Intracardiac echocardiographic thrombus detection just before transseptal puncture: a nightmare outside the door

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Transseptal puncture has become a routine procedure particularly in experienced electrophysiological laboratories,1–3 but serious complications are still possible4,5 and have to be carefully avoided. Intracardiac echo has been widely used in order to increase safety in electrophysiological procedures,6,7 and particularly in atrial fibrillation ablation.8–10 The image below refers to an intracardiac echo-guided transseptal puncture during ablation of persistent atrial fibrillation. The sheath with the needle was gently pulled back from the top-right atrial septum. During this time, the needle was continuously flushed. No thrombus was evident at the intracardiac echo probe (Soundstar 3D Biosense Webster, Inc.) Until this moment. When a jump of the sheath toward the fossa ovalis was clearly observable, the flushing was stopped in order to get information from the pressure line connected to the needle. Before advancing the needle outside the sheath, the echo (a) showed a small thrombus, clearly visible over the tip of the sheath. In Fig. 1a, the effect of tenting of the sheath over the fossa ovalis and the small thrombus over the sheath, is observable. At this time, all the system was pulled back and the thrombus was aspirated into the sheath, thus avoiding its possible passage into the left atrium. The procedure was repeated a second time, without any prior heparin infusion. No thrombus was observed at this time (Fig.1b), and the transseptal puncture was successfully performed without any complication. After the puncture, an intravenous bolus of heparin was performed, in order to reach an anticoagulation time of at least 300. The ablative procedure was then performed without any complication.

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