Ann Thorac Surg 2009;88:2021-2022. doi:10.1016/j.athoracsur.2009.05.044
© 2009 The Society of Thoracic Surgeons
Case Reports
Metal Allergy to Amplatzer Occluder Device Presented as Severe Bronchospasm
Reza A. Khodaverdian, MDa,*,
Kent W. Jones, MDb
a Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
b Intermountain Heart and Lung Surgical, Intermountain Medical Center, Murray, Utah
Accepted for publication May 14, 2009.
* Address correspondence to Dr Khodaverdian, Division of Cardiothoracic Surgery, University of Utah, 3C127 30 N Medical Dr, Salt Lake City, UT 84132 (Email: rkhoda{at}yahoo.com).
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Abstract
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Percutaneous closure of an atrial septal defect has become increasingly popular among interventional cardiologists. With this relatively new technology being more widespread, it is important to acknowledge any device-related complications. We report a case of severe bronchospasm secondary to a metal allergy after an atrial septal defect device closure requiring device removal.
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Introduction
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Advances in catheter-based technologies have allowed successful closure of atrial septal defects by a percutaneous approach. Meanwhile, there are certain limitations and contraindications to this relatively new technique that should be acknowledged.
A 27-year-old woman with a known history of atrial septal defect (ASD) presented with a cerebrovascular accident manifested by aphasia. During her evaluation, a secundum-type ASD with shunting at rest was documented. She was referred for percutaneous closure of her defect. The ASD was closed using an Amplatzer Septal Occluder (ASO) device (AGA Medical, Golden Valley, MN) under echocardiographic guidance. The patient noted shortness of breath immediately after recovering from anesthesia. Her respiratory symptoms became increasingly worse during the next 2 months after the procedure, despite aggressive medical management. Retrospectively, she reported a severe metal allergy since childhood, to the extent that wearing any metal jewelry resulted in severe contact dermatitis. Her respiratory symptoms continued to worsen and resulted in a hospital admission and endotracheal intubation. She was subsequently extubated but continued to experience severe bronchospasm.
After an extensive workup, reaction to the ASO device (AGA Medical) was presumed to be the primary cause of her respiratory symptoms. She subsequently underwent uncomplicated ASO device removal 4 months after her ASD closure with the ASO device. Surgery was performed through a standard median sternotomy approach. After removal of the device, the defect in the atrial septum (1.2 x 2.0 cm) was closed with a pericardial patch. Postoperatively she experienced dramatic improvement of her symptoms. She remains symptom-free now at 11 months after her operation.
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Comment
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Percutaneous closure of an ASD was described by King and Mills [1] in 1976. However, it was not until the mid-nineties when device closure of an ASD became an established alternative to surgical closure. A number of different transcatheter ASD closure devices are available. The ASO device has gained popularity among interventional cardiologists due to its short learning curve and ease of use. Based on the results of the clinical trial in the United States that enrolled more than 1,000 patients, the ASO was the first device to receive Food and Drug Administration approval for closure of the ostium secundum ASD [2]. After Food and Drug Administration approval of the ASO device in 2001, approximately 35,000 patients have undergone implantation of the ASO device in the United States alone.
Although device closure of an ASD has been reported to be safe, it has been associated with serious complications that required emergent or urgent surgical intervention. The most common adverse events involved device malposition and migration. Arrhythmias, residual shunts, cardiac perforation, atrioventricular valve regurgitation, infectious endocarditis, thrombus formation on the device, and sudden death have all been reported [3].
A metal allergy severe enough to require device removal is a rare complication of the ASO device. Nitinol, an alloy composed of 55% nickel and 45% titanium is used in the device to provide its super-elasticity and shape memory properties [4]. It has been documented that blood and urine nickel levels increase after implantation of the device [5, 6]. The nickel level gradually returns to baseline within 4 to 6 months post-implantation. Although high nickel levels may not be a concern in most patients receiving the device, patients with a metal allergy may present with an allergic reaction. This reaction to the device has been documented as dermatitis or pericardial effusion [7, 8]. We present a case of severe bronchospasm and respiratory insufficiency caused by an allergic reaction to the ASO device in a patient with prior history of a metal allergy. It is reasonable to consider a metal allergy as a contraindication to percutaneous closure of an ASD. The clinical significance of nickel release after ASO device implantation in patients without metal allergy is unclear and is subject to further studies.
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References
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- King TD, Mills NL. Secundum atrial septal defects: nonoperative closure during cardiac catheterization J Am Med Assoc 1976;235:2506-2509.[Abstract/Free Full Text]
- Amin Z, Hijazi Z, Bass J, et al. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects Catheter Cardiovasc Interv 2004;63:496-502.[Medline]
- Berdat PA, Chatterjee T, Pfammatter JP, et al. Surgical management of complication after transcatheter closure of an atrial septal defect or patent foramen ovale J Thorac Cardiovasc Surg 2000;120:1034-1039.[Abstract/Free Full Text]
- Lertsapcharoen P, Khongphatthanayothin A, Srimahachota S, et al. Self expanding platinum-coated nitinol devices for transcatheter closure of atrial septal defect: prevention of nickel release J Invasive Cardiol 2008;20:279-283.[Medline]
- Burian M, Neumann T, Weber M, et al. Nickel release, a possible indicator for the duration of antiplatelet treatment from a nickel cardiac device in vivo: a study in patients with atrial septal defects implanted with an Amplatzer occluder Inter J Clin Pharmacol Ther 2006;44:107-112.
- Ries MW, Kampmann C, Rupprecht HJ, et al. Nickel release after implantation of the Amplatzer occluder Am Heart J 2003;145:737-741.[Medline]
- Kim KH, Park JC, Yoon NS, et al. A case of allergic contact dermatitis following transcatheter closure of patent ductus arteriosus using Amplatzer ductal occluder Int J Cardiol 2008;127:98-99.[Medline]
- Lai DW, Saver JL, Araujo JA, et al. Pericarditis associated with nickel hypersensitivity to the Amplatzer occluder device: a case report Catheter Cardiovasc Interv 2005;66:424-426.[Medline]
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N. G. Kounis, G. N. Kounis, C. Koutsojannis, G. Tsigkas, G. Almpanis, and A. Mazarakis
Metal Allergy, Atrial Septal Occluder Devices and the Risk of Kounis Syndrome
Ann. Thorac. Surg.,
December 1, 2010;
90(6):
2087 - 2088.
[Full Text]
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Abstract
Introduction
