"Sailing through rough waters", how cardiologists handled aortic perforation during LAA closure.

Inadvertent ascending aorta perforation is a rare yet serious complication that can occur during trans-septal puncture (TSP) performed for balloon mitral valvuloplasty, mitra-clip procedure, left atrial appendage (LAA) closure, etc. a recent EHJ case report highlights one such case of inadvertent aortic perforation during TSP for LAA closure which was addressed on table by sealing with a duct occluder device.

An 82-year-old female with a history of atrial fibrillation and repeated episodes of major bleeding on direct oral anticoagulant therapy, with a high risk for thromboembolism and was referred for left atrial appendage closure.

During the procedure, an unrecognized puncture of the aorta by the transseptal puncture (TSP) needle and inadvertent advancement of the sheath resulted in ascending aorta perforation.(Figure)

The patient was haemodynamically stable and there was no evidence of a pericardial effusion on trans-esophageal echo (TEE). A dose of protamine sulphate was administered. As the patient was haemodynamically stable with the transseptal sheath in situ, which allowed temporary sealing of the puncture, it was decided to seal the atrial-aortic puncture percutaneously.

An Amplatzer™ Duct Occluder (ADO) 8/6 mm (St. Jude Medical, Inc.) was percutaneously inserted via the Swartz™ SL1 transseptal sheath and pulled back into position at the aortic puncture site. The procedure resulted in successful sealing of the puncture site.(Figure)

But the storm was far from over!!

During the procedure, a thrombus was visualized by TEE at the tip of the 0.35-inch wire positioned via the transseptal sheath in the ascending aorta. Heparin was re-administered immediately. Soon thereafter, ST-elevation was noted in the anterior electrocardiogram leads. Coronary angiography was immediately performed and showed a thrombotic filling defect in the middle left anterior descending artery. This was treated with balloon dilatation and aspiration thrombectomy, with a good angiographic result and TIMI 3 restoration of flow. LAA closure was aborted.

Following the procedure, the patient was treated with 3 months of clopidogrel therapy at a dose of 75 mg daily, together with long-term low-dose Apixaban (2.5 mg twice daily).

When crossing the septum with the needle, it is prudent to perform a pressure tracing and to ensure it is in the left atrium, before advancing the sheath. In this case, this precautionary measure could have assisted in detecting the aortic puncture immediately, allowing safe removal of the thin needle, most often without the need for further intervention.

Besides highlighting the need to follow all the described steps of a septal puncture, this case gives two other messages:

1. Using ADO in a patient who is unlikely to be fit for surgical correction can be a life-saving alternative.

2. One should abstain from reversing heparin while wires and sheaths are in-situ unless there is evidence of active major bleeding.

Source: European Heart Journal - Case Reports, Volume 5, Issue 4, April 2021, ytab154, https://doi.org/10.1093/ehjcr/ytab154