case_images: PMC11775611_01
case_images: CT angiography of the LA. (A) Cross-sectional view showing the ASD occluder reaching the edge of the atrial septum; (B) Reconstruction model of the left atrium showing that the closure device occupied the entire atrial septum surface. ASD, atrial septal defect; RA, right atrium; LA, left atrium.
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case_images: The closure device filled the whole atrial septal surface on left atrial computed tomography (CT) angiography (Figure 1).
case_images: Transseptal puncture. (A) BRK puncture needle abutting against the closure device; (B) BRK puncture needle passing through the outer closure device; (C) passage of the Run-through guidewire into the left atrium through the balloon; (D) balloon dislodgement; (E) use of a 4.0 mm high-pressure balloon to dilate the puncture hole, showing the 'waist' compression phenomenon; (F) use of a 5.0 mm high-pressure balloon to dilate the puncture hole, assisting the outer sheath passage.
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case_images: Initial attempts to pierce the atrial septum using a Swartz sheath and BRK puncture needle were unsuccessful (Figure 2A). The left atrium was finally reached using a guided needle through the BRK puncture needle (Figure 2B and C). A 2.0 mm percutaneous transluminal coronary angioplasty (PTCA) balloon slipped to the distal end of the Run-through guidewire and dropped into RSPV when repeatedly dilating the transseptal hole and attempting to advance it forward (Figure 2D). Subsequently, we repeatedly attempted to dilate the atrial septal route with high-pressure balloons measuring 3.0 mm, 4.0 mm, and 5.0 mm (Figure 2E). Finally, the transseptal hole was fully enlarged, and the Swartz sheath successfully reached the LA to establish access (Figure 2F).
case_images: Capturing the balloon. (A) Swartz sheath reaching the LA; (B) exchange of Agilis sheath reaching the RSPV ostium, and insertion of a snare; (C) successful capture of the balloon; RSPV, right superior pulmonary vein; RT, Run-through guidewire.
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case_images: Abbott) was used to obtain access to the orifice of the RSPV (Figure 3A). A Run-through guidewire was then carefully positioned near the dislodged balloon. An angiography catheter was inserted through the Agilis sheath, and a snare device was used to retrieve the dislodged balloon (Figure 3B). After multiple efforts, it successfully captured the balloon at the near end (Figure 3C).
case_images: The captured-balloon and its stump.
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case_images: The balloon stump was removed from the heart (Figure 4).
case_images: The three-dimensional (3D) model of the LA showed circular PVI combined with roof line ablation, and ablation of the LA septal surface terminated atrial flutter.
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case_images: Abbott) for the left atrial roof line and PVI (Figure 5), with a temperature of 43 C, power settings of 30-35 W, saline perfusion at 17 mL/min, and contact pressure of nearly 5-20 grams. Atrial flutter was persistently induced after conversion to sinus rhythm, and electroanatomical mapping suggested tachycardia associated with ASD occluder. Focal ablation successfully restored normal heart rhythm (Figure 5).