Provocative Cases -> Teaching Case Reports D-PO01 - Featured Poster Session (ID 11) Poster

D-PO01-095 - Working Smarter Instead Of Pushing Harder: Use Of Balloon Septoplasty For Transseptal Access For Left Atrial Appendage Occlusion (ID 918)


Background: Transseptal puncture (TSP) is a component of many cardiac procedures, but can be challenging in patients with previous TSPs, ASD repairs, and septal scarring, and a need for larger sheaths. Balloon septoplasty has been described for difficult left atrial (LA) access in AF ablations.
Objective: Present the use of balloon septoplasty for access to the LA as a safe and successful strategy for difficult TSP in left atrial appendage occlusion (LAAO) procedures.
Results: A 77-year-old male with paroxysmal AF and history of melanoma, falls, and brain amyloid, with no prior cardiac procedures, was referred for LAAO. Under direct fluoroscopic and TEE visualization, TSP in the fossa ovalis was obtained using sequential use of an SL1 catheter and large-curl Agilis over a curled Toray guidewire. Through this access, the LAAO device was deployed, but was not able to be positioned optimally in the chicken wing-shaped LAA. A second, more inferior and posterior TSP approach was attempted. Multiple wires, including a Toray guidewire, with increased support were used unsuccessfully. Ultimately, LA access was facilitated using balloon septoplasty. 6 x 40 mm and 8 x 40 mm compliant balloons (Charger, Boston Scientific) were used in succession over a Toray guidewire and inflated to 14 ATMs for serial dilation of the interatrial septum (Figure). The LAAO delivery sheath was then easily advanced into the LA to allow for delivery of the LAAO device.
Conclusion: TSP carries risk of cardiac perforation, particularly when excessive forward force is required to advance large sheaths into the LA. Balloon septoplasty is a feasible and safe technique to facilitate LA access when TSP is difficult.