PMC4782469_01
Balloon sizing the atrial septum through a retrograde approach
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F1
Bethlehem, PA) was advanced over the wire and centered across the atrial septum under transesophageal and fluoroscopic control [Figure 1]. There was no hemodynamic perturbation with the wire and angioplasty catheter in place. Balloon sizing revealed a 7-mm waist.
(a) Transseptal puncture through right internal jugular vein from the neo-LPA to LA. (b) LA angiogram through the sheath before stenting, arrow indicates the site of atrial septum. (c) LA angiogram showed the malpositioned Diabolo stent being entirely in the LA. (d) LA angiogram after successful Diabolo stent placement. LPA = Left pulmonary artery, LA = Left atrium
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F2
Brockenbrough puncture from the neo-left pulmonary artery to the atrium was performed under fluoroscopic and transesophageal guidance [Figure 2a]. Amplatzer super stiff wire (Boston Scientific Corporation, Marlborough, MA) was positioned in the right atrium and an 11-Fr Mullins sheath (Medtronic, Minneapolis, MN) was advanced into the right atrium [Figure 2b]. It however became apparent that the large sheath distorted the anatomy and the stent was actually deployed in the left atrium [Figure 2c]. Once the stent was nicely seated across the atrial septum the waist was further dilated to 8 mm [Figure 2d].
(a) Diabolo stent placement across neo-LPA to LA fenestration, arrow points to the snare site at the middle of the balloon catheter. (b) SVC angiogram after Diabolo stent placement showing a patent stented fenestration with good fenestration position. LPA = Left pulmonary artery, LA = Left atrium
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F3
The stent was deployed in the same manner described earlier creating a Diabolo configuration across the pulmonary artery to atrial access site [Figure 3a and b].