1. Volume 28, Issue 4, Pages 250-253 (August 2012)
High-risk transseptal puncture in a patient with a “pancake” deformity in the left atrium caused by descending aorta displacement 
Takuro Nishimura, MD, Seiji Fukamizu, MD, Noriko Matsushita, MD, Rintaro Hojo, MD, Takekuni Hayashi, MD, Tomomi Abe, MD, Kota Komiyama, MD, Yasuhiro Tanabe, MD, Tamotsu Tejima, MD, PhD, Harumizu Sakurada, MD, PhD, Mitsuhiro Nishizaki, MD, PhD, Masayasu Hiraoka, MD, PhD 
Journal of Arrhythmia 
Volume 28, Issue 4, Pages (August 2012)
DOI: /j.joa
Copyright © 2012 Japanese Heart Rhythm Society Terms and Conditions

2. Fig. 1
The descending aorta was in direct contact with the center of the posterior LA wall. The esophagus was descended to the level of the LA along the left side of the descending aorta. AAo: ascending aorta; LAA: left atrial appendage; DAo: descending aorta; LSPV: left superior pulmonary vein; RA: right atrium; LA: left atrium; Eso: esophagus.
Journal of Arrhythmia  , DOI: ( /j.joa )
Copyright © 2012 Japanese Heart Rhythm Society Terms and Conditions

3. Fig. 2
(A) The “pancake” LA was sandwiched by the aorta. The atrial septum was small. DAo: descending aorta; LA: left atrium; RA: right atrium; AoV: aortic valve. (B) Chest radiography showed displacement of the descending aorta and elevation of the right diaphragm.
Journal of Arrhythmia  , DOI: ( /j.joa )
Copyright © 2012 Japanese Heart Rhythm Society Terms and Conditions

4. Fig. 3
(A) RAO caudal-similar perspective: the FO can be seen from the RA side. DAo and AoV exist around the broken line. RT3D-TEE permitted perfect visualization of the fossa ovalis and the “pancake” LA sandwiched by the aorta. (B) We positioned the whole system in the superior vena cava, then withdrew it under RT3D-TEE guidance and placed it in the fossa ovalis. No classic jump feeling into the fossa was experienced. (C) 2D TEE mid-esophageal aortic valve short axis. (D) We carefully pushed the needle through to the LA. FO: fossa ovalis; LA: left atrium.
Journal of Arrhythmia  , DOI: ( /j.joa )
Copyright © 2012 Japanese Heart Rhythm Society Terms and Conditions

5. Fig. 4
Pulmonary vein isolation was performed successfully without complications. Green tags represent the route of the transseptal sheath.
Journal of Arrhythmia  , DOI: ( /j.joa )
Copyright © 2012 Japanese Heart Rhythm Society Terms and Conditions