Transseptal access to the left atrium from the left femoral vein.

Transseptal (TS) access to the left atrium (LA) is obtained routinely via right femoral vein approach.1 Alternative approaches have been reported occasionally.2,3 A 66-year-old female patient was referred to our institution for wide QRS complex tachycardia workout. She had no angina or heart failure, although severely depressed left ventricular function was described on echocardiography. Multiple episodes of sustained tachycardia with LBBB morphology were recorded on ambulatory Holter-ECG. The QRS complex and electrical axis during tachycardia and during sinus rhythm were identical. The tachycardia was refractory to the available drugs. The patient had an electrophysiologic study and LA tachycardia was diagnosed. Ablation was attempted, with difficult passage of the TS needle through the right iliac vein and subsequent difficult rotation of the TS set. The procedure was prematurely stopped because of inadvertent puncture of the aortic root without any hemodynamic sequel. She was discharged in incessant tachycardia with drug-controlled ventricular rate. One month later the patient presented again with uncontrolled ventricular rate. A second ablation procedure was undertaken. An EnSite NavX (St. Jude Medical, St. Paul, MN, USA) system for electroanatomic mapping was used. This time the TS needle stopped at the level of the right iliac vein. After several unsuccessful attempts to surmount the iliac vein, the introducer was withdrawn. Several tiny bulges were seen on its wall (Figures 1A and B). A contrast injection described right iliac vein without any marked tortuosity. After replacing the TS set it was again not possible to get past the iliac vein and ultimately the needle stylet was seen to go outside the contour of the introducer. After removal of the introducer, a tearing on its wall was seen (Figure 1B). A new contrast injection did not show any leak out