Aortic iatrogenic perforation during transseptal puncture and successful occlusion with Amplatzer ductal occluder in a case of mitral paravalvular leak closure

Abstract

Complications of transseptal puncture are significant and potentially life threatening. Aortic perforation is one of these complications and it needs to be repaired immediately. We report the case of a 48-year-old female with a history of rheumatic mitral valve disease. She underwent three previous mitral valve replacements. Her last echocardiogram reported an anterolateral leak in the mitral prosthesis. Catheterization was performed. During the procedure, when attempting to perform transseptal puncture, catheterization was complicated by a forcefully puncture of the aortic root by the Brockenbrough needle followed by an immediately advancement of an 8-Fr Mullins sheath. We decided to leave the 8-Fr sheath in the aortic root recognizing the danger of removing the sheath and finally we advanced a 6/4 mm Amplatzer ductal occluder (ADO I) through the Mullins sheath and under fluoroscopy and TEE guidance we achieved a successful deployment of the device and closure of the perforation. Subsequently, the paravalvular leak was closed with an Amplatzer Vascular Plug (AVP III 10/5 mm). There are only three cases of a similar technique for the same injury in which the authors describe successful closing of aortic perforation with percutaneous closure devices. Our case is the first described during a mitral paravalvular leak closure. It is also the first to describe a different technique of leaving the Mullins sheath in the aortic root and advancing the Amplatzer device through it to achieve successful closure of the aortic perforation. We preferred the percutaneous closure over open-heart repair. © 2015 Wiley Periodicals, Inc.

Percutaneous occlusion of transseptal puncture‐related free wall perforation at the coronary sinus with a ventricular septal occluder during left atrial appendage closure: A case report

“…As cardiac tamponade may be a life‐threatening condition, urgent open‐heart surgery seems to be the most promising treatment option to close the atrial leakage. However, some cases have reported the use of percutaneous device occlusion to close aortic perforation or cardiac perforation during transseptal puncture 5–9 . What these cases have in common is leaving the transseptal sheath in place until an occluder passes through it rather than prematurely withdrawing it.…”

“…However, some cases have reported the use of percutaneous device occlusion to close aortic perforation or cardiac perforation during transseptal puncture. [5][6][7][8][9] What these cases have in common is leaving the transseptal sheath in place until an occluder passes through it rather than prematurely withdrawing it. Based on the recommendations from the above literature, when we encountered the complication of free wall perforation at the coronary sinus, the first solution was to attempt percutaneous occlusion of the perforation with a ventricular septal occluder through the transseptal sheath.…”

Inadvertent ascending aortic perforation after transseptal puncture: Successful treatment with an Amplatzer Duct Occluder II device

“…[9] Mijangos-Vázquez et al also reported on a similar complication, which was dealt with by Amplatzer Duct Occluder I. [10] However, we used an Amplatzer Duct Occluder II device, which is a softer device, to avoid any potential interference with the aortic valve cusps. As the 8-Fr sheath (effectively at least 3-mm diameter perforation) that was passed into the aorta, to avoid ongoing residual leak, we selected a 6-mm diameter device.…”

“…Due to very limited experience with these devices for cardiac perforations, complications remain largely unknown but are likely to be rare. [10]…”

Transseptal Access to the Left Atrium: Tips and Tricks to Keep it Safe Derived from Single Operator Experience and Review of the Literature

“…With inadvertent puncture of adjacent structures, if noted early and dilator/sheath advancement avoided, usually catastrophies may be averted. However, expanding the iatrogenic hole with sheath advancement could be potentially catastrophic [ 37 ]. Thromboembolic complications may well be prevented by adequate anticoagulation (discussed below) and meticulous aspiration and flushing routine during the procedures, especially when exchanging wires and/or catheters; de-airing is also very important in order to avoid air embolism.…”