Clin Res Cardiol 108, Suppl 1, April 2019
Inadvertent puncture of the aortic root by mislead transseptal catheterization: introducing a clinical algorithm based on anatomical analysis
T. Fink1, H. Chen1, X. Zhan2, M. Chen3, L. Eckardt4, D. Long5, J. Ma6, R. Rosso7, S. Mathew1, Y. Xue2, W. Ju3, K. Wasmer4, C. Ma5, J. Yang6, T. Maurer1, B. Yang3, C.-H. Heeger8, S. Yen Ho9, K.-H. Kuck1, S. Wu2, F. Ouyang1
1Kardiologie, Asklepios Klinik St. Georg, Hamburg; 2Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital,Guangzhou, China, Guangzhou; 3Cardiology, Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China, Nanjing; 4Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Münster; 5Cardiology, Department of Cardiology, Anzhen Hospital, Capital Medical University, Beijing, China, Peking, CN; 6Center of cardiac arrhythmias, Fuwai Hospital of the Chinese Academy of Medical Sciences, Beijing, Beijing, CN; 7Department of Cardiology, Tel-Aviv Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel, Tel-Aviv, IL; 8Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck; 9Royal Brompton Hospital, London, UK;

Aims: Inadvertent puncture of the aortic root (AR) is a well-known complication of transseptal puncture (TSP). Strategies for handling of this potentially lethal complication have not been identified yet. In this study we present typical anatomical locations and clinical management of aortic root puncture (ARP) due to TSP.

Methods and Results:All patients with ARP were retrospectively collected from 7 hospitals. ARP was identified and classified regarding angiographical and intraoperative findings in cardiac surgery: (1) TSP from the right atrium (RA) to the non-coronary sinus (NCS), (2) TSP from RA to the non-coronary sinutubular junction (STJ), (3) TSP from RA to the ascending aorta (AA).

A total of 24 patients with inadvertent ARP were identified. In 19 patients penetration of the Aorta was accomplished by the inner dilator, in 5 patients by the complete sheath. Previous cardiac surgery had been performed in 6 patients.There were 13 RA-to-NCS punctures, 2 RA-to-STJ punctures and 9 RA-to-AA punctures. No cardiac tamponade (CT) occurred in patients with RA-to-NCS and RA-to-STJ punctures. In 8 of 9 patients with RA-to-AA puncture CT occurred immediately requiring urgent pericardiocentesis and surgical repair. Two patients died after surgical repair. In the 16 patients without surgical therapy no shunt from the AR to the RA was observed 3 months after the procedure.

Conclusion: ARP due to mislead TSP via NCS or STJis usuallynot associated with a severe clinical course while ARP into the AA via the epicardial space generally leads to cardiac tamponade requiring surgical repair.

Figure 1: Example of a RA-to-AA puncture. A+B: Fluoroscopic images. B+C: Operation situs during cardiac surgery.

Figure 2: Clinical algorithm.
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