Patient movement during transseptal puncture—need for caution

1 . Introduction produced by cough, the needle pierced IAS. The Mullins sheath was advanced into LA and the needle During balloon mitral valvuloplasty (BMV) by the was withdrawn. LA mean pressure before BMV was Inoue method [1], the left atrium (LA) is entered by 35 mmHg. BMV was carried out successfully followtransseptal puncture and the Inoue balloon catheter ing transseptal puncture. After BMV, LA mean positioned across the mitral valve. A case of transseppressure came down to 7 mmHg. tal puncture is described to illustrate the danger that can occur when the patient moves during the puncture. In this, a case of difficult transseptal puncture 3 . Discussion was aided by cough. It is being reported to serve as a warning and to recognise a potential source of Sometimes transseptal puncture is difficult due to complication. anatomical reasons of LA. Distortion of the anatomy of fossa ovalis occurs with mitral valve disease [4]. IAS tends have a more horizontal orientation and the 2 . Case fossa lies lower down. The patient had very high left atrial pressure producing bulging of interatrial septum A 20-year-old girl underwent BMV for severe towards the right atrium. This caused difficulty in rheumatic mitral stenosis by the Inoue method. positioning the Brockenbrough needle properly in the Echocardiography showed that the interatrial septum fossa ovalis during transseptal puncture. The needle (IAS) was bulging towards the right atrium. Transtended to make a tangential track in IAS due to the septal puncture was done by the Brockenbrough same reason. When all measures failed, cough promethod [2], modified using a Mullins sheath [3]. duced a violent jerk resulting in puncture. During After positioning the Mullins sheath carrying the cough, the movement probably and fortuitously reBrockenbrough needle in the fossa ovalis, attempts sulted in proper positioning of the needle against were made to enter LA. Repeated attempts were IAS. During cough, Valsalva manoeuvre might have futile. The needle tended to make a tangential track in produced a transient alteration in the shape and IAS. At this point, when the needle was pointing orientation of the plane of IAS relative to the needle towards the fossa ovalis, the patient had a sudden tip. This might have helped the patient. bout of coughing. During the violent movement Transseptal puncture is associated with known complications [5]. The patient was fortunate to escape without cardiac injury during transseptal *Present address: SCTIMST, Trivandrum, 695 011 India. Tel.: 191puncture while coughing. Although cough aided 471-555-532; fax: 191-471-446-433. E-mail address: saikm@sctimst.ker.nic.in (K.M. Krishnamoorthy). transseptal puncture, it might not always be so and is