoma just behind the aortic wall. Fluoroscopy showed a clear left-oriented course of the introducer. However, the disappearance of the pressure curve and the impression of a stucked introducer precluded to push it further (Panels A and B). A transoesophageal echocardiogram showed a localized haematoma in the anterior atrial wall, just behind the aortic posterior wall (Panels C–F). The evolution was uneventful except for short-lasting thoracic pain.