LAUSR

A 71-year-old male with kyphoscoliosis (Fig. 1a), persistent atrial fibrillation recurrent to amiodarone, LVEF 35%, and suspicious of tachycardiomyopathy was admitted for pulmonary veins isolation. An Agilis NxT Steerable introducer (St Jude Medical, Minnetonka, MN, USA) and an intracardiac echo (ICE) probe were advanced into the superior vena cava and right atrium, respectively. Fluoroscopy and ICE showed deviation of the inferior vena cava towards to the left that causes displacement of the sheath and transseptal puncture needle (BRK-1 98 St. Jude Medical) opposite to the fossa ovalis (FO) (Fig. 1b). An ablation catheter (TactiCath, Abbott Medical) was moved through the sheath until engaging the FO (Fig. 1c). The sheath was advanced over the catheter and positioned against the FO. The catheter was interchanged with a Super Stiff Guidewire 0.032 × 180 cm integrated in the Agilis NxT Steerable introducer using its stiff end for puncturing the FO during the application of 30 W of radiofrequency (RF) over its soft and curve tip with a generator (RF FORCE FXValleylab/COVIDIEN) in cutting mode through a Rocker Switch Pencil (COVIDIEN) (Fig. 1d). Finally, both dilator and sheath were introduced over the wire into the left atrium (Fig. 1e, f). An inferior approach for engaging the FO with a deflectable catheter through Agilis sheath to execute a transseptal puncture using RF through the stiff end of a wire is feasible when anatomical alterations preclude the use of the conventional technique [1, 2].