It is reported that during a procedure the aortic root was forcefully punctured with a brockenbrough needle.Catheterization was performed.The atrial septum was thicker than normal and no stent was visualized.The brockenbrough needle slipped from de fossa ovalis and, inadvertently the aortic root was forcefully punctured.An 8-fr mullins sheath was immediately advanced following the puncture.It was decided to leave the 8-fr sheath in the aortic root recognizing the danger of removing the sheath.Finally a 6/4 mm non-medtronic ductal occluder was advanced through the mullins sheath and under fluoroscopy and tee guidance, a successful deployment of the device and closure of the perforation was achieved.Subsequently, the paravalvular leak was closed with an non-medtronic vascular plug.The physician assessed that the perforation was because of a mistake by the surgical team, and the patient anatomy never contributed to the event.
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