Descending Aorta Perforation During Transseptal Puncture for Left Atrial Appendage Closure.

Background
Aortic root injury during transseptal puncture (TSP) is a rare but well-recognized complication. However, injury to the descending aorta has not previously been described in this context.Case Summary
A 57-year-old woman underwent left atrial appendage closure. During TSP using the VersaCross Connect radiofrequency-powered system and a 15-F steerable sheath, an unrecognized perforation of the descending aorta occurred. Despite repeated transthoracic echocardiograms showing no pericardial effusion and initial hemodynamic stability, she subsequently developed a mediastinal hematoma and bilateral pleural effusion. Management required an emergency percutaneous thoracic endovascular aortic repair, followed by surgical evacuation of the hematoma.Discussion
Excessive tenting during radiofrequency-powered TSP, related to interatrial septum aneurysm, resulted in injury to the descending aorta with life-threatening consequences.Take-home Message
Radiofrequency-powered systems for TSP have enhanced tissue penetration capability and should therefore be used with caution, particularly in the presence of an interatrial septum aneurysm and atypical echocardiographic windows.