High Risk Transseptal Puncture in a “Pancake” Left Atrium Due To Descending Aorta Displacement

A 63-year-old man was referred to our hospital for pulmonary vein isolation (PVI) for symptomatic paroxysmal atrial fibrillation (AF). He had a history of pulmonary tuberculosis for which he had undergone right upper lobectomy. A “pancake” deformity of the left atrium (LA) was observed on 64-slice multislice computed tomography. The descending aorta was in direct contact with the center of the posterior LA wall. The esophagus was descended to the level of the LA along the left side of the descending aorta. A real time 3-dimensional transesophageal echocardiography (RT3D-TEE) probe was inserted into the esophagus to the level of the LA. This imaging technique permitted us not only to perfectly visualize the fossa ovalis but also to appreciate the orientation of the needle 3-dimensionally. We could then push the needle through to the LA safely. Thereafter, PVI was performed successfully without complications. Even though transseptal puncture can be carried out without echocardiographic guidance in most cases, in this setting, RT3D-TEE proved to be a very helpful imaging technique to gain LA access. In order to prevent serious complications, it is necessary to examine and evaluate every patient carefully before PVI.