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Ann Thorac Surg 2006;81:e29-e30
© 2006 The Society of Thoracic Surgeons

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Case report

Late Cardiac Perforation After Transcatheter Closure of Patent Foramen Ovale

^a Department of Cardiovascular Diseases, Azienda Ospedaliero-Universitaria, Ancona, Italy
^b Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria, Ancona, Italy
^c Department of Radiology, Azienda Ospedaliero Universitaria, Ospedali Riuniti Umberto I–G.M. Lancisi–G. Salesi, Ancona, Italy

Accepted for publication February 14, 2006.

^_* Address correspondence to Dr Cecconi, Via Guazzatore 66, 60027 Osimo (AN), Italy; (Email: morcecconi{at}tiscalinet.it).

	Abstract

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Cardiac perforation after transcatheter closure of a patent foramen ovale is a very rare complication. We report a case of left atrial wall perforation and aortic root erosion occurring 16 months after implantation of an Amplatzer patent foramen ovale occluder that required emergent surgery.

	Introduction

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Cardiac perforation is a rare, life-threatening complication of transcatheter atrial septal defect and patent foramen ovale (PFO) closure [1–4]. This complication has been described after implantation of various devices, including the Amplatzer septal occluder and the Amplatzer PFO occluder [1–5]. The incidence of cardiac perforation after the placement of an Amplatzer septal occluder is approximately 0.1 % [1]. Cardiac perforation by an Amplatzer PFO occluder is even rarer, and we believe it has been reported in only 3 patients [1, 3]. We describe a case of left atrial wall perforation associated with erosion of the aortic root, which occurred 16 months after placement of an Amplatzer PFO occluder. This is the longest latency between transcatheter closure of a PFO and cardiac perforation reported until now.

A 65-year-old man presented with chest pain to the emergency department. Because of a history of multiple cerebral transitory ischemic events, he had undergone a transcatheter PFO closure with a 25-mm Amplatzer PFO occluder at another institution 16 months prior. However no specific details on the procedure were available; the device was reported to be correctly positioned, and no recurrent cerebral ischemic events occurred.

On examination, the patient was clinically and hemodynamically stable. Electrocardiogram showed nonspecific ST-wave and T-wave changes. Transthoracic echocardiography demonstrated a mildly hypertrophied left ventricle with a normal systolic function, an enlarged aortic root and ascending aorta (maximum diameter, 4.2 cm), the Amplatzer PFO occluder within the atrial septum, and a mild to moderate pericardial effusion without evidence of cardiac tamponade. The patient was referred for a computed tomographic scan, which demonstrated a localized thickening of the posterior wall of the aortic root without diagnostic images of intramural hematoma or intimal flap. A transesophageal echocardiogram confirmed this finding and showed the "penetration" of the left atrial disk of the Amplatzer PFO occluder into the anterosuperior left atrial wall and the posterior wall of the aortic root (Fig 1). In addition, a left pleural effusion was found. A magnetic resonance angiographic scan showed an extravasation of the dye from the left atrial cavity into the pericardium and the pleura, bilaterally. This was consistent with a left atrial wall perforation by the Amplatzer PFO occluder. Thus an emergent surgery was planned. After removal of blood clots, a small perforation (3 mm in diameter) of the anterosuperior left atrial wall was detected (Fig 2). In addition, a concomitant erosion of the posterior wall of the aortic root involving the adventitia and the media was observed. Cardiopulmonary bypass was established as usual, and the device was removed. The septal defect was repaired by direct suture, while the anterosuperior left atrial wall was reinforced by means of pledgets. In addition, the aortic wall was secured with sutures reinforced with pledgets. Both pleural cavities were opened and blood was found and removed. The early postoperative course was characterized by reopening for bleeding. The patient was discharged on postoperative day 9 without further complications.

View larger version (79K): [in this window] [in a new window]   Fig 1. Transesophageal echocardiographic view of the Amplatzer patent foramen ovale occluder showing the "penetration" of the left disk (arrow) into the anterosuperior left atrial wall and aortic root. (Ao = aorta; LA = left atrium; RA = right atrium.)

View larger version (158K): [in this window] [in a new window]   Fig 2. Intraoperative illustration showing the perforation of the anterosuperior left atrial wall (arrow). (Ao = aorta; SVC = superior vena cava.)

	Comment

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This procedure is effective and safe [6]; however it is associated with a certain risk of complications, including embolization of the device, air embolism, vascular access site problems, and also, very rarely, cardiac perforation [1, 3, 5, 6].

This last complication has been reported after closure of atrial septal defect and PFO using various devices [1–5]. Among patients with an Amplatzer device it was mainly described after closure of atrial septal defect using the Amplatzer septal occluder [1, 2, 4]. It occurs at the anterosuperior wall of the atria and may also extend to the aortic root [1, 2, 4]. It has been hypothesized that the Amplatzer septal occluder transmits deformative forces at the point of contact between the device, the anterosuperior atrial wall, and the aorta [2], which may result in cardiac perforation. Possible risk factors that may lead to cardiac perforation by the Amplatzer septal occluder (including a deficient aortic or superior rim of the ostium secundum atrial septal defect, or both, and an oversized device) have been identified [1, 2].

Cardiac perforation related to the Amplatzer PFO occluder is a very rare event that we believe was reported in only 3 previous cases [1, 3]. The site and cause are similar to those found using the Amplatzer septal occluder [1].

Although it is desirable to implant smaller devices, the risk of cardiac perforation does not seem to be closely related to the size of the device itself, as it has also been reported for the Amplatzer septal occluder [2]. In our patient, a relatively small device (25 mm) was implanted; moreover, the erosion of the atrial wall was caused by the left occluder disk, which is smaller than the right one. We can hypothesize two factors that potentially concurred in the development of the cardiac perforation: (1) an upward location of the foramen ovale with a reduced distance between it and the anterosuperior atrial wall; (2) the concomitant dilatation of the proximal thoracic aorta, which might have promoted the contact between the device and the atrial wall and the aorta itself.

Cardiac perforation is usually associated with cardiac tamponade [1–5]. In our case, the extravasation of blood both in the pericardium and in the pleura probably prevented overt tamponade.

The long latency between the implant and the cardiac perforation (16 months) must be emphasized. Because timing for cardiac perforation development is unpredictable, a careful lifelong follow-up is needed, particularly in patients at higher risk, as those with dilatation of proximal thoracic aorta.

	Acknowledgments

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We thank Prof Antonio Maria Calafiore for his critical review and suggestions.

	References

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1. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. 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]
2. 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]
3. Trepels T, Zeplin H, Sievert H, et al. Cardiac perforation following transcatheter PFO closure Catheter Cardiovasc Interv 2003;58:111-113.[Medline]
4. 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]
5. Christen T, Mach F, Didier D, Kalangos A, Verin V, Trindade PT. Late cardiac tamponade after percutaneous closure of a patent foramen ovale Eur J Echocardiogr 2005;6:465-469.[Abstract/Free Full Text]
6. Windecker S, Wahl A, Nedeltchev K, et al. Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke J Am Coll Cardiol 2004;44:750-758.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sante Bucari Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cecconi, M. Articles by Perna, G. P. Search for Related Content PubMed PubMed Citation Articles by Cecconi, M. Articles by Perna, G. P. Related Collections Congenital - acyanotic