A transseptal puncture hazard that was close!

Introduction The possible complications of transseptal puncture occur in approximately 1% of procedures. In the electrophysiology setting, increased pericardial effusion or tamponade risk is associated with left-sided arrhythmia ablations. Reported complications relate to aortic puncture or left/right atrial free wall perforation. There is much anatomical variation in the intra-atrial septum and subsequently the transseptal needle may not always fall into the fossa ovalis. The presence of previous interventions on the atrial septum, dilated atria, dextrocardia, or prior heart surgery have varying degrees of anatomic atrial distortion, resulting in fossa ovalis displacement and representing a challenge to transseptal puncture owing to movable traditional landmarks.