Ann Thorac Surg 2006;81:2312-2313
© 2006 The Society of Thoracic Surgeons
Case report
Early Cardiac Perforation After Atrial Septal Defect Closure With the Amplatzer Septal Occluder
Hans-Henning Sauer, MD
a
,
*
,
Kalliopi Ntalakoura, MD
a
,
Christoph Haun, MD
a
,
Trong-Phi Le, MD
b
,
Viktor Hraska, MD, PhD
a
a Department of Pediatric Cardiac Surgery, Eppendorf University Hospital, University of Hamburg, Hamburg, Germany
b Department of Pediatric Cardiology, Eppendorf University Hospital, University of Hamburg, Hamburg, Germany
Accepted for publication August 15, 2005.
* Address correspondence to Dr Sauer, Department of Pediatric Cardiac Surgery, Eppendorf University Hospital, Martinistrasse 52, 20246 Hamburg, Germany (Email: h.sauer{at}uke.uni-hamburg.de).
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Abstract
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We report a case of aortic perforation after transcatheter closure of an atrial septal defect by an Amplatzer septal occluder. During emergency surgery, perforations of the dome of the right atrium and the noncoronary sinus of Valsalva of the aorta were repaired. Atrial septal defect was primarily closed. A short anterosuperior rim should be considered a risk factor for aortic perforation in transcatheter atrial septal defect closure.
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Introduction
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Surgical repair is the gold standard for treatment of a secundum type of atrial septal defect (ASD). Morbidity and mortality are extremely low, and long-term follow-up has demonstrated excellent survival and functional capacity [1]. Recently major advances have been made in device closure of ASDs. Reported closure rates have been good, and it is assumed to have similar morbidity and mortality when compared with surgical repair [2]. However, device closure is not without complications [3–6]. Early and late cardiac perforations are life-threatening complications with the incidence varying from 0.1% to 4% [7]. We present 1 patient with perforations of the right atrium and the aortic root 1 day after transcatheter ASD occlusion by an Amplatzer device (AGA Medical Corp, Golden Valley, MN).
A 31/2-year-old girl (length, 104 cm; weight, 12.9 kg) underwent device closure of a type II ASD, measuring 13 x 15 mm by echocardiography with a stretched balloon diameter of 17.5 mm and adequate rims. Interatrial septum was measured 37 mm in total length. The atrial septal defect was closed with a 17-mm Amplatzer septal occluder (AGA Medical Corp) using echocardiography and angiography. There was no residual shunt or impingement on intracardiac structures. Procedure-related hospital policy requested an overnight hospital stay. The patient was asymptomatic before collapse on day 1. Urgent echocardiography showed significant pericardial effusion with signs of tamponade. Pericardiocentesis was performed under echocardiographic control. This revealed dark, gross blood. With the patient becoming unstable, she was intubated. Once stabilized, emergent surgical exploration through a median sternotomy found a hemopericardium, and perforations were identified in the anterosuperior right atrial wall and the contiguous noncoronary sinus of the aortic root. Cardiopulmonary bypass was commenced and cardioplegic arrest was initiated. The aorta was opened to rule out aortic dissection, and the perforations on both the aorta and the right atrium were repaired. The device was removed, and the ASD was primarily closed. The patient was weaned off bypass without difficulties. The postoperative course of our patient was uneventful and free of neurologic events. Echocardiography at discharge showed no residuals and excellent ventricular function.
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Comment
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Atrial septal defect closure has classically been achieved surgically. Although surgical mortality and morbidity are minimal, percutaneous closure of secundum ASD has become an attractive therapeutic alternative due to comparable success rates combined with similar morbidity and shorter hospital stay [2]. However, most, but not all, secundum ASDs are amenable to device closure. Current criteria include a defect size of less than or equal to 32 mm and a 4 mm rim of atrial septal tissue surrounding the defect [8].
Patients with deficient anterosuperior rim may be at higher risk for device erosion. With short or deficient anterosuperior rim, the disks of the Amplatzer (AGA Medical Corp) straddle the ascending aorta. In addition, with double-disk devices the left atrial disk sits on the back of the aorta. The anterosuperior atrial wall and adjacent aorta are uniquely vulnerable, considering that this area was the site of perforation in our case and with other cases in which all erosions occurred at the dome of the atria near the aortic root.
Initial reports of aortic wall erosion led to the recommendation of intentionally over-sizing the device with deficient anterosuperior rim to ensure the device disks straddle and remain flared around the ascending aorta to prevent discrete areas of pressure where erosion may occur [9]. Yet the over-sizing theory may be controversial because such devices may prove the opposite effect by also triggering circumscribed areas of pressure in which fatal perforations may occur. When over-sizing the device, care also has to be taken so as not to interfere with surrounding intracardiac structures. In addition, the defect should be stretched but not overstretched during balloon sizing. The device to unstretched ASD ratio was shown being significantly larger in the adverse event group [8], and overestimated defects will set off unnecessary oversized devices.
In conclusion, symptoms consistent with cardiac perforation after attempted ASD device closure warrant prompt evaluation. Widespread awareness of potential adverse effects may allow for timely recognition. Patients with short or deficient anterosuperior rim and oversized occlusion devices may be at higher risk for device perforation.
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References
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- Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years N Engl J Med 1990;323:1645-1650.[Abstract]
- Holzer R, Hijazi ZM. Interventional approach to congenital heart disease Curr Opin Cardiol 2004;19:84-90.[Medline]
- Berdat PA, Chatterjee T, Pfammatter JP, Windecker S, Meier B, Carrel T. Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale J Thorac Cardiovasc Surg 2000;120:1034-1039.[Abstract/Free Full Text]
- Preventza O, Sampath-Kumar S, Wasnick J, Gold JP. Late cardiac perforation following transcatheter atrial septal defect closure Ann Thorac Surg 2004;77:1435-1437.[Abstract/Free Full Text]
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- 2002 US Food and Drug Administration The Amplatzer PFO Occluder SSPB. Summary of safety and probable benefit. 2. OUS clinical experience. 2002Available at: http://www.fda.gov/cdrh/pdf/h000007b.pdf. Issued April 22, 16-9.
- Divekar A, Gaamangwe T, Shaikh N, Raabe M, Ducas J. Cardiac perforation after device closure of atrial septal defects with the Amplatzer septal occluder J Am Coll Cardiol 2005;45:1213-1218.[Abstract/Free Full Text]
- Amin Z, Hijazi ZM, Bass JL. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defectsreview of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63:496-502.[Medline]
- Harper RW, Mottram PM, McGaw DJ. Closure of secundum atrial septal defects with the Amplatzer septal occluder devicetechniques and problems. Catheter Cardiovasc Interv 2002;57:508-524.[Medline]
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Abstract
Introduction
