IJCA-18161; No of Pages 2 International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Close proximity between pulmonary artery and left atrial appendage leading to perforation of the artery, tamponade and death after appendage closure using cardiac plug device☆ Koji Hanazawa a,⁎,1,2, Michele Brunelli a,2,3, Joerg Saenger b,1, Anett Große a,2,3, Santi Raffa a,2,3, Bernward Lauer c,1,3, J. Christoph Geller a,1,2 a b c
Arrhythmia and Electrophysiology Section, Zentralklinik Bad Berka, Germany Institute of Pathology, Zentralklinik Bad Berka, Germany Division of Cardiology, Zentralklinik Bad Berka, Germany
a r t i c l e
i n f o
Article history: Received 24 April 2014 Accepted 27 April 2014 Available online xxxx Keywords: Left atrial appendage occlusion Cardiac tamponade Pulmonary artery Sudden death
Sir: A 75-year-old female with paroxysmal atrial fibrillation (AF), hypertension and diabetes mellitus (CHA2DS2-Vasc score: 5) presented for left atrial appendage (LAA) closure because of previous subdural hematoma during oral anticoagulation. Transesophageal echocardiography (TEE) during sinus rhythm (SR) demonstrated good LAA flow (N50 cm/s) and no thrombus. The orifice's length of the LAA was 18 mm and the depth of the LAA neck was 27 mm. Following transseptal puncture, an Amplatzer™ Cardiac Plug (24 mm, AGA, St. Jude Medical, Minneapolis, MN, USA) was deployed uneventfully using fluoroscopy and TEE. During and 45 min after the procedure, there was no pericardial effusion, and the patient was feeling well. However, 24 h later, she suddenly became hypotensive, and cardiopulmonary resuscitation was started. Echocardiography revealed massive pericardial effusion with cardiac tamponade. After initial
☆ This is the first case report to demonstrate the close anatomical relationship between LAA and pulmonary artery. ⁎ Corresponding author. Tel.: +49 3645851210; fax: +49 3645853506. E-mail address: [email protected] (K. Hanazawa). 1 Acquisition of data or analysis and interpretation of data. 2 Final approval of the version to be submitted. 3 Drafting the article or critically revising it for important intellectual content.
drainage and persistent bleeding, thoracotomy was performed. After opening of the pericardium, perforation of the bottom of the pulmonary artery by one of the struts of the device was seen. Despite closure of the perforation, the patient subsequently died due to the prolonged resuscitation efforts. At autopsy, perforation of the LAA by a strut of the device was detected which had subsequently led to erosion of and bleeding from the pulmonary artery (Fig. 1). 3-D reconstruction of the cardiac computer tomography data revealed that one of the two lobes of the LAA was very close (and actually touched) the inferior pulmonary artery (Fig. 2). In that situation, device implantation may have a higher risk of struts extending through the LAA wall and damaging the arterial wall. Whether the contractility of the LAA and the underlying rhythm (SR vs. AF) also play a role in facilitating this complication is unknown. There are two similar case reports [1,2] following LAA closure. However, to the best of our knowledge, this is the first report that reveals the close anatomical relationship between LAA and pulmonary artery as the most likely explanation for this lethal complication. Usually, cardiac tamponade occurs at the time of the procedure due to perforation during device deployment [3,4]. Although strut perforation of the LAA may occur more frequently, in most cases complete closure of the LAA may prevent cardiac tamponade and clinical consequences. However, strut perforation of the LAA also eroding the pulmonary artery wall will – as in this and the two other published cases – cause massive bleeding despite complete occlusion of the LAA, and this complication can occur during implantation but also later and lead to cardiac shock and death. So far, little attention has been paid to the anatomical relationship of the LAA with surrounding structures when interventional closure is performed. This case report suggests that this anatomical relationship should be carefully assessed before and during LAA closure, and device modifications may be needed to avoid this severe complication.
References [1] Bianchi G, Solinas M, Gasbarri T, et al. Pulmonary artery perforation by plug anchoring system after percutaneous closure of left appendage. Ann Thorac Surg 2013;96(1): e3–5.
http://dx.doi.org/10.1016/j.ijcard.2014.04.260 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Hanazawa K, et al, Close proximity between pulmonary artery and left atrial appendage leading to perforation of the artery, tamponade and death after..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.260
e2
K. Hanazawa et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Left Panel demonstrates the perforation point of the LAA (black arrow). One strut of the LAA closure device made a minimal perforation hole in the superior lobe. Right Panel shows the perforated hole (black circle) from inside the PA (the anterior wall of the pulmonary artery was cut). LAA = left atrial appendage; and PA = pulmonary artery.
Fig. 2. The 3-D reconstruction of the left atrium in the left anterior oblique projection (Panel A) and the antero-posterior projection (Panel B) reveals the anatomical relation between LAA and PA. The first lobe was covered by and touched the PA. LAA = left atrial appendage. PA = pulmonary artery. RSPV = right superior pulmonary vein. LA = left atrium. LSPV = left superior pulmonary vein. LIPV = left inferior pulmonary vein. [2] Sepahpour A, Ng Martin KC, Storey P, et al. Death from pulmonary artery erosion complicating implantation of percutaneous left atrial appendage occlusion device. Heart Rhythm 2013;10(12):1810–1. [3] Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomized non-inferiority trial. Lancet 2009;374:534–42.
[4] Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S. Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry. Circulation 2011;123:417–24.
Please cite this article as: Hanazawa K, et al, Close proximity between pulmonary artery and left atrial appendage leading to perforation of the artery, tamponade and death after..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.260
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Close proximity between pulmonary artery and left atrial appendage leading to perforation of the artery, tamponade and death after appendage closure using cardiac plug device☆ Koji Hanazawa a,⁎,1,2, Michele Brunelli a,2,3, Joerg Saenger b,1, Anett Große a,2,3, Santi Raffa a,2,3, Bernward Lauer c,1,3, J. Christoph Geller a,1,2 a b c
Arrhythmia and Electrophysiology Section, Zentralklinik Bad Berka, Germany Institute of Pathology, Zentralklinik Bad Berka, Germany Division of Cardiology, Zentralklinik Bad Berka, Germany
a r t i c l e
i n f o
Article history: Received 24 April 2014 Accepted 27 April 2014 Available online xxxx Keywords: Left atrial appendage occlusion Cardiac tamponade Pulmonary artery Sudden death
Sir: A 75-year-old female with paroxysmal atrial fibrillation (AF), hypertension and diabetes mellitus (CHA2DS2-Vasc score: 5) presented for left atrial appendage (LAA) closure because of previous subdural hematoma during oral anticoagulation. Transesophageal echocardiography (TEE) during sinus rhythm (SR) demonstrated good LAA flow (N50 cm/s) and no thrombus. The orifice's length of the LAA was 18 mm and the depth of the LAA neck was 27 mm. Following transseptal puncture, an Amplatzer™ Cardiac Plug (24 mm, AGA, St. Jude Medical, Minneapolis, MN, USA) was deployed uneventfully using fluoroscopy and TEE. During and 45 min after the procedure, there was no pericardial effusion, and the patient was feeling well. However, 24 h later, she suddenly became hypotensive, and cardiopulmonary resuscitation was started. Echocardiography revealed massive pericardial effusion with cardiac tamponade. After initial
☆ This is the first case report to demonstrate the close anatomical relationship between LAA and pulmonary artery. ⁎ Corresponding author. Tel.: +49 3645851210; fax: +49 3645853506. E-mail address: [email protected] (K. Hanazawa). 1 Acquisition of data or analysis and interpretation of data. 2 Final approval of the version to be submitted. 3 Drafting the article or critically revising it for important intellectual content.
drainage and persistent bleeding, thoracotomy was performed. After opening of the pericardium, perforation of the bottom of the pulmonary artery by one of the struts of the device was seen. Despite closure of the perforation, the patient subsequently died due to the prolonged resuscitation efforts. At autopsy, perforation of the LAA by a strut of the device was detected which had subsequently led to erosion of and bleeding from the pulmonary artery (Fig. 1). 3-D reconstruction of the cardiac computer tomography data revealed that one of the two lobes of the LAA was very close (and actually touched) the inferior pulmonary artery (Fig. 2). In that situation, device implantation may have a higher risk of struts extending through the LAA wall and damaging the arterial wall. Whether the contractility of the LAA and the underlying rhythm (SR vs. AF) also play a role in facilitating this complication is unknown. There are two similar case reports [1,2] following LAA closure. However, to the best of our knowledge, this is the first report that reveals the close anatomical relationship between LAA and pulmonary artery as the most likely explanation for this lethal complication. Usually, cardiac tamponade occurs at the time of the procedure due to perforation during device deployment [3,4]. Although strut perforation of the LAA may occur more frequently, in most cases complete closure of the LAA may prevent cardiac tamponade and clinical consequences. However, strut perforation of the LAA also eroding the pulmonary artery wall will – as in this and the two other published cases – cause massive bleeding despite complete occlusion of the LAA, and this complication can occur during implantation but also later and lead to cardiac shock and death. So far, little attention has been paid to the anatomical relationship of the LAA with surrounding structures when interventional closure is performed. This case report suggests that this anatomical relationship should be carefully assessed before and during LAA closure, and device modifications may be needed to avoid this severe complication.
References [1] Bianchi G, Solinas M, Gasbarri T, et al. Pulmonary artery perforation by plug anchoring system after percutaneous closure of left appendage. Ann Thorac Surg 2013;96(1): e3–5.
http://dx.doi.org/10.1016/j.ijcard.2014.04.260 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Hanazawa K, et al, Close proximity between pulmonary artery and left atrial appendage leading to perforation of the artery, tamponade and death after..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.260
e2
K. Hanazawa et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Left Panel demonstrates the perforation point of the LAA (black arrow). One strut of the LAA closure device made a minimal perforation hole in the superior lobe. Right Panel shows the perforated hole (black circle) from inside the PA (the anterior wall of the pulmonary artery was cut). LAA = left atrial appendage; and PA = pulmonary artery.
Fig. 2. The 3-D reconstruction of the left atrium in the left anterior oblique projection (Panel A) and the antero-posterior projection (Panel B) reveals the anatomical relation between LAA and PA. The first lobe was covered by and touched the PA. LAA = left atrial appendage. PA = pulmonary artery. RSPV = right superior pulmonary vein. LA = left atrium. LSPV = left superior pulmonary vein. LIPV = left inferior pulmonary vein. [2] Sepahpour A, Ng Martin KC, Storey P, et al. Death from pulmonary artery erosion complicating implantation of percutaneous left atrial appendage occlusion device. Heart Rhythm 2013;10(12):1810–1. [3] Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomized non-inferiority trial. Lancet 2009;374:534–42.
[4] Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S. Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry. Circulation 2011;123:417–24.
Please cite this article as: Hanazawa K, et al, Close proximity between pulmonary artery and left atrial appendage leading to perforation of the artery, tamponade and death after..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.260
